Breast Reconstruction Rippling. Previous Fat Grafting to Help With Ripples. Minimal Results. Suggestions?(photo)

Question

I am a 29 year olf female 1.5 years post breast reconstruction with submuscular high-profile mentor silicone implants (450cc). I am experiencing visible implant rippling (w/o bra only) on the R breast through the center cleavage and top of implant over the slope. I have had 3 fat grafting procedures (30 cc at a time) to help with the rippling - minimal help. Should I continue with the fat grafting, are there other procedures I should look at, Or is this as good as it gets? No lat flap. Thanks!

Lewis Albert Andres, MD · Answer

Hello!  Thank you for your question!  Fat grafting has become a popular procedure to improve aesthetic outcome following breast reconstruction or for improvement of contour after lumpectomy.  Much of the newest research has investigated the properties of fat, in terms of its stem cell properties and associated advantages.	It has significantly ameliorated radiation damage by increasing vascularity.  Also, it adds additional "fatty tissue" atop the reconstructed breast mound to further contour any concavities or deformities, while also masking implant visibility with rippling and such.At our Breast Reconstruction Center, we have utilizing this technique almost routinely to maximize the aesthetic outcomes after lumpectomy or mastectomy.  We have utilized the micro-fat grafting technique, and have been obtaining maximal fat graft survival into the breast.  After harvesting of the fat from areas with excess fat, usually the belly, hips, or thighs, the fat is processed and injected back into the breast using the aforementioned techniques.  Our patients have been very happy with the results as well as the areas where the liposuction was performed.  Contour has been much improved using the micro-fat grafting technique, and the downtime is minimal.  Survival rate of the fat is reports 50-90%, and thus is usually compensated for upon injection of the fat.  Sometimes it takes multiple procedures.  	Fat grafting has become a mainstay in breast reconstruction and has added another edge to breast reconstruction for aesthetics with minimal morbidity and complications.  If you are agreeable to it, I would continue with the fat grafting, especially if you are resistant to any flap procedure.  Discuss the survival rate and why the fat is failing to correct the deformity with your surgeon.  Best wishes for a great result!

Young R. Cho, MD, PhD · Answer

Thank you for your question.  Rippling can be seen when the surface of an implant shadows through the tissue, often found where the breast tissue coverage is thin.  You have already tried one approach would be to add some thickness to the breast tissue by fat grafting where fat is carefully layered between the skin and the implant. Another is to add a dermal matrix sheet between the breast and the implant where the rippling is visible to blunt the impression of the implant on the overlying skin.  Additionally, you can try changing implants to ones that are more overfilled such as the Inspira implants from Allergan or go with a shaped implant that is less prone to rippling.I would visit with a board certified plastic surgeon to discuss your options in more detail.

Richard H. Fryer, MD · Answer

You need more tissue to help with the rippling. This can either be more of your own tissue (fat grafting) or biological tissue (Alloderm, Surgimend etc). Thirty mililiters of fat grafting may also not be enough. I'm sitting in the OR where I just finished grafting 125 ml to a breast (different type of reconstruction on a different patient so don't compare).

	Or you may need a sheet of artificial dermis to help crate a barrier between the implant and your skin.  Your surgeon can help you decide what the best options for you may be.

Richard Baxter, MD · Answer

From the photos you posted it appears that you have a beautiful result. I would agree with fat grafting as the first option for improvement of rippling in a case like yours, but if you have had 3 sessions and still need better coverage then an acellular dermal matrix graft such as Strattice or Alloderm would be worth considering. Disadvantage is that it is a bigger surgery than fat grafting.

Robert Whitfield, MD · Answer

This is particularly challenging.  Round devices can give you a shelf like appearance.  Shaped implants avoid this appearance.  You can continue with fat grafting but you may have to be satisfied with very moderate improvements.

Darryl J. Blinski, MD · Answer

From your posted photo I think your result is excellent. So try additional fat grafts  to slightly improve the wrinkling.

Daniel Del Vecchio, MD · Answer

Pre expansion followed by fat grafting can yield long term fat survival

	over your reconstruction- i have demonstrated this in over 

	30 cases  and have presented this at the Baker Gordon 2012 in Miami.  

	 

	See the attached link and video

	 

	Best regards,

	 

	Dtt deLvecchio

C. Bob Basu, MD, MPH, FACS · Answer

Based on your bikini top photo, it looks like you have a great result from your mastectomy reconstruction. congratulations. Unfortunately, as you know, the mastectomy leaves behind thin skin. So you have very little coverage over your implants (even with the under the muscle or submuscle/acellular dermal matrix techniques). Rippling is a limitation of any implant based reconstruction. One option may be to go larger with your implant size to help fill the implant pocket, However, this will not totally remove rippling. Another option is to consider the form-stable silicone gel implants that are available in limited investigational capacities. Hope this helps.

Breast Reconstruction Rippling. Previous Fat Grafting to Help With Ripples. Minimal Results. Suggestions?(photo)

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