Breast lift with implant after major weight loss - can serial fat grafting meaningfully restore volume and softness? (Photos)

Question

40F, ~100-lb weight loss. Before surgery I had significant natural breast volume but severe ptosis. I underwent augmentation-mastopexy with 295cc implants. My goal was to lift my existing breast tissue and restore volume lost with weight loss, not to have a breast reduction. I later obtained my pathology records, which document removal of 188 g from one breast and 124 g from the other, described largely as fatty breast tissue. Preoperatively, I understood that only a small amount of tissue would be removed/sent to pathology. I am currently approximately a 36DD, but my breasts feel very firm and implant-dominant. A revision surgeon examined me and said he did not believe I have capsular contracture; he felt I simply have relatively little tissue covering the implants. I also experience burning/discomfort around the implants. I would ultimately like softer, more natural-feeling breasts and would prefer to remove the implants if reconstruction is realistically possible. I am also unhappy with the very high nipple position; the breasts look more natural to me when I manually pull the lower breast skin downward. My questions for revision/reconstructive surgeons are: After explantation, can serial fat grafting meaningfully restore volume and softness in a patient like me? Can fat grafting be performed at the time of explant, followed by additional rounds later? Is there any surgical technique for redistributing/preserving my remaining breast tissue to maximize volume after explant?

Gregory A. Buford, MD, FACS · Answer

There are a few options to help you achieve a much better look and feel of your breasts:
1.  Your nipple to fold distance is way too long which is why your nipples look so high and why your breasts look better when you pull the tissue down.  By reducing this distance, you effectively create more optimally balanced breast dimensions overall.  Right now your breasts are very bottom heavy.  This would help to situate the nipples in a better position and potentially create slightly greater upper pole volume.
2.  While fat grafting could definitely help, I find that with many weight loss patients there is very little fat to actually use.  If this is the case, then I would strongly encourage you to look into the use of alloClae to help better blend the implant with the overlying tissue.  
3.  You could also think about a more cohesive implant to create a more structured look in combination with fat grafting.

I work with a growing population of weight loss patients and see this type of scenario very frequently.  And so I know that this combination can work.  Simple fat grafting alone is not going to give you the best outcome.

I hope this helps and wish you the very best in your surgical journey.

Michelle Zweifler, MD · Answer

Breast surgery in massive weight loss can be challenging and revisions may be helpful.  
In general breast, implants give volume to the breast, significantly more than one stage of fat grafting.  Fat grafting may take 2-3 or more stages to achieve the desired volume.  
Breast lifts with repositioning the natural breast tissue may help with the bottoming out and a times we use a mesh “internal bra” to help with lower pole support.

John LoMonaco, MD, FACS · Answer

Thanks for the photos and congrats on your weight loss.

You have a few options to correct the issues that bother you the most.  One would be correction of the "bottoming out" you have from the existing implants and lift which gives you the bottom heavt/high nipple look.  This is a common problem in weight loss patients because your prior gain-loss cycles damage your elasticity and your skin cannot hold the implant, so it drops.

The correction would be to rearrange your existing breast tissue to make a smaller, higher breast using a smaller implant surrounded by your natural (but rearranged) tissues so the breast feels more natural.

Another option is to rearrange the breast tissue (I use the LeJour technique) with no implant.

The third option is to employ fat grafting. My personal (25 year) experience with weight loss patients and fat grafting is poor, no matter what technique I use to purify and gently handle the fat.  It just seems that the body is programmed to burn fat and I've seen very little benefit from the grafts.  Also remember that fat grafting can cause changes to your mammogram that can make cancer screening more difficult, so your personal and family history is important to consider here too.

Photo is a LeJour breast lift with no implant in a weight loss patient

Mert Demirel, MD · Answer

Yes, serial fat grafting can improve softness and add some natural volume after explant, but it usually cannot fully replace the volume or projection of an implant, especially after major weight loss and prior mastopexy.
Fat grafting works best as a softening and contouring tool. It can improve thin tissue coverage, soften implant-dominant firmness after explant, and fill selected areas such as the upper pole or cleavage. However, only a portion of transferred fat survives, and multiple sessions are often needed.
Fat grafting can sometimes be done at the time of explant, but the amount may be limited by tissue quality, blood supply, available space, and safety. After implants are removed, the tissues may be thin or compressed, so many surgeons prefer a conservative first round and then additional grafting after healing.
There are also surgical techniques to preserve and rearrange remaining breast tissue during explant. Depending on your anatomy, this may include explant with lift, auto-augmentation, dermal flap support, lower-pole reshaping, or internal tissue rearrangement. The goal is to use your own remaining tissue as much as possible rather than simply removing the implant and tightening skin.
The high nipple position is a separate but important issue. If the nipple looks high because the lower breast/fold is tight or under-filled, adding lower-pole shape or releasing/reconstructing the lower envelope may help. Actually moving nipples lower is difficult, so the revision usually focuses on reshaping the breast mound beneath the nipple.
My advice would be to consult a revision/explant surgeon who performs both auto-augmentation mastopexy and fat grafting. Ask whether your plan should be staged: implant removal and tissue reshaping first, then serial fat grafting after the breast settles. A softer, more natural breast may be achievable, but the final size will likely be smaller and should be based on your remaining tissue and donor fat.

Luis A. Mejia, MD · Answer

Yes. Fat grafting, lipofilling, is an excellent way to replace the hard feel of an implant with soft, natural-feeling tissue. Because it uses your own purified fat cells, it completely eliminates the "implant-dominant" sensation.
Because the fat is your own living tissue, it behaves exactly like natural breast tissue, it is soft, moves naturally, and warms to your body temperature. This will directly address the firmness and implant-dominant" feel you are experiencing.
Dr. Luis Mejia
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Breast lift with implant after major weight loss - can serial fat grafting meaningfully restore volume and softness? (Photos)

Answers (5)

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