Rippling and Fat Grafting?

I had a double mastectomy and will be replacing my expanders with silicone implants under the muscle. I am 5'7, 138 lbs, have thin skin and was a 34C. I want to remain a 34C and was told that 350cc would be about the equivalent size. Several threads mention fat grafting for rippling but don't know whether it's necessary at this time and I can't tell whether it is effective for avoiding ripples. I need feedback on whether I should consider this procedure before I head to surgery.

Doctor Answers 10

Fat grafting and the second stage breast reconstruction.

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Fat grafting can be a very powerful contouring technique in breast reconstruction. The use of fat grafting in the second stage can improve skin flap thickness, depressed upper poles, and soften the transition of the medial and lateral breast. Rippling in breast reconstruction is due to thin flaps and/or an enlarged pocket. Decreasing the pocket size and thickening the flaps with fat works very well. This can be performed either at the second stage or in a tertiary procedure.

Boca Raton Plastic Surgeon
5.0 out of 5 stars 26 reviews

Fat graft timing

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Go ahead with the implant placement and allow your skin to heal around the implant. Once your tissues have settled into place, then you should be evaluated for any contour enhancement with fat grafting being one of those options that is suitable to address rippling if it indeed develops.

Theodore Diktaban, MD, FACS
Manhattan Plastic Surgeon
4.0 out of 5 stars 28 reviews

Do not undergo fat grafting.

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You should have determined final implant size at some intermediate stage during your expansion, at which time you could be pretty close to choosing implants at or near the volume you had in your expanders at that point. Now, hopefully, after over-expansion for several months to allow the myofibroblast activity to be reduced in your maturing scar capsule around your expanders, you are ready for the exchange to silicone gel implants.

350cc should add just under 1 1/2 cup sizes, so you will likely end up being closer to a B-cup than C-cup in most manufacturers' bras. You may want to consider closer to 500cc to add 2 cup sizes to your post-mastectomy chest.

Fat grafting for the breast area is still considered "experimental;" most experienced breast surgeons understand that even with (non-existent) "perfect technique" in grafting fat, some of the fat will die, causing scar tissue within the breast, and possibly calcifications, both of which can interfere with the detection of breast cancer. In the reconstructed breast, this may be less (but still some) of a concern.

If you have rippling after placement of your final implants, fat grafting would be one of the potential solutions, though it should be considered carefully in light of the concerns noted above. But in no case would I recommend it prophylactically--it may not be needed!

Good luck with your reconstruction! Best wishes! Dr. Tholen


Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 263 reviews


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It is very difficult to determine the exact size and shape implant you will require to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast augmentation surgery including different approaches, techniques and implant choices. This is because several measurements not to mention your breast characteristics are needed to determine the optimal implant size to obtain your goals. Without knowing these dimensions it would be difficult to make this determination. For example, the existing base width of your breast will determine, in many cases, the maximal volume per implant profile that you can accommodate. To illustrate; a 100 cc difference may make a significant difference with a narrow base width breast, but much less of a difference if you have a wide chest wall and wide breast “foot print”. Therefore, just because your friend may have a great result with let’s say a 350 cc implant to make her go from a “A” cup to a “C” cup size does not mean that you will have the same result with the same size implant. . Further simply placing implants in a bra to determine the size best for you is not always accurate as the bra often distorts the size, is dependent on the pressure the bra places plus the implant is outside your breast and not under it among other variables. Computer software morphing programs that automatically determine the best implant size can be helpful in some but not all cases (e.g. doesn’t work well in my experience with existing implants, sagging or asymmetric breasts). Using “want to be” photos however are useful if simply provided to the surgeon as I will further explain in the below link.


Fat Grafting after Implant Breast Reconstruction

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When considering Autologous Fat Grafting, it is better to wait several months after placement of the permanent implants for breast reconstruction. Time will diminish any potential swelling and allow the expanded skin to contract around the new implants. Once you have fully recovered, and if rippling does develop later, your surgeon will be able to target the "problem areas" on the new breasts with fat grafts. If needed, sometimes fat grafting can be done at the same time as the nipple reconstruction surgery.

Thanks for your question. Best of luck with your surgery!

Gregory Park, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 178 reviews

Rippling and Fat Grafting?

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Fat grafting is a treatment for rippling when and if it occurs. I gather from your question that you do not have rippling at this time.  In this setting, the fat grafting does have hazards and no real benefits. 

I would proceed with the expansion, and observe the size that is most appealing to you as the expansion proceeds. That will help you and your surgeon determine the best implant size, and this may not be the same as the pre-expansion choice.j

Thanks for your question, and best wishes.

Jourdan Gottlieb, MD
Seattle Plastic Surgeon

Fat grafting during breast reconstruction

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If you are having significant rippling during the tissue expander phase and your skin envelope is very thin and stretched out, then consider fat grafting before placement of permanent silicone gel implant. The amount of fat that can be grafted may be very limited but can and have shown to improve skin envelope quality and thickness which will diminish the rippling even after your implant is placed. Another option is use of acelluar dermal matrix such as Strattice or Alloderm to place in between the skin envelope and your implant. This is where it's critical to discuss with your plastic surgeon to see which options are viable and suitable for you.

Best Wishes,

Stewart Wang, MD FACS, Wang Plastic Surgery

Stewart Wang, MD, FACS
Los Angeles Plastic Surgeon
4.6 out of 5 stars 28 reviews

Fat grafting and rippling

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Over the past several years, many plastic surgeons are increasingly using fat grafting techniques.  These techniques are great to help improve contour irregularities, including rippling, after breast reconstruction.  Since you have not had your tissue expander removal and implant placement yet, I would suggest that you wait on the fat grafting.  Have your tissue expander exchanged for the implant; after this procedure, you will better be able to assess your results and whether you need any additional surgeries.  You will find that the implant looks and feels a lot different than the expander.  


I usually perform my tissue expander removal and implant placement first.  I then allow the implant to settle and then assess what else needs to be done -- whether it be fat grafting or moving on to nipple areola reconstruction.  I would suggest that you discuss your options with your plastic surgeon.  Good luck!

Anureet K. Bajaj, MD
Oklahoma City Plastic Surgeon
5.0 out of 5 stars 21 reviews

Fat grafting after mastectomy

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I am glad to hear that you are doing well. Fat grafting is the cutting edge of reconstructive breast sugery at this time. I do not do it at the same time as the implant exchange. That is a third stage procedure for me. The implants feel and look a lot different than the expanders. Allow healing after your second procedure before you make any more decisions.

Norman Bakshandeh, MD, FACS
New York Plastic Surgeon

Breast Surgery

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I think fat grafting has proven to be a pretty good way of treating rippling, although its not as predictable as other surgeries it works well and is safe

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