Combined Use of Implant and Fat Grafting for Breast Augmentation

Hybrid Breast Augmentation: Double Benefit or Double Risk? A Comparative Study of 932 Cases

BACKGROUND

The authors propose a hybrid breast augmentation (HBA) method combining implants and fat grafting and explore the outcome and safety through a retrospective, single-center, propensity score-matched, comparative study.

METHODS

Outcome, satisfaction, and complications were compared between the HBA group (302 cases) and the implant-based breast augmentation (IBA) group (353 cases), and between the HBA group and the autologous fat grafting (AFG) group (277 cases).

RESULTS

The mean follow-up period was 31.7 months. After propensity score matching (PSM), 270 cases were matched between the HBA and IBA groups, and 156 cases were matched between the HBA and AFG groups. Compared with the IBA group, HBA achieved higher scores of implant visibility/palpability and upper pole contour with the specialists' evaluations (before and after PSM; P < 0.05). Regarding patient satisfaction, the scores of softness (before and after PSM), smoothness of the upper pole (before PSM), and overall satisfaction (after PSM) of the HBA group were better ( P < 0.05). Implant-related complications occurred at a similar rate. Compared with the AFG group, HBA achieved higher scores of shape (before and after PSM) and symmetry (after PSM) with evaluations by specialists ( P < 0.05). The scores of shape, symmetry, and overall satisfaction in the HBA group were better (before and after PSM; P < 0.05). The HBA group showed a lower incidence of palpable cysts, fat necrosis, oil cysts, and fat calcification (before PSM; P < 0.05).

CONCLUSION

When the three techniques were compared objectively, HBA presented better indices of aesthetic outcomes, satisfaction, and acceptable complications rates when compared with IBA and AFG.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Reoperative Transaxillary Subfascial Breast Augmentation and Fat Grafting: Technical Highlights and a Step-by-Step Video Guide

SUMMARY

Reoperative procedures after breast augmentation are frequently more complex than primary cases because of local complications and insufficient soft-tissue coverage. Although the transaxillary incision is often indicated in primary breast augmentation, limitations of this approach include secondary surgery and correcting complications after using this approach via the same incision. Combining the transaxillary technique with a subfascial pocket has been suggested to avoid breast scarring and the limitations of submuscular pockets represented by breast animation. With advances in autogenous fat grafting (AFG) techniques, implant coverage alternatives and more natural outcomes have been reported from more superficial implant pockets. Simultaneous AFG with silicone implants (defined as hybrid breast augmentation) has been evaluated recently as an attractive procedure. These two techniques combine to provide breast projection and natural cleavage while camouflaging implant edges. AFG is also important to reduce the intermammary distance and achieve a smoother transition between the breasts. The transaxillary approach can be useful in reoperative breast augmentation and avoids additional scarring on the breast. This article and the accompanying videos provide a detailed, step-by-step guide to reoperative hybrid breast augmentation using a subfascial transaxillary approach, with a predictable and optimized surgical outcome.

Kite Mastopexy: Small Scar and Tissue-conserving Technique

Background

Breasts are considered one of the most physically and sexually appealing features of the female body. Reduction/augmentation techniques have greatly evolved in the last decades.We are reporting our experience with an innovative technique for mastopexy that recovers the aesthetics of the breast and avoids over-resection of its lower pole.

Methods

Inclusion criteria were women who underwent kite mastopexy with or without implants between January 2018 and May 2022 in a single center (Bogota, Colombia). Exclusion criteria were patients with American Society of Anesthesiology score more than II, with any uncontrolled chronic illness and/or medical history of diabetic mellitus, metabolic syndrome, body mass index more than 32 kg per m2, and active smokers.

Results

We found 133 consecutive female patients. Age range was 18 and 67 years (median 39). Breast implants were used for the purpose of kite mastopexy in 52% cases. Patients were divided into two groups: implants (group 1) versus no implants (group 2). Procedure 1 involved mastopexy without implants; procedure 2 included current implant users who underwent either implant removal or in whom implants were not used for the sake of mastopexy. Procedures 3 and 4 included patients who underwent either new implant placement or implant exchange, respectively. Average time of surgery was 1.5 hours. Minor complications were mostly related to wound dehiscence. No major complications were reported.

Conclusions

Kite mastopexy restores the breast aesthetics by following specific markings, a new plication of breast pillars, and a reduced scar. Our technique demonstrates a very low rate of complications while entailing natural and appealing results.

Patient-Reported Outcomes After Autologous Fat Grafting in Prosthetic Breast Reconstruction: Prospective Cohort Study Using a Multivariate Analysis

INTRODUCTION

There is widespread recognition of the importance of assessment of patient satisfaction and well-being after breast reconstruction. However, few studies of fat grafting performed simultaneously with implant-based breast reconstruction (IBBR) have accounted for confounding factors, such as patient background and information bias. The aim of this study was to examine patient satisfaction and well-being using multivariate analysis of BREAST-Q scores in patients treated with IBBR combined with fat grafting.

METHODS

Seventy-one consecutive patients who underwent IBBR with silicone breast implants were enrolled for a prospective cohort study. Among these patients, 56 responded to the BREAST-Q questionnaire, including 24 who underwent fat grafting at the same time as IBBR (FAT+ group) and 32 who underwent IBBR alone (FAT- group). The BREAST-Q questionnaire was completed 1 year after surgery. Statistical analysis was performed using descriptive and summary statistics to identify differences between the 2 groups.

RESULTS

Logistic regression analysis showed that the FAT+ group was significantly more likely than the FAT- group to have satisfaction with breasts (P = 0.0201) and satisfaction with outcome (P = 0.0364).

CONCLUSIONS

Multivariate analysis with consideration of confounding factors indicated that addition of fat grafting to IBBR improves outcomes of breast reconstruction. These results suggest that a minor surgical procedure of fat grafting can improve patient satisfaction and outcomes after breast reconstruction.

Use of free flaps in aesthetic breast surgery: a single centre experience and literature review

BACKGROUND

Implant-based breast augmentation is one of the most performed procedures in aesthetic surgery, whereas autologous tissue application is confined to fat grafting as adjuvant procedure. The use of free flaps in cosmetic mammoplasties is not popular, but the number of reports in the literature is increasing. We believe that autologous tissue transfer for cosmetic purposes could be a valuable alternative for volume enhancement in selected conditions, especially following weight loss. In this paper, we provide a systematic literature review of the current literature of using autologous free flaps for breast augmentation in non-cancer patients, and we also report our experience on this topic to identify possible indications and criteria for the patients' selection.

METHODS

PRISMA's guidelines have been followed for the literature review. In order to demonstrate the feasibility, safety and patient satisfaction with breast volume enhancement with autologous tissue, a retrospective single-centre study was conducted on women who underwent breast volume enhancement with autologous tissue. Patient's satisfaction was assessed with a visual analogue scale (VAS) creating an ad-hoc outcome scale, and the data were summarised with a descriptive statistic.

RESULTS

Twelve patients were enrolled in the study. Weight loss was the main indication for surgery. The average length of procedure was 5.1 h, and the hospitalization was 2.3 days. After 12 month, the patient outcome was excellent in 2 cases, good in 9 cases and moderate in 1 case.

CONCLUSIONS

Although further research is needed, the literature review and our case series show that the use of free flaps for breast volume enhancement is safe and gives a satisfactory outcome.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

Optimizing Surgical Outcomes with Small-Volume Silicone Implants Associated with Autogenous Fat Grafting in Primary and Revision Breast Augmentation Surgery: Soft Weight Hybrid (SWEH) Concept

BACKGROUND

Simultaneous association of autologous fat grafting (AFG) with silicone implants, defined as a hybrid procedure, has been proposed for breast augmentation (BA). In some patients, larger-volume implants may result in larger incisions, with long-term effects including implant palpability, soft tissue atrophy, and secondary ptosis. Some patients do not want large volume implants, or have insufficient soft tissue coverage. Recent improvements in AFG have led to new surgical options in BA for addressing these cases.

OBJECTIVES

This study combines AFG in BA using small-volume implants, known as the SWEH (soft weight hybrid) approach, and evaluates aesthetic advantages and outcomes following primary/secondary BA.

METHODS

25 patients (50 breasts) underwent SWEH procedures; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant and patients refused large-volume implants. Three-dimensional images were obtained using a Divina 3D scanner system (AX3 Technologies, Miami, USA) to assess breast volume (BV) and intermammary distance (IMD) during follow-up.

RESULTS

Mean patient age was 29.3 years (range: 21-42) and mean body mass index was 19.3 kg/m² (15.3-27.2). The most common implant (SmoothSilk surface Round/Ergonomix style) volume was 180 cc (175-215), and patients received a mean volume of 125 cc of fat (89-168)/breast in the subcutaneous tissue. Preoperative average BV measurements were 236.85 cc (170-335). At 3 and 12 months post-procedure, the average BV values were 488.82 and 478.73cc, respectively (p=0.475). The average preoperative IMD was 31.76 mm (range, 22-43); at 3 and 12 months post-procedure, the average IMD was 20.47 and 20.94 mm, respectively (p=0.61). Postoperative complications included subcutaneous banding in the axilla (n = 1; 4%) and hypertrophic scarring (n = 1; 4%). Breast imaging exams were performed; in 2 breasts (8%) localized oil cysts were observed; no cases of suspicious calcifications, fat necrosis, or lumps were seen. Fat retention rate (1 year) was calculated by the difference between the BV expected with 100% fat intake and the real BV observed. In our sample we observed an average of 72.7 (range: 69.2-77.3, SD: 2.63) and 76.7 (range: 72.3-79.9, SD: 2.18) percent of fat intake on the right and the left breast respectively. No rippling, implant malposition, or infection was observed during a mean follow-up of 22 months (6-40).

CONCLUSIONS

SWEH is a useful surgical alternative that combines the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of larger-volume implants. The association of small-volume gel implants and smaller scars can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

BACKGROUND

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA.

OBJECTIVES

The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA.

METHODS

In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant.

RESULTS

Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months).

CONCLUSIONS

SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Assessing Clinical Outcomes in Autologous Fat Grafting: A Current Literature Review

Autologous fat grafting, first described in the 1890s, has since undergone many modifications to optimize safety and efficacy. These changes have resulted in the technique that we now consider standard of care, one that is applied to reconstruction and cosmetic enhancement of the breast and the face both independently and in conjunction with surgical treatment. There is a growing body of evidence that this application has positive outcomes for patient satisfaction, surgeon satisfaction, and overall aesthetic appearance. This article summarizes the body of literature regarding these outcomes, reviews complications of fat grafting in the face and breast, and discusses controversies including radiologic imaging changes and longevity of grafting. Level of Evidence: 4.

Multiple polyurethane implant punctures during fat grafting: case report and review of the literature

BACKGROUND

Breast augmentation with implants continues to be the most popular aesthetic surgical procedure performed worldwide. Fat grafting may improve the results of breast augmentation and breast reconstruction with implants. However, fat grafting to the breast with implants carries the risk of implant puncture. To our best knowledge this is the first case in which polyurethane implant puncture during fat grafting is described.

CASE PRESENTATION

We report multiple bilateral implant punctures with the cannula during fat grafting in a patient who previously underwent breast reconstruction with polyurethane implants.

CONCLUSIONS

Implants that promote tissue ingrowth may be more prone to puncture with the cannula during fat grafting. Specific planning and surgical maneuvers decrease the risk of implant puncture.

LEVEL OF EVIDENCE

Level V, case report.

Hybrid Breast Augmentation: A Reliable Formula for Preoperative Assessment of Fat Graft Volume Based on Implant Volume and Projection

BACKGROUND

Autogenous fat grafting (AFG) is an established technique used as an adjunct to breast augmentation (BA) to redesign breast shape. Surgeons often use experience and intuition to estimate AFG volume, which can result in incorrect assessment of donor areas and unnecessary fat removal.

OBJECTIVES

This aim of this study was to develop a method based on a mathematical formula, which utilizes implant volume and projection to predict AFG volume.

METHODS

Thirty patients (60 breasts) underwent primary hybrid BA. A software package (SketchUp) was used to simulate 3-dimensional AFG and implant volumes, which in turn were used to develop an equation for estimating AFG volume according to 3 different implant projections. The results for each group were compared, via Pearson's correlation coefficient, with the results of the clinical series.

RESULTS

All patients received Motiva Ergonomix SmoothSilk/SilkSurface implants, ranging in volume from 175 to 355 cc (mean, 265 cc), as well as an average AFG volume of 79.2 cc/breast (range, 50-110 cc). Twenty-nine patients (96.6%) were either very satisfied or satisfied during a mean follow-up of 18 months (range, 6-28 months). A high correlation was observed between the AFG performed in the cohort and predictions obtained from the formula (r = 0.938, P < 0.001).

CONCLUSIONS

The AFG volume in hybrid BA procedures can be estimated utilizing measurements based on implant volume/projection. This low-cost method can be applied to guide surgical decision-making in patients who are candidates for BA.

LEVEL OF EVIDENCE: 4

Fat Grafting and Breast Augmentation: A Systematic Review of Primary Composite Augmentation

Fat grafting during primary breast augmentation has the ability to address the limitations of soft tissue coverage of breast implants. The purpose of this study was to evaluate the current evidence on patient selection, surgical techniques, and assessment of outcomes with composite breast augmentation.

Patient-Reported Outcomes of Aesthetics and Satisfaction in Immediate Breast Reconstruction After Nipple-Sparing Mastectomy With Implants and Fat Grafting

Background

Direct-to-implant (DTI) and tissue expander/implant (TE/I) reconstructions are the most common implant-based reconstructions after nipple-sparing mastectomy (NSM). However, there are little data beyond complication rates comparing these options. Fat grafting has emerged as an adjunct in NSM reconstructions to improve aesthetic results; however, its impact on patient perceptions of aesthetic outcomes remain unknown. To improve patient-centered care, aesthetic outcomes must be considered from the patients' perspective.

Objectives

To evaluate patient-reported outcomes of aesthetic satisfaction and quality of life in patients undergoing immediate DTI vs TE/I reconstruction after NSM and to assess the role of fat grafting on these outcomes.

Methods

This is a prospective cohort study comparing NSM patients undergoing DTI or TE/I reconstruction. Patient-reported outcomes were evaluated using the BREAST-Q. Continuous and categorical variables were analyzed using t test and Fisher's exact test, respectively.

Results

Fifty-nine patients underwent 113 reconstructions with either DTI (n = 41) or TE/I (n = 18). Mean follow up was 12.1 months. DTI and TE/I patients had comparable satisfaction with outcome, though TE/I patients had significantly larger final implant sizes. TE/I who underwent fat grafting also had significantly higher satisfaction with outcome and psychosocial wellbeing.

Conclusions

Patient-reported outcomes are comparable between DTI and TE/I reconstructions after NSM. In order for TE/I patients to achieve a similar level of satisfaction, they may require a larger final implant and additional operations compared to DTI patients. Additionally, fat grafting improves overall satisfaction. TE/I patients may have different aesthetic expectations than DTI patients, emphasizing patient-centered discussions are essential to optimizing outcomes after NSM.

Level of Evidence

3.

Composite breast reconstruction: Implant-based breast reconstruction with adjunctive lipofilling

INTRODUCTION

Options for breast reconstructions enclose autologous tissue transfers or implants. Fat grafting is gaining more interest in this specific field of breast surgery. This study concentrates on the technique and aesthetic results of breast reconstruction with fat grafts combined with implants, in women who have undergone total mastectomy.

METHODS

Breast reconstructions (n = 23) was performed using a protocol of intratissular expansion with serial deflation-lipofilling. In order to achieve the best aesthetic outcome, an additional small implant was placed. A retrospective data analysis was performed. In all patients a tissue expander was placed at the time of mastectomy or after removal of a previous breast reconstruction. The mean of lipoaspirate material for the reconstruction was 333 mL (range 120-715 mL). To create an adequate volume of the reconstructed breast, a supplementary small implant was placed, with a mean volume of 222 mL (range 125-375 mL). The mean follow-up was 33 months (range 19-50 months).

RESULTS

A MRI analysis was performed in eight patients at least 9 months after the last lipofilling procedure, demonstrating a mean of 171 mL (range 64-538 mL) of transferred fat, a mean fat survival of 53% and a volume ratio of fat graft/implant of 0.97 (range 0,3-3,8).

CONCLUSION

This composite technique of using autologous fat tissue and implants shows aesthetic pleasant results and must be considered as a valid alternative in a subset of patients. Further investigations to optimize the fat graft take must be encouraged.