The role of autologous fat grafting in secondary microsurgical breast reconstruction

Autologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use.

A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison.

Two hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22-564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07-1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight.

Fat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.