Women who decide to have a mastectomy, whether for risk reduction or treatment of breast cancer, have the option of reconstruction to maintain the shape and weight of a breast. If they decide to have the breast rebuilt, then again they have options: implant reconstruction or autologous tissue reconstruction. Autologous reconstruction uses tissue — skin, fat, and sometimes muscle — from another place on your body to form a new breast. The tissue, called a “flap,” usually comes from the belly, the back, buttocks, or inner thighs.
The choice for breast reconstruction is a personal decision between you and your doctor. If implant reconstruction is chosen, this can be done as one procedure or as a two-stage procedure. If it is done as one procedure, this is called direct to implant (DTI). If it is done as two surgeries, in the first stage, a tissue expander is placed to stretch the tissues and make room for the implant. During the second stage, the tissue expander is replaced by an implant. The expander, and the final implant, can be placed under or on top of the chest wall muscle. In breast reconstruction, silicone implants are usually chosen, as they have a more natural look, weight and feel in an intimate setting. Saline and air implants are also commonly used.
However, even with the most natural implants, especially in thin patients, there may be rippling of the implants or, very commonly, thinning of tissue at the upper part of the chest wall. This deformity can be very obvious and distressing to patients. In these cases, lipofilling, also called fat grafting or autologous fat transfer, can be done.
For fat grafting, suction assisted lipectomy (or liposuction) is done at the beginning of the procedure. The most common, and best, sources of this fat are the flanks and upper abdomen. There are many ways to then process the fat so that the fat which is then used to add volume to the breast has the highest chance of being viable. Your surgeon can share with you the type of process which she or he uses. The fat is injected through tiny incisions to the areas of the breast that need to be filled. Please keep in mind that if you have had multiple belly or abdominal surgeries, you may not be a candidate for this procedure. Also, since fat is taken from the abdomen, if there is a reason that you may need flap reconstruction in the future, the tissue from the abdomen cannot be used. If there is volume loss, or if there is a large volume deficit from the onset, you may need more than one surgical session to fill the area.
Another thing to keep in mind is that some of the fat injected in the breast may be reabsorbed by the body over time. This may mean that there is some volume loss over time, which may result in the breast feeling lumpy. These areas of “lumps” or fat necrosis occur if there is a clump of fat which has little blood flow and dies off. Lumps may also form due to uneven depositing of the fat. This is not problematic, but these lumps may cause concern and anxiety and will need to be evaluated by your doctor.
Fat grafting can also be done for women who have had radiation as part of their breast cancer treatment and have a resultant volume deficit or deformity of the breast. It appears that fat grafting for this purpose does make the breast softer, and radiation effects are not as obvious. By injecting the fat, the skin becomes softer. Fat grafting can also correct the defects.
Fat grafting after a partial mastectomy or lumpectomy may also produce some discrepancies on future mammograms, which may mean that you have to have “second look” imaging, or even a biopsy to determine the nature of the lumps.
Patients must understand that a breast reconstructed entirely with an implant or with their own tissue will create the look and weight of a natural breast. However, the sensation to the skin and nipple will be lost. This is because the nerves that provide sensation to touch must be sacrificed during the surgery, and they do not grow back. Some women have reported that their fat-graft-reconstructed breast has some sensation and feels soft–much like the other unreconstructed breast.