Autologous fat tissue transfer

([9–11] 
and by others) as a routine method for two-stage 
interventions or partial reconstruction. In the 
meantime, it could be shown that even a complete 
breast reconstruction is feasible even after a total 
mastectomy and can be used as an alternative to 
open flap plastic surgery in clinical applications.
• An S2A guideline has been issued  on the 
subject of lipofilling under leadership 
of  the German Societiy  of  Plastic and 
Reconstructive Surgery. 
We would like to refer to our experience in the 
complete reconstruction using water-jet assisted 
liposuction (WAL) and the BEAULI protocol.
10.7.2 Personal Approach
The preconditions for the reconstruction are as 
follows:
a b
c d
Fig. 10.17 (a, b) Preoperative, (c, d) 1 year after breast lift with a simultaneous autologous fat tissue transplantation 
of 200 mL per side
10 Fat grafting to the Breast
100
 – Concluded treatment including 6  months of 
concluded postoperative treatment (irradia-
tion/chemotherapy).
 – A detailed explanation of all other available 
alternative processes, especially microvascu-
lar pedicled flap plastic surgery. Our female 
patients, who were treated, were suitably 
informed in advance, and they indicated that 
they reject any other method of reconstruction 
for themselves.
 – The existence of sufficient fat deposits for a 
series of four to eight suctions with autolo-
gous fat tissue transplantation.
All the concerned patients must be aware 
of the fact that the treatment can thus last for 
more than 2  years or even longer. Parallel to 
fat tissue transplantation, an appropriate reduc-
tion plastic surgery on the opposite side, an 
ipsilateral abdominal advancement flap, and 
a buildup of the nipple-areola complex can be 
performed.
• In any case, it is recommended to take a 
look into the results of histology, because in 
some cases only small safety distances exist 
during the tumor resection and thus natu-
rally an enhanced risk of relapse exists.
It is also important to point out that as per the 
latest information that exists today, there is no 
predictable enhanced risk of a relapse caused by 
autologous fat tissue transplantation. Neverthe-
less an individual risk of relapse always exists 
independent of the therapy.
Due to the somewhat varying procedures, we 
would like to describe the process involved after 
breast  ablation as well as after the previously 
undergone irradiation in different chapters.
10.7.3 After Ablation
If there is only a very thin layer of  soft tissue 
available or even a missing of the M. pectoralis, 
a very less amount of fat can be grafted, respec-
tively, in the first few steps (50–100 mL). Since 
the subcutaneous fat tissue grows with every step, 
a somewhat increased volume can be introduced 
with every intervention. After those steps a skin 
expander can be implanted (10.7.3.1)
If an expander  is already in place, then this is 
released, respectively, for each step in order to 
lower the tension with the ongoing fat injection. Ini-
tially one should distribute about 50–100 mL subcu-
taneously, until a clear tension of the skin is achieved. 
Then one can again reduce this strong stress through 
a relief of the expander by about 50–100 mL vol-
ume. The great advantage of the expander for the 
patient lies in the fact that a noteworthy breast vol-
ume is gained and one does not need to wear an 
epithesis which should be avoided postoperatively 
in order to reduce the negative impact of additional 
pressure. In case of silocone implants the exchange 
for an expander is recommended.
10.7.3.1 Subcutaneous Expander 
Once a sufficiently thick subcutaneous fat layer 
has been achieved (above 1 cm), in the next step, 
one has the opportunity of applying an expander. 
We utilize simple, round expanders with an 
 external valve (!), in order to facilitate a future 
removal through the smallest possible incision. In 
case there is a small breast on the other side, then 
the expander alone is sufficient. If a bigger breast 
has to be reconstructed, then simultaneously 
abdominal advancemet flap can be undertaken.
• In any case, one has to give preference to 
placing the expander subcutaneously. A 
muscle position would later always result in 
unfavorable movements of the breast dur-
ing muscular tension.
10.7.3.2 Abdominal Advancement 
with Expander Insertion
In order to harvest extra skin or subcutaneous fat 
tissue for the buildup of the breast, the stomach 
skin can be shifted up to a limit of 5 cm on the 
affected side. We proceed as follows.
The position of the sub-mammary fold is 
marked while the patient is standing, on the 
healthy side, and the lower expansion is clearly 
indicated on the sternum, in order to get a mark-
ing for the necessary lifting up at a later stage. 
On the ablation side, the new sub-mammary 
fold newly planned is marked out about  5  cm 
more caudally than on the healthy side.
K. Ueberreiter et al.
101
The ablation scar is excised (don’t forget 
the histology!). A subcutaneous, epimuscu-
lar preparation  is carried out up to the level of 
this planned newly formed fold. Then the mus-
cle  fascia is  separated through the entire length 
of the future sub-mammary fold, and from here, 
a further 5 cm is prepared towards caudal - dorsal 
below the fascia (in the muscular area). Then the 
fascias are again separated at this level in order to 
prepare a fascial patch adherent to the subcuta-
neous tissue. The preparation is carried out from 
here further ventral (epifascial) between the fas-
cia and the subcutaneous fat tissue.
A mostly blunt detachment must be carried out 
up to far caudally (level of the navel). In doing so, 
a careful hemostasis must be carried out especially 
of the perforators. Support through light retractors 
or endoscopes is highly recommended.
The insertion of a Redon drainage into the 
wound hollow is also recommended. It is possible 
to carry out even a double suture row for attach-
ment to the muscle fascia lying beneath it through 
the approximately 5 cm wide fascia layer. Thus one 
has reached a very reliable and permanent forma-
tion of the new sub-mammary fold (Fig. 10.18).
The fatty tissue under the newly created sub-
mammary fold can later be thinned out and mod-
eled by suctioning. 
A further advantage in raising that advancemet 
flap lies in the fact that one can now generally and 
very easily introduce a tissue expander of about 
300 mL (up to 500 mL) (Fig. 10.19). The valve 
should best be placed laterally on a rib, in order 
to guarantee a simple puncture at a later stage. 
We always use the smallest valve.
The further procedure has been described 
above (see Sect. 10.1.1).
The evaluation of patient data as part of a pan- 
European multicenter study [12] after conclusion of 
treatment and at least 6 months (average 2.6 years) 
of time having passed has yielded the following 
result: at an average, four to six fat tissue transplan-
tations with, respectively, 159 mL (±61 mL) over 
a period of 21 months (9 months up to a max. of 
2.5 years), in order to achieve an end volume of 
1020 mL (±515 mL) for a complete breast buildup. 
In this study, the patients exhibited a significant 
higher intervention rate and volume demand after 
adjuvant radiation therapy (p < 0.041).
The following were seen as postoperative 
complications:
 – Local infection (0.74%)
 – Granuloma (0.74%)
 – Fat necrosis (2.59%)
All of these complications did not exhibit 
any clinical relevance. A high degree of patient 
satisfaction could be registered (95.42%) with 
Marking of the sub mammary fold
5 cm
New sub mammary fold
Strips of fascia
a
b
Ablation scar
Preparation
M. rectus
abdominis
Marking of the new
sub mammary fold
Fascia
Direction of the navel
Fig. 10.18 (a, b) Tummy tuck (a) from the front (b) lat-
eral (schematic diagram) (prepared as per a drawing by 
K. Ueberreiter)
10 Fat grafting to the Breast
102
good to very good aesthetic results (67.68%) 
(Fig. 10.20).
10.7.3.3 Significance