The concept of transplanting autologous fat to the breasts is not new. In 1895 Czerny published a paper describing the successful transfer of a fist-sized lipoma from the buttock to the breast of a patient who had undergone glandular excision for mastitis (1). In 1910 Hollander was the first to describe fat injections to the breast for correction of mastectomy defects (2). Numerous publications followed as the idea of fat grafting for the correction of both cosmetic and functional problems developed. Many of the early attempts at fat grafting, however, were not successful, primarily due to the tendency of the fatty tissue to resorb, making the results unpredictable (3,4,5,6,7). Thus, fat grafting fell out of favor for many years. With the advent of liposuction by Fournier (8) and Illouz (9) in the 1980s there was renewed interest in the use of autologous fat for reinjection. Chajchir and Benzaquen (10) reported their experience of transplanting fat over a 4-year period and noted 86% favorable results, while Ersek reported disappointing results in a 3-year follow-up (11). Thus, fat grafting in general was still thought to be unpredictable.

In 1985, Mel Bircoll presented the first modern-day paper on breast augmentation using fat grafting at the California Society of Plastic Surgeons (12). This paper, as well as another paper describing fat grafting after transverse rectus abdominis musculocutaneous flap reconstruction (13), led to a position paper by the Ad-Hoc Committee on New Procedures of the American Society of Plastic Surgeons (ASPS) “deploring the use of autologous fat injection in breast augmentation.” The committee made no reference to any scientific findings, but it was their opinion only that the scarring and calcifications that would develop would make mammography difficult and that breast disease might go undetected. Coincidentally, in the same issue of Plastic and Reconstructive Surgery, an article by Brown was published reporting calcifications in 50% of mammograms performed 2 years after breast reduction surgery (14). There was no suggestion that breast reduction surgery was “deplorable” despite mammographic findings similar to those after fat grafting. Nonetheless, fat grafting to the breast again fell out of favor and was not performed, or at least not discussed, at any plastic surgery meetings.

In the 1990s, after several years of refining the technique, Coleman published his first of many papers using the successful, reproducible technique of lipostructure (15,16). Encouraged by positive results with fat grafting to the face, hands, and body, Coleman began to experiment with fat grafting to the breasts. From 1995 to 2000, he performed breast fat grafting to 17 patients. Some of these patients were primary augmentations, while others were patients with tuberous breasts, visible implants, or tissue defects secondary to breast cancer. These results in 2007 showed a lasting volume correction and soft, natural breasts. Postoperative mammography revealed a few oil cysts and a few calcifications, which were changes typically seen after any breast procedure (17). There was no interference with breast cancer detection, and 1 patient was diagnosed with a breast cancer in an area other than that which was grafted. As more plastic surgeons around the world have begun to successfully perform breast fat grafting procedures and have published their work, the ASPS and the American Society for Aesthetic Plastic Surgery have reversed their earlier moratorium. They now state that “Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries; however, results are dependent on technique and surgeon expertise” (18, p.10). Thus, fat grafting has returned to the surgeon’s armamentarium for both breast augmentation and for the correction of a multitude of breast problems.

Fat grafting may be performed to correct or improve a wide variety of breast problems. These problems may be small, such as residual defects after flap reconstruction or lumpectomy defects, or large, such as the creation of an entire breast after mastectomy or implant removal. Other uses include disguising breast implants in thin patients or in patients with visible capsular contractures, correction of tuberous breasts, correction of Poland syndrome, creation of breast cleavage, correction of pectus excavatum, and covering of a bony sternum. Because the fat can be placed in the exact areas where the deficiency exists, the uses are endless. Specific shaping of the breast or chest can be accomplished with fat, whereas an implant is not as versatile.

The primary limitation of fat grafting to the breast is associated with the availability of donor sites and the volume that can be obtained. In patients with a paucity of excess fat, fat grafting may not be an option. The volume of fat that needs to be grafted to make a significant change is considerably more than one would expect based on experience with breast implant volumes. Because the fat is integrated into the tissues and not placed behind the gland or muscle in one unit as with implants, the change is not as dramatic. In general, the addition of approximately 300 cc of fat per breast will result in an increase of approximately one cup size. The addition of much more than that during one procedure is not usually possible due to tissue compliance and the potential of fat necrosis due to a lack of blood supply. Additional volume may be added during subsequent procedures if the patient still has available donor sites. To be appropriate candidates, patients must have realistic expectations for a modest change in size. A change in cup size from an A to a C, for example, is not realistic in one procedure. If that is the patient’s desire, then silicone or saline implants should be considered. It is unlikely that fat grafting to the breast will ever replace the need for implants in patients who desire significant volume changes or in patients with a very low body mass index (19,20).

The design for the surgery is different for each patient, depending on the goal to be achieved. Preoperative photos are taken of each patient with hands at the sides, with hands on the hips, and with hands placed on top of the head. In addition, photos are often taken in those positions with the patient also bending 45 deg at the waist and with the patient standing and the photographer sitting. Having patients with implants squeeze the implants with their hands demonstrates the degree of capsular contracture, and squeezing the implants with their pectoralis muscles often demonstrates defects that cannot otherwise be appreciated. This gives an excellent opportunity to really study the breasts and to identify subtle asymmetries. From those photos, a tracing is done, and the procedure is mapped out specifically for that patient. We use a color-coded system to indicate where fat will be placed (green for significant volume changes and yellow for feathering), where fat will not be placed/borders of fat placement (orange), where the incisions will be made (red), and where the fat will be harvested (purple). The plan is made in consultation with the patient so that she will have a thorough understanding of where fat will be added and where it will be removed (19,20).