Key points

Introduction

Breast augmentation is a well-known procedure and continues to be one of the most frequently performed esthetic surgeries worldwide. The development of modern silicone implants as well as new surgical techniques has led to widespread acceptance of breast augmentation in recent years.

Although breast augmentation has a high rate of patient satisfaction, some patients may present unsatisfactory results and will require surgical revision. In the authors’ experience, many of these reoperations are required for soft tissue–related problems, such as implant visibility and rippling, and not necessary for implant failure. In fact, although providing satisfactory postoperative recovery, subglandular implant placement may sometimes result in visibility of the implant edge and limited soft tissue coverage. With the introduction of subpectoral implant placement, reduced implant visibility and a lower incidence of capsular contracture were observed in some series. However, undesirable superior displacement of the implant and implant animation are frequently observed in some groups of patients.

Recently, a new implant position uses the subfascial plane, which is gaining popularity because of the more satisfactory postoperative recovery it yields compared with submuscular techniques. It has been the authors’ experience, as with other investigators, that a satisfactory outcome and good results following subfascial breast augmentation can be achieved in selected patients.

As observed with the subfascial approach, there has been a resurgence in the use of autologous fat grafting for breast surgery for a variety of indications over the past 10 years. In fact, autologous fat grafting has been performed more frequently since 2008, when new clinical recommendations were released. Based on various clinical studies, the American Society of Plastic Surgeons (ASPS) concluded that fat grafting may be considered for treatment of breast defects associated with oncological diseases and esthetic deformities. Although refinement in fat-grafting procedures has improved reproducibility, it has been the authors’ impression that a standardized technique remains to be described.

Given that form-stable breast implants and the subfascial technique are effective and predictable procedures for esthetic breast surgery, a variety of poor outcomes in breast augmentation may result from the limited ability of the overlying soft tissue to adequately cover the silicone implant. Consequently, the relevance of autologous fat grafting as an associated technique to improve the results of breast augmentation may be investigated. In addition, it is reasonable to emphasize that if autologous fat grafting and implant-based breast augmentation are equally reproducible, and involve similar risk and surgical time, it is possible to combine both techniques in one surgical procedure.

The objective of this article is to provide an overview of the subfascial approach to primary and secondary breast augmentation with form-stable implants associated with autologous fat grafting. Although breast augmentation is a well-studied procedure, previous reports concerning the subfascial technique are limited, especially related to the most recent generations of form-stable breast implants. In addition, there are few detailed clinical reports that specifically address the operative planning, outcomes, and complications following simultaneous autologous fat grafting. Therefore, in this article a detailed description of the authors’ method, including the preoperative evaluation and intraoperative care is provided, for patients undergoing primary and secondary breast augmentation associated with lipofilling. The surgical technique, advantages, and limitations are also discussed. When combined with clinical expertise, this evidence will help the plastic surgeon provide patients with predictable and safer esthetic outcomes.

Introduction

Breast augmentation is a well-known procedure and continues to be one of the most frequently performed esthetic surgeries worldwide. The development of modern silicone implants as well as new surgical techniques has led to widespread acceptance of breast augmentation in recent years.

Although breast augmentation has a high rate of patient satisfaction, some patients may present unsatisfactory results and will require surgical revision. In the authors’ experience, many of these reoperations are required for soft tissue–related problems, such as implant visibility and rippling, and not necessary for implant failure. In fact, although providing satisfactory postoperative recovery, subglandular implant placement may sometimes result in visibility of the implant edge and limited soft tissue coverage. With the introduction of subpectoral implant placement, reduced implant visibility and a lower incidence of capsular contracture were observed in some series. However, undesirable superior displacement of the implant and implant animation are frequently observed in some groups of patients.

Recently, a new implant position uses the subfascial plane, which is gaining popularity because of the more satisfactory postoperative recovery it yields compared with submuscular techniques. It has been the authors’ experience, as with other investigators, that a satisfactory outcome and good results following subfascial breast augmentation can be achieved in selected patients.

As observed with the subfascial approach, there has been a resurgence in the use of autologous fat grafting for breast surgery for a variety of indications over the past 10 years. In fact, autologous fat grafting has been performed more frequently since 2008, when new clinical recommendations were released. Based on various clinical studies, the American Society of Plastic Surgeons (ASPS) concluded that fat grafting may be considered for treatment of breast defects associated with oncological diseases and esthetic deformities. Although refinement in fat-grafting procedures has improved reproducibility, it has been the authors’ impression that a standardized technique remains to be described.

Given that form-stable breast implants and the subfascial technique are effective and predictable procedures for esthetic breast surgery, a variety of poor outcomes in breast augmentation may result from the limited ability of the overlying soft tissue to adequately cover the silicone implant. Consequently, the relevance of autologous fat grafting as an associated technique to improve the results of breast augmentation may be investigated. In addition, it is reasonable to emphasize that if autologous fat grafting and implant-based breast augmentation are equally reproducible, and involve similar risk and surgical time, it is possible to combine both techniques in one surgical procedure.

The objective of this article is to provide an overview of the subfascial approach to primary and secondary breast augmentation with form-stable implants associated with autologous fat grafting. Although breast augmentation is a well-studied procedure, previous reports concerning the subfascial technique are limited, especially related to the most recent generations of form-stable breast implants. In addition, there are few detailed clinical reports that specifically address the operative planning, outcomes, and complications following simultaneous autologous fat grafting. Therefore, in this article a detailed description of the authors’ method, including the preoperative evaluation and intraoperative care is provided, for patients undergoing primary and secondary breast augmentation associated with lipofilling. The surgical technique, advantages, and limitations are also discussed. When combined with clinical expertise, this evidence will help the plastic surgeon provide patients with predictable and safer esthetic outcomes.

The subfascial approach

Introduced in the 1990s, the subfascial approach is especially interesting for surgeons who have been seeking alternative planes with less morbidity. In fact, placing the silicone implant next to the glandular tissue may result in a disappointing outcome in terms of. A visible implant edge is especially apparent in underweight patients with severe hypomastia and less soft tissue coverage, where a transition can be seen at the borders of the silicone implant. From an anatomic point of view, the pectoral fascia is a distinct, identifiable layer and is suitably strong, as is apparent during intraoperative manipulation ( Fig. 1 A, B). Although the fascia may be thin in the lower pole, it is not thin in the upper sector corresponding to the underlying muscles such as pectoralis muscle. According to Ventura and Marcello, this anatomic aspect is helpful for creating a foundation to support the implant at the lower edge, preventing inferior displacement and palpation of the implant border. In a study of 1000 cases of subfascial breast augmentations, Tijerina and colleagues observed that the upper displacement of the implant can be limited because the pectoral fascia force the implant downward. In the upper thorax, the pectoral fascia is useful in minimizing the visibility of the edges of the implant and provides coverage over an anatomic implant ( Box 1 ).

( A, B ) Breast and pectoral fascia anatomy following subfascial form-stable breast augmentation. The anterior wall of the implant pocket consists of pectoral fascia, breast parenchyma, subcutaneous tissue, and skin. The stronger support system that results from placing the implant under the fascia tends to keep the implant’s upper third from altering its shape and position ( A ). Breast and pectoral fascia anatomy following subfascial form-stable breast augmentation associated with autologous fat grafting ( B ).

Despite the controversy concerning the suboptimal soft tissue coverage provided by the subfascial approach and the limitation involved with the thickness of the pectoral fascia, some studies have demonstrated a satisfactory outcome in selected patients. In the authors’ previous clinical long-term study using the subfascial approach, they emphasized the importance of the pocket plane in the dynamics between the implant and the soft tissues. In fact, it has been their impression that besides the positive aspects of the supplementary soft tissue coverage, the subfascial approach provides more rapid postoperative recovery than the total submuscular pocket and avoids breast animation when the pectoral muscle is contracted ( Fig. 2 ).

( A–F ) (Case 1) Preoperative frontal view, left oblique view, and left view of a 27-year-old patient with hypoplastic breasts ( A, C, E ). Postoperative (2 years) frontal view, left oblique view, and left view following bilateral implant with Allergan Style 510 MX (290 g), showing a very good outcome ( B , D , F ).

Form-stable implants

Silicone breast implant technology has advanced over the last 3 decades with the introduction of new textures and high-cohesive anatomic implants. These implants resemble the natural shape of the breast, granting them wide acceptance by both patients and surgeons.

In the authors’ clinical experience, form-stable implants are available with 3 different types of gels: soft cohesive (MemoryShape, Contour Profile Gel-CPG; Mentor Corporation, Santa Barbara, CA, USA), highly cohesive (Style 410; Allergan, Inc, Irvine, CA, USA), and dual-gel soft touch (Style 510; Allergan, Inc). The Style 410 implant and the Contour Profile Gel CPG implant have been available in Brazil since the 1990s and 2000, respectively, to women seeking breast augmentation and reconstruction. The Style 410 implant is a form-stable, highly cohesive, silicone gel-filled breast implant designed with a low-diffusion silicone elastomer shell (Intrasheil barrier technology). These implants also use a Biocell surface texture available in various sizes in Europe and Brazil since 1994, in Canada since 2006, and in the United States since 2012. Biocell texturing on the implant shell promotes tissue adherence to reduce implant rotation and capsular contracture. Both Style 410 and 510 implants are available in a wide range of shapes to permit the selection of an implant appropriate to each patient’s anatomy. The CPG MemoryShape is a textured contoured implant filled with cohesive silicone gel, intended for use in esthetic and reconstructive breast surgery and available in a wide range of shapes. The differences between the CPG implant and 410 are slightly increased crosslinking of the gel, and more textured outer surface.

In the authors’ clinical experience, they have observed a significant benefit in placing the Style 410 implant in the subfascial pocket. Recently, they have been using this same position with the Style 510 implant with satisfactory outcomes. In fact, the newest dual-gel Style 510 implants have a concave posterior that conforms and adheres better to the chest wall, and the edging of the Style 510 implant makes this device easier to control during insertion ( Box 2 ). In addition, this biodimensional, anatomically shaped implant preserves the teardrop configuration, maintaining projection and, consequently, breast shape. In fact, Nipshagen and colleagues, using a 3-dimensional MRI for in vitro and in vivo shape evaluation of subpectoral round and shaped silicone gel-filled implants, observed that Style 510 implants preserved projection, probably because of the high-density silicone core.

Another important aspect is related to satisfactory outcomes in terms of implant visibility and wrinkling. In a study of 163 patients, Hedén and colleagues demonstrated a high satisfaction rate with the Style 410 shaped, form-stable gel implant and a low rate of wrinkling. Similarly, Lista and colleagues, in a sample of 440 patients who underwent primary subglandular breast augmentation with the Style 410 implant, concluded that this property helped decrease wrinkling and rippling, which was observed in only one patient (0.2%).

Despite the advantages of these form-stable implants, the use of highly cohesive, textured, anatomically shaped implants has its drawbacks ( Box 3 ). Schots and colleagues, in a sample of 73 cases of augmentation mammaplasty using the Style 510 implants, observed unilateral malrotation in 8.2% of patients after a mean period of 10 months; 7 patients underwent reoperation. Lista and colleagues, in a retrospective review, observed a 16.6% rate of complications, with 10.7% of patients requiring reoperation. The most common complication was malrotation (5.2% of patients), and this was predominantly managed nonoperatively.

In order to avoid this complication and to ensure implant stability, it is crucial to evaluate the exact dimensions of the implant’s height and width, which helps to create an adequate pocket and avoid implant rotation ( Box 4 ). If an implant has insufficient volume compared with the dimension of the available pocket, rotation will occur more frequently. If necessary, the skin may be adjusted with vertical or periareolar resections in order to achieve an appropriate match between the implant and pocket volume. It has been the authors’ impression that the Style 410 or 510 implant can achieve excellent results without the customary submuscular placement often used with older-style round implants.

Autologous fat grafting

Autologous fat grafting is extensively used in reconstructive and esthetic surgery to repair volume and contour defects with technical variations on fat harvesting, preparation, and reinjection. According to the International Society of Aesthetic Plastic Surgery in 2009, fat grafting represented almost 6% of the nonsurgical procedures within the realm of esthetic surgery, with more than 514,000 procedures performed worldwide.

Over the past 10 years, there has been a reintroduction in the use of autologous fat grafting for breast surgery. In fact, there are numerous clinical studies that corroborate esthetic outcome and patient satisfaction. First introduced by Bircoll in the 1980s for esthetic breast surgery, autologous fat grafting had the major advantage of autologous tissue transplantation in terms of natural and long-term results, even when secondary and tertiary surgical sessions were necessary. However, at that time, the American Society of Plastic and Reconstructive Surgery (ASPRS) Ad Hoc Committee on New Procedures concluded that the potential scarring and calcifications could interfere with diagnosis of breast cancer. According to the available data, the ASPRS committee demonstrated that fat grafting could result in the formation of nodule formation and calcifications, potentially affecting breast cancer screening.

In 2008, the ASPS established a new committee, the Fat Grafting Task Force, which concluded that fat grafting may be considered for breast augmentation and correction of defects associated with oncological conditions. In their report, the Task Force emphasized that no evidence was found in the previous studies that suggested interference with early diagnosis of breast cancer. Therefore, fat grafting can be considered a surgical tool for breast shaping because of its relative ease of use and low morbidity.

Although various surgical procedures have been described for improving survival of fat grafts, including washing, centrifugation, decantation, and not washing, there is still controversy about their esthetic outcome, complications, and long-term results.

Coleman and Saboeiro introduced the structural fat grafting technique and emphasized the importance of removing nonviable aspirate components, such as oil and blood cells by centrifugation. Following the initial description, Coleman’s technique has been popularized; it also emphasizes an atraumatic method of fat harvesting, centrifugation, and, especially, a small amount of fat injection in order to provide maximal contact between fat and the recipient tissue. This technique has gained clinical application and has become crucial to many procedures described in numerous further studies. In fact, it has been the authors’ experience that grafted fat that is too large for injection may present central necrosis due to a lack of adequate blood perfusion and secondary neoangiogenesis. Thus, minimizing the amount of fat grafted during injection will maximize the surface area of contact between the fat and recipient tissue.

Contrary to the centrifugation principles, Khater and colleagues concluded in a clinical and experimental study that in noncentrifuged adipose tissue, more active preadipocytes were maintained, which could possibly lead to enhanced survival of injected fat. Similarly, Rohrich and colleagues performed a quantitative analysis of the role of centrifugation and harvest site and found that the fat survival rate after centrifugation was no better than after filtration. Ramon and colleagues compared fat prepared either via centrifugation or via cotton towel drying in a mouse model and observed no differences in fat weight or volume.

Recently, some investigators have described a satisfactory outcome for grafting fat to the breast in order to improve contour deformities. Spear and colleagues observed satisfactory outcomes after fat injections to the breast in 37 patients, recommending autologous fat grafting in and around reconstructed breasts as a safe procedure. However, the effectiveness of fat grafting associated with silicone breast augmentation has not been determined and justified by a significant clinical series in the literature.

Zheng and colleagues studied 66 patients who underwent autologous fat grafting for breast augmentation, following them for up to 5 years. In this series, overall esthetic improvement was observed in about 80% of patients, as evaluated by independent plastic surgeons or judged by patients themselves. Auclair and colleagues, in a series of 197 patients treated over a 3-year period, described a new concept for composite breast augmentation surgery that combines silicone breast implants with natural overlying fat grafting. According to the investigators, the technique was indicated when the overlying soft tissue was insufficient to adequately cover the underlying silicone, in both breast implant revision and primary breast augmentation. Through quantitative 3-dimensional imaging of the grafted fat in the subcutaneous space, the investigators concluded that breast augmentation with simultaneous implants and fat represents a versatile approach and achieves a synergistic outcome. In this sample, 57% of the injected graft volume persisted at 1 year, and cysts, masses, and fat necrosis were not observed.

Despite the benefits and satisfactory results described, there is a lack of controlled, prospective clinical studies evaluating the technical aspects related to autogenous fat grafting such as fat harvesting and processing methods, injection techniques, as well as donor site areas and outcomes of fat intake. In fact, harvested fat contains different types of cells, including mature fat cells, fibroblasts, adipose-derived stem cells, and endothelial cells, and the percentages of these cell populations may differ between patients. Similarly, there is no consensus concerning the viability of cell types between the various fat harvesting and preparation techniques. These limitations were clearly observed in the earlier systematic reviews described above.

From the authors’ point of view, and despite the good results observed in their sample, the long-term complications of fat grafting for esthetic breast surgery have still not been reported and determined in a large series. Existing data concerning fat grafting for esthetic breast surgery are restricted to case series and retrospective reviews. Some studies demonstrate that fat grafting may result in varying degrees of nodule formation and calcifications, which could potentially interfere with breast cancer screening. Nonetheless, recent clinical studies have demonstrated that fat-grafting results have improved, with a decreased incidence of local complications and less fat necrosis after autologous fat transplantation.