PURPOSE: With concerns about the high rate of breast implant complications, surgeons and patients increasingly seek alternative options. A general belief that fat transfer provides less volume than many patients may need for augmentation led us to expand previously published concepts1,2 into a multiplanar anatomic approach to consistently permit transfer of larger volumes. Avoiding breast parenchyma itself, there are 6 distinct anatomic planes in the breast. We proposed that by grafting each of these separately, greater volumes could be added without overwhelming the capacity for neovascularization. Also, by modulating volumes placed in each plane, specific shapes, better symmetry, and increased central projection might be achieved.
METHODS: Preoperatively, patients are marked when vertical, creating contour maps outlining each anatomic plane to be grafted. Augmentation planes and graft harvest sites were infiltrated with nondistorting volumes of 1:500,000 epinephrine; 30 minutes were awaited for vasoconstriction. Gold-plated, multiholed 2.4- and 3.0-mm cannulas (1 mm orifices) facilitated harvest of particulate fat. Preferential harvest of accessory breast mounds would improve peripheral contours of the breasts and decrease chest circumference. Harvest syringes were heparinized to prevent fibrin formation and potentiate growth factors.3 All harvested fat was commingled, creating a confluent “mosaic graft” mass with consistent physiologic properties. Cannulas (1.5 mm; 1 mm holes) on 10-ml syringes were used to graft each anatomic plane using 2-mm incisions and cross-tunneling. Cannulas were kept tangential to the chest wall to avoid intrathoracic penetration. Volumes were transferred to create desired shape and size. Compression wear was used for harvest sites, but not on breasts themselves. The 6 anatomic planes are listed below, with expected enhancements and potential transfer volumes noted:
- Subpectoral/preperiosteal (projection of entire breast mound), 50 ml
- Intrapectoral (central and superior fill), 30 ml
- Prepectoral (central and superior fill), 50 ml
- Deep subglandular (inferior enhancement and central projection), 60 ml
- Superficial/subcutaneous (inferior fullness and medial cleavage), 30 ml
- Subareolar/intra-nipple (youthful projection of nipple areolar complex), 24 ml
EXPERIENCE: Over 5 years, in 3 dozen cases (average 2-year follow-up), there were no significant complications, no fat necrosis nodules, and no secondary revisions. Skin expansion was not needed. Enhancements ranged from 120 to 300 ml per breast.
RESULTS: Natural appearing breasts were consistently produced, indistinguishable from unoperated breasts by visual inspection and palpation. Scarring was negligible. Patients reported no issues with subsequent mammograms.
CONCLUSIONS: Breast augmentation with up to 300 ml of fat graft bilaterally can be accomplished using a 6-plane, anatomically based technique. This approach can also be applied for reconstructive care, postexplant augmentation, asymmetry correction, and for reconfiguration of postpregnancy and postmenopausal concerns. Further work is needed to determine fat survival in each grafted plane.
1. Coleman SR, Saboeiro AP. Primary breast augmentation with fat grafting. Clin Plast Surg. 2015;42:301–306, vii.
2. Kerfant N, Henry AS, Hu W, et al. Reply: subfascial primary breast augmentation with fat grafting: a review of 156 cases. Plast Reconstr Surg. 2018;141:317e.
3. Teplica D, Robinson B. Heparin-enhanced harvest and decanting for autologous fat transfer. Plast Reconstr Surg Glob Open. 2018;6:1690e.