The combination of an autologous LD flap and lipomodelling to augment the volume obviating the need for an implant is attractive for many patients, giving good consistency and a more natural and durable breast shape and reducing the incidence of implant-related complications or recurrences in the longer term [18, 19, 28, 33]. The latissimus dorsi flap is an ideal recipient site for fat grafting because of its excellent vascular network that can support large volumes of injected fat [34] with up to 500 ml of purified fat in a single sitting being possible. In a large single institution series, it was possible to achieve symmetry with the contralateral breast in 70% of patients. In those 30% where volume enhancement with fat grafting was insufficient, symmetry was achieved through contralateral mastopexy/reduction or insertion of a prosthesis on the reconstructed side [18, 19, 28] (◘ Fig. 20.2).

Breast reconstruction with implants is associated with a number of potential problems. First, a defect in the cleavage area resulting in a visible step in the upper pole of the reconstructed breast and asymmetry of the cleavage area compared with the contralateral side. A second defect is frequently seen at the medial aspect of the breast characterized by a lack of filling and an excessively wide intermammary space. Finally there can be a lack of filling on the lateral aspect of the reconstructed breast immediately beneath the anterior axillary line. In addition there may be irregularities due to variable flap thickness and areas where implant coverage is thinned resulting in visible and palpable wrinkling. In the delayed reconstruction setting, especially when chest wall radiotherapy has been administered, the remaining skin may be of poor quality, scarred, lacking in elasticity and often with a thin layer of subcutaneous fat. Preemptive fat grafting may help to improve the quality of the flaps before or after definitive surgery. Fat transfer can be utilized to overcome these defects [24–26, 28, 35, 36]. In the upper medial pole of the cleavage area, fat is transferred mainly into the pectoralis major muscle. In the medial aspect of the breast (the intermammary area), fat should be transferred into the pectoralis muscle and between the skin and the periprosthetic capsule. The lateral defect can also be treated with an injection between the skin and the periprosthetic capsule. In these last two cases, an implant exchange is strongly recommended as inadvertent implant puncture is possible, especially in the presence of thin flaps. Smaller amounts of fat are generally required in these circumstances compared with autologous reconstructions, commonly involving volumes ranging from 50 to 150 cm³ of purified fat (◘ Fig. 20.3).

Tissue quality must be carefully assessed as it is often inferior to autologous reconstructions. The recipient sites should not be saturated to ensure the best possible graft survival. The aesthetic results are usually very good and improve the cosmetic outcome compared to use of an implant alone. In addition, pericapsular fat injection may reduce the capsular contracture rate, which has been shown in animal models [37], but further clinical studies are needed to support this use.

The idea of reconstructing an entire breast mound with exclusive use of fat transfer [38, 39] is surgically challenging. This technique is only applicable to a select number of cases, and specifically three main conditions must be met. The patient’s contralateral breast should be of small to moderate volume. The chest wall tissues at the mastectomy site have to be of good quality (in terms of thickness of the subcutis and muscle layers and their suppleness), and, finally, the patient must possess donor sites with plentiful excess of fat to allow for multiple harvest and transfer procedures. If all these criteria are fulfilled, then the patient can be considered for this technique and should be informed of the multiple-stage nature of this reconstruction and the fact that the breast mound may not be fully restored for some considerable time. Based on these limitations, few women elect to have this type of reconstruction when it is offered [39] (◘ Fig. 20.4).

The principles of fat harvesting, fat processing by centrifugation and the injection technique are similar to those described for general lipomodelling.

There are two main scenarios for an exclusive lipomodelling reconstruction:

Retrospective analysis suggests that the transferred fat volume needs to be about twice the amount necessary when compared with combined reconstruction with a latissimus dorsi flap for obtaining the same degree of breast volume enhancement. The possible explanation for this significant difference is the lack of a mechanical and vascular scaffold, which is conferred by the latissimus dorsi flap [39].