Breast Augmentation by Fat Transfer (Fat Graft) – History

Dr. Nicolaidis started explanting breast implants in the Fall of 2018, primarily for patients with breast implant illness (BII). But he continued to do breast augmentations with implants at the time, the thinking being that not all patients develop BII. As he saw more and more patients with BII, he began to question what were the risk factors that would lead one patient to become ill with breast implants and another to remain fine. Following discussions with and presentations by various “BII experts”, Dr. Nicolaidis started trying to identify these risk factors for BII, for example skin problems suggesting a poor defence system to the environment or history of autoimmune disease. In the Spring of 2021, as Dr. Nicolaidis was seeing more patients for explantation of implants than for augmentation, he began to meet patients who had developed BII even though they had no supposed risk factors. He therefore could no longer predict which patients could receive breast implants without developing problems. At this point, Dr. Nicolaidis became concerned that he could be harming ANY patient by implanting breasts. For these reasons, Dr. Nicolaidis stopped using breast implants in May 2021. He has since become the leading explant (removal of breast implants and their surrounding capsule) Surgeon in Canada, having performed 1050 explant cases by September 2024.

Dr. Nicolaidis was also fortunate enough to hear the first formal presentation on fat transfer by Sidney Coleman in 2000, when Dr. Nicolaidis was still working in New York. Fat was removed from the patient using liposuction, then concentrated and re-introduced in the face by Dr. Coleman. In order for the fat to survive, it had to be injected in small quantities and fine lines, surrounded by the patient’s tissues which would vascularize the fat. In the years following Dr. Coleman’s presentation, progressively larger quantities of fat were transferred to other parts of the body, notably the breasts and buttocks. As larger quantities are injected in an area, more fat loses direct contact with the patients’ tissues, leading to resorption rates around 50% (meaning that 50 % of the transferred fat will disappear over time). If too much fat is transferred, cysts may form which can be misinterpreted on mammograms as possible breast cancer. A work-up then becomes necessary to eliminate possible breast cancer.

Breast Augmentation by Fat Transfer (Fat Graft) – Objective

Although Dr. Nicolaidis no longer poses breast implants, there remains the option of breast augmentation by fat transfer to the breast. Dr. Nicolaidis was hesitant to offer fat transfer to explanted patients initially because of the theoretical concern of increasing the risk for breast cancer with the transfer of fat cells as well as his insistence on not risking yet another ordeal for these patients. He has since confirmed that no study or investigation has ever shown or suggested any increased risk of breast cancer with fat transfer to the breast in the 20 years since its beginnings.

As already mentioned, the survival of fat transferred to the breast (or anywhere else in the body) is based on the fat being in direct contact with the patient’s breast tissue in order to receive oxygen and blood. For these reasons, fine lines of fat are injected within the breast tissue. As more and more fat is transferred to the breast, the chance of an accumulation of fat increases such that some fat is no longer exposed to the patient’s tissues. That fat will subsequently die, leading to resorption (loss) of the fat and possible cyst formation or microcalcifications. These can be misinterpreted on mammograms as possible breast cancer, requiring investigations to rule out that possibility. In summary, the less fat is transferred, the lower the resorption rates and the less complications. For these reasons, Dr. Nicolaidis prefers small to medium -volume fat transfers to the breast, rather than large volumes. Also for these reasons, patients who desire very large augmentations by fat transfer require more than one fat transfer surgery in order to attain their objective.

One obvious population of patients who can benefit from fat transfer to the breast are those who have had their breast implants removed for BII or other reasons. These patients will often ask if it is possible to transfer fat to the heir breasts at the same time as their explantation; however, Dr. Nicolaidis is very conservative and careful in addressing this request. Keep in mind that a surgeon cannot control exactly where the transferred fat goes; rather, fat will go wherever there is space. If the fat goes into the area where the implants were just removed, that fat will immediately die and may lead to a super infection. For these reasons, Dr. Nicolaidis will consider LIMITED fat transfers at the time of explantation, provided the implants were under the muscle (which will serve as a barrier to prevent the fat from entering the explant space) and provided the dissection around the nipples is minimal. Of course, the patients who can benefit the most from fat transfer are those who have minimal breast tissue to begin with, making it even more difficult to inject fat in their tissue and more likely for the fat to go into the explant area. For all of these reasons, Dr. Nicolaidis will USUALLY perform fat transfers to the breast as a secondary procedure 3 to 6 months after explantation, allowing him to correct any resulting irregularities or asymmetries after explantation.The other advantage of doing DELAYED fat transfer (rather than at the time of explantation) is that MORE fat can be transfered to the breast since the explant space is closed and there are no incisions through which the fat will escape.

Breast Augmentation by Fat Transfer (Fat Graft)– Anesthesia

Most cases require general anesthesia for maximum patient safety and comfort as well as more aggressive fat removal.

Breast Augmentation by Fat Transfer (Fat Graft)– Surgical techniques

Fat is removed from unwanted areas using simple liposuction techniques. However, rather than throw out this fat, the fat is concentrated through numerous means and reinjected in areas lacking fullness. Care must be taken in order to avoid excessive injections in any given areas in order to avoid fat cell necrosis (or death), leading to more fat resorption, or cyst formation.

Breast Augmentation by Fat Transfer (Fat Graft)– Recovery

Patients are generally asked to wear a compression garment for the first several days to one month after surgery in the liposuctioned areas. On the other hand, we try to avoid pressure on the regions receiving the fat.

Breast Augmentation by Fat Transfer (Fat Graft)– Return to work

Patients can usually return to work in just a few days, though swelling and bruising usually take several weeks to subside.

Breast Augmentation by Fat Transfer (Fat Graft)– Possible complications

The most common problem after liposuction involves irregularities of the skin surface, including depression or wrinkling. As already mentioned, up to 50% of the transferred fat can be resorbed (or disappear). Fat transfer risks include cyst formation, infection, microcalcification and death of the fat cells, leading to resorption.

Breast Augmentation by Fat Transfer (Fat Graft)– Post op Instructions

In the first week after fat injection, be sure to :

  • Keep your dressings dry and clean ;
  • Wash with a sponge unless Dr. Nicolaidis says otherwise ;
  • Avoid pressure over the area of fat injection ;
  • Wear your compressive garments (if provided) at all times for the areas liposuctioned ;
  • Walk at least 5 minutes every hour during the day (do NOT simply stay in bed constantly).

Your first post-operative appointment for fat injection with Dr. Nicolaidis is very important, even if you feel very well. Call us as soon as possible if you do not have an appointment already scheduled (the first visit is normally scheduled before surgery).

After the first week of fat injection :

  • Patients may shower;
  • Continue to avoid pressure over the area of fat injection for at least 2 more weeks ;
  • Protect your new scars from sun exposure for a total of 6 months ;
  • Continue wearing compressive garments (if provided) until Dr. Nicolaidis says otherwise ;
  • In order to avoid blood clot complications, keep moving (walk regularly during the day).

Please note :

  •  It is normal to have some bruising in the area of fat injection in the first weeks after surgery.
  •  For your comfort, be sure to take your pain medication as prescribed.

For further information about fat transfer & fat injections (Fat Graft), please click here : American Society of Plastic Surgeons