The breast implant is one of the most important device ever developed in the field of plastic and reconstructive surgery. Despite more than 60 years of technological advances in breast implants, the revision rate for breast augmentation is still high at a rate of 24% at 4 years and 36 % at 10 years. The reasons for revision are often due to soft tissue related problems which include capsular contracture and inadequate overlying tissue causing visibility of the implants, a condition plastic surgeons called “soft tissue failure”. Simply put, one of the major drawbacks of breast implants is their unnatural appearance when the overlying soft tissue volume is out of balance with implant volume. This often occurs in thin woman with minimal breast tissue who chooses large implant sizes. For these patients, the early breast augmentation result often have unnaturally tight, high and rounded breasts. Overtime, the pressure of the large implant causes atrophy of an already thin breast tissue leading to ptosis (saggy breasts) and rippling deformity (visibility of the implants). These deformities are extremity difficult to correct due to inadequate soft tissue envelope.

Fat grafting to the breast has seen significant rise in popularity since 2008. Therefore, fat grafting as an adjunct to breast augmentation – also known as composite breast augmentation, is a natural evolution in aesthetic breast surgery over the past 3 years. Now women with thin soft tissue who desires large breast implants, are perfect candidate for composite breast augmentation. In the composite breast augmentation surgery, the implants are placed in the either submuscular, subfascial or subglandular plane, and the fat is grafted throughout the upper and lower poles of the breasts to provide additional soft tissue coverage to the implant. A precise examination is performed on each patient by Dr. Goldberg. Dr. Goldberg will note symmetry of the breasts and chest, breast tissue density, and the thickness of the breast tissue. The patients selected for composite breast augmentation are thin with body mass index under 20. The fat is often harvested from the hip and flank region in these thin patients. The fat is harvested using 3mm diameter cannulas. The average amount of fat harvested from the thigh is 320 cc (ranges from 150 cc to 2000cc). For the implant devices, Dr. Goldberg often uses textured cohesive gel implants. The implants are placed through a small 4cm incision in the breast crease. The fat is then layered in the subcutaneous tissue plane using a small blunted cannula, also known as lipofilling. On average, about 50 to 100 cc of fat is used in each breast to cover the implant in the superomedial transitional zones also known as the cleavage area of the breasts. The smaller amount of fat is placed in the lower pole of the breasts. Implants and fat, working together, provide the best attributes each as to offer: the core volume projection of implants and the natural look and feel of fat. Dr. Goldberg named composite breast augmentation as the “Brazillian breast augmentation” and she believes that this is the new cutting edge in breast augmentation.

In recent years, plastic surgeons have come to understand that facial aging is not attributable to gravity induced droopiness alone, but it is also a consequence of volume loss caused by soft tissue and bony atrophy. Over the past 10 years, fat grafting or fat transfer to the face has become popular technique in facial rejuvenation. Fat grafting is a popular method for facial rejuvenation because it is an ideal filler. The following qualities make fat an ideal filler: It is your own tissue and naturally biocompatible. It is available sufficient quantities in most patient. It is naturally integrated into your own tissue and can potentially become permanent. It could be removed if necessary.

Fat grafting to the face is an art that requires meticulous technique and expertise. Good retention of the harvested fat requires proper harvesting technique and atraumatic handling of the fat during the purification process. Lastly, the technique of transferring the fat requires small layering of fat into different tissue planes in a refine fashion. All three steps of harvesting, fat purification, and transfer technique lead to good retention of the transferred fat and aesthetic result.

Therefore, fat grafting is a technique in the correction of aging deformity of the 21st century. It is used to correct hollow eyes, sunken cheeks, deepening nasolabial folds, and marrionnette lines. Fat grafting has been shown to improve the quality of the skin where the fat was injected. The wrinkles seems to soften, the pore size decreases, and the pigmentation also improves with time. The best part of the fat grafting is that it could be done as an in office procedure under local anesthesia.


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