In Brazil, in 2020, the incidence estimated by the National Cancer Institute (INCA)
concerning breast cancer in women was 66,280 cases, according to the primary location
of the tumor and gender, corresponding to 29.7% of the neoplasms estimated for the
year, which reinforces the position of cancer more prevalent in women. Between 2015
and 2018, there were 66,532 deaths from breast cancer nationwide, affecting 65,768
women (98.85%) and 764 men (1.15%)1.
Thus, a breast cancer diagnosis has a considerable psychological impact on patients,
which can cause depressive disorders, amplification of physical symptoms, functional
impairment, and decreased adherence to the proposed treatments2. Therefore, breast cancer treatment through mastectomy has an important influence
on patients’ quality of life, which has caused an increasing number of searches for
reconstructive procedures after mastectomy, either immediately or late(3.)
In 1893, the fat graft was described by Neuber4, having increased its use and acceptance over the years. Since 1990, together with
the advancement of techniques and extensive experimental and clinical studies, there
has been a growth in the number of plastic surgeons using autologous fat grafting
as a technique for breast reconstruction3.
With these advances, in 1997, it was decided through the resolution of the Federal
Council of Medicine No. 1,483/97 that breast reconstruction is part of the treatment
of the disease when there is an indication for correction of deformities generated
by mastectomy5. Moreover, in 2018, law no. 13,770 was sanctioned, ensuring to women with breast
cancer the right to reconstructive plastic surgery in both breasts, even if the tumor
only appears in one of them, guaranteeing the right to contralateral breast symmetrization
and reconstruction of the areolopapilar complex6.
In 2005, Spear7 reported that autologous fat transplants, also known as lipografting, are a safe
technique capable of correcting or improving deformities in mammary reconstructions7. Since 2007, the French Society of Plastic and Reconstructive Surgery has advised
using autologous fat graft strictly. However, in 2011 they changed their position,
suggesting that the procedure would become part of a clinical protocol8,9. The American Society of Plastic Surgeons, on the other, discouraged the use of fat
grafting for years. However, in 2015, the society reported evidence supporting the
use of fat grafting to maximize the aesthetic results of post-mastectomy breast reconstruction10.
In Brazil, between 2015 and 2019, according to the Department of Informatics of the
Unified Health System (DATASUS), there were 51,269 hospitalizations for mastectomies,
including radical mastectomy with lymphadenectomy, simple, radical with axillary lymphadenectomy
in oncology and simple mastectomy in oncology11. Moreover, according to the census conducted in 2018 by the Brazilian Society of
Plastic Surgery, reparative surgeries correspond to 39.7% of plastic procedures performed
in Brazil, with breast reconstructions being 6.1%12.
Thus, because of the number of mastectomies performed in the national territory and
the psychological advantages of breast reconstructions and the percentage that these
surgical interventions represent within plastic surgery, it is important to understand
more about the available therapeutic options.
Conduct a review of the literature on the use of lipografting in breast reconstruction
after breast cancer treatment.
A literature review was conducted based on: 1) preparation of a question to be researched;
2) choice of data sources; 3) election of keywords for search; 4) search and storage
of results; 5) selection of articles according to inclusion and exclusion criteria;
6) extraction of data from selected articles; 7) synthesis and interpretation of the
The main question of the search was: “what is the application of autologous fat graft
in breast reconstruction after mastectomy in patients affected by breast cancer?”.
The articles were surveyed using PubMed, MEDLINE, LILACS and SciELO databases in July
2020, and the descriptors were used: “breast reconstruction”; “fat grafting,”; “breast cancer”, using the Boolean operator “AND”.
The studies should contain information on the use of lipografting in breast reconstruction
after mastectomy performed for cancer treatment to be included in this literature
The inclusion criteria used were articles published between 2010 and 2020; full articles
available free of charge; articles in Portuguese or English; randomized controlled
trials; and case reports. Exclusion criteria were duplicate articles and articles
outside the theme addressed.
We found 838 articles in the databases surveyed, of which 20 were selected for data
extraction, with their synthesizing and interpretation (Figure 1).
Figure 1 - Flowchart of the selection of articles for analysis.
Figure 1 - Flowchart of the selection of articles for analysis.
The extracted information was separated into the following topics: author, year, objective,
considerations (Table 1).
Chart 1 - Summary of the articles included.
||Present a concept of breast reconstruction with fat graft combined with internal tissue
||Breast reconstruction with fat graft combined with tissue expansion is a promising
method of total breast reconstruction after mastectomy.
|Sowa et al.14
||Describe the case of a patient with invasive ductal carcinoma treated with mastectomy
with subsequent breast reconstruction using flap and fat graft.
||The fat graft removed from zone IV in a DIEP flap is an ideal option for cosmetic
breast augmentation in patients who wish to achieve a natural and moderate increase
of the neckline line in the upper thorax.
|Fujiwara et al.15
||Describe the details of a breast reconstruction case using an expander and tissue
implant, combined with fat grafting, in a patient with severe depressive breast deformation
after breast conservation therapy.
||The results showed that the presenting method might be an option for late reconstruction
after conservative breast therapy.
|Skendelas et al.10
||Present a case of a patient with a mutation in the T37K BRCA variant and an unusual
pattern of recurrence of breast cancer after mastectomy, reconstruction and early
||The diagnosis was complicated by the anticipated side effects of the fat graft, which
is a well-established reconstructive procedure. As BRCA-positive and variant patients
are generally younger patients who can seek breast reconstruction options for aesthetic
purposes, we believe that the possibility of breast cancer recurrence should always
remain at the forefront of the differential diagnosis in the case of an unusual clinical
|Bennet et al.4
||Determine whether fat grafting is associated with the results reported in patients
undergoing mammary reconstruction.
||Fat grafting can improve breast satisfaction, psychosocial and sexual well-being in
patients undergoing breast reconstruction.
|Stumpf et al.16
||Evaluate local and systemic recurrence of breast cancer in patients submitted to autologous
fat graft in immediate reconstruction after conservative surgery for breast cancer.
||There was no significant difference for local or systemic recurrence of breast cancer
in the groups studied. The immediate autologous fat graft appears to be a safe procedure.
|Cheng et al.17
||Describe a case of a 36-year-old woman with mucinous carcinoma in the right breast
discovered two months after the fat graft.
||This case again raises the question about the possible links between breast cancer
and fat grafts.
|Al-Kalla et al.2
||Describe a case of a 68-year-old male patient submitted to unilateral breast reconstruction,
successful only with the fat grafting technique.
||Although the behavior of transferred fat is not well understood, fat grafting is a
very powerful reconstructive modality to recreate the unique shape of the male breast
|Daye e Conant18
||Highlight the mammographic and tomosynthetic findings observed after lipomodeling
that may present diagnostic challenges in this patient population.
||In conclusion, with the increasing use of autologous fat grafting in breast cancer
survivors, radiologists should acquire an in-depth knowledge of the imaging changes
that follow this procedure. It is recommended to perform pre-and post-lipomodeling
images to restore a baseline for patients undergoing this procedure.
|Howes et al.19
||Evaluate the viability of breast reconstruction only by autologous fat graft in the
context of RoFA mastectomy.
||This case demonstrates the potential for the use of fat grafting in reconstruction.
Results in larger patient populations are needed to confirm these findings.
|Mestak et al.3
||Describe a case of breast reconstruction after mastectomy using autologous fat transfer
combined with brava external tissue expansion system.
||The use of the BRAVA external expansion system to improve the fat graft is an appropriate
technique for breast reconstruction after a mastectomy. This technique produces soft
and natural breasts in fewer surgical sessions, with minimal risk of complications.
Patient adhesion, however, is extremely necessary to achieve the desired results.
|Alharbi et al.9
||Discuss the possible relationship between lipografting and cancer recurrence.
||The issue of breast cancer risks has again been raised and encouraged people to continue
to be careful.
|Bezerra et al.7
||Validate a way to correct breast contour defects after the previous reconstruction
through conventional techniques with fat grafting after eight years of practice.
||Lipografting is a safe technique, with low morbidity and high satisfaction levels
for those involved, even though it is necessary to perform multiple surgical procedures
to achieve a good result.
|Chaput et al.8
||Report recurrence of an invasive ductal carcinoma four months after autologous fat
||Atypical in its chronology and histology, this case allows us to raise questions about
this procedure and its controversial characteristics about breast cancer again.
|Hoppe et al.20
||Describe an optimized treatment and follow-up protocol for new breast reconstruction
after total mastectomy only with lipotransfer.
||Complete breast reconstruction with large volume fat grafting is, alternatively, possible
to standard techniques in selected cases. At least 4 to 6 lipotransfers are required
over two years. Patients with prior radiotherapy may require up to 8 sessions in almost
three years of treatment.
|Kim et al.21
||Describe bilateral liponecrotic pseudocysts after breast fat injection.
||Autologous fat grafting in the breast is not a simple procedure and should be performed
by well-trained and qualified plastic surgeons. During surgery, care should be taken.
|Mojallal et al.22
||Presenting a case of bilateral philodic tumors in a 28-year-old woman with Poland
syndrome and discuss (1) the relationship between the condition and breast cancer,
(2) the modes of surveillance in patients with Poland syndrome and (3) its impact
on breast reconstruction.
||Patients with Poland syndrome have the same risk of breast cancer or borderline tumors
as the general population. Therefore, when a patient with this syndrome presents for
treatment, bilateral mammography and an ultrasound should be performed before proceeding
with the mammary reconstruction. The possible development of breast cancer in patients
with the anomaly should influence the surgeon's choice of reconstruction techniques,
including fat grafting.
|Panettiere et al.23
||Describe the reconstruction of an irradiated breast using lipografting after reconstruction
failure with prosthesis.
||Fat graft transplantation can be a reliable and safe option for body reconstruction
in selected patients.
|Rigotti et al.24
||Compare the incidence of local and regional recurrence of breast cancer between two
contiguous time windows in a homogeneous population of 137 patients submitted to adipose
tissue transplantation after a modified radical mastectomy.
||Although further confirmation is required from multicenter randomized clinical trials,
our results support the hypothesis that autologous lipoaspirated transplantation combines
impressive regenerative properties with null or marginal effects on the likelihood
of post-mastectomy locoregional recurrence of breast cancer.
|Salgarello et al.25
||Presented the preliminary results of alternative surgical treatment in breast oncoplastic
surgery, consisting of fat injections before implant placement.
||Preliminary results show that fat injection into irradiated tissue before alloplastic
breast reconstruction may reduce radiation-related complications in implants. The
benefits of fat grafting are following the theoretical basis of this surgery. Larger
studies are needed to confirm our observations.
Chart 1 - Summary of the articles included.
In addition, among the main points described in the analyzed articles, 17 pointed
out benefits of the autologous fat graft procedure, 13 commented on whether there
was a correlation between the procedure and cancer recurrence, 12 talked about the
issue of radiological findings and their differentiation, and 2 presented special
clinical cases, one of male breast reconstruction and another of reconstruction after
mastectomy in a patient with Poland syndrome.
Autologous fat has revitalizing capacity in tissues affected by breast cancer treatment,
favoring its biological and mechanical restoration10,25. This material has ideal properties because it naturally integrates tissues since
it is autologous, being biocompatible3.
Thus, adipose tissue transplantation is a good way to treat the effects caused by
breast oncologic therapies, as well as chronic diseases and cosmetic unsatisfactory,
and can be done uniquely or combined with other approaches13,15,24.
In breast reconstruction by lipografting, the procedure produces soft breasts with
a soft tactile sensation, improved skin texture, increased subcutaneous layer and
superior symmetry, recovering the natural contour3,14,20. Its results include minimal scars and efficacy in the simultaneous restoration of
The procedure can be performed in almost all patients since the significant contraindications
are only for patients with active local neoplasms or radiodermatitis and can be done
with local or general anesthesia. The technique is considered relatively easy and
low cost and can be used after therapeutic failure with other types of reconstruction23.
However, like every surgical procedure, some complications may occur, being them:
liponecrotic pseudocysts, infection, granuloma, hematoma, fatty necrosis and fibrosis10,20,21. Among these complications, the rates of occurrence are low, with most of them being
controlled by breast imaging, evolving with spontaneous resolution18,20.
Moreover, the lipografting procedure presents estimated volume loss after grafting
between 25 and 43.5%, varying the results according to several studies19. If a second session is held, the absorption rates are between 20% and 30%7. Furthermore, the advent of the Coleman technique allowed the reduction of fat resorption
rates and complications4,16.
Regarding the question raised in studies on whether there is a correlation between
autologous fat use and cancer recurrence, it is estimated that for every 1,000 women
who undergo lipografting, 7 may develop a local relapse after one year. In contrast,
for every 1,000 who do not undergo lipografting, nine may present recurrence; that
is, the real impact of autologous fat graft on the resurgence of breast cancer is
unknown. There is no significant evidence to link lipografting to new cases of neoplasia17,24.
After lipografting, some reports have described radiological findings that suggest
the formation of calcifications and nodules in the breasts, which at first could be
confused with breast cancer14,19. However, more recent studies show that radiologists should not have difficulties
distinguishing between tumor calcifications and post-graft fat. It is possible to
treat complications without the occurrence of post-operative deformities and concern
with malignancy of the findings3,19. Moreover, USG plays an important role in the follow-up of patients after lipografting23.
Autologous fat grafting is also appropriate for restoring the breast of male patients
after mastectomy to remove breast cancer. Due to the characteristics of the male chest
wall, this procedure can offer more satisfactory and natural results since the prostheses
are designed for female patients2.
In addition, in patients with Poland syndrome associated with breast cancer, lipografting
should be reserved to restore infraclavicular and anterior axillary defects and should
be performed only after careful pre and post-operative examination mammography, ultrasound
and magnetic resonance imaging, if indicated22.
Through the review, it was possible to verify that the use of autologous fat in breast
reconstruction is a well-established procedure, consisting of a good technique, generating
good results, such as soft breasts, improvement in skin texture, increase of subcutaneous
layer, symmetry and recovery of the natural contour. These results help improve the
quality of life of patients undergoing the procedure since they have psychosocial
However, lipografting can cause complications such as pseudocysts, infection, granuloma,
hematoma, fibrosis, fatty necrosis, and local ischemia. Thus, the plastic surgeon
must have experience performing the procedure to apply the correct technique, reducing
the risks of complications. In addition, it is important that radiologists who follow
the case are well trained and can interpret radiographic findings with greater accuracy.
Moreover, there must be more long-term studies, with the support of the Plastic Surgery
Societies, to understand if there is a real correlation between breast cancer resurgence
and autologous fat in breast reconstructions, ensuring greater understanding and safety
about the procedure.
1. Ministério da Saúde (BR). Instituto Nacional de Câncer José Alencar Gomes da Silva
(INCA). Atlas de mortalidade por câncer - tabulador [Internet]. Rio de Janeiro: Ministério
da Saúde/INCA; 2014; [acesso em 2020 Ago 08]. Disponível em: https://www.inca.gov.br
2. Al-Kalla T, Komorowska-T E. Total male breast reconstruction with fat grafting. Plast
Reconstr Surg Glob Open. 2014 Nov;2:e257.
3. Mestak O, Mestak J, Bohac M, Edriss A, Sukop A. Breast reconstruction after a bilateral
mastectomy using the BRAVA expansion system and fat grafting. Plast Reconstr Surg
Glob Open. 2013 Dez;1(8):71-5.
4. Bennet KG, Qi J, Kim HM, Hamill JB, Wilkins EG, Mehrara BJ, et al. Association of
fat grafting with patient-reported outcomes in postmastectomy breast reconstruction.
JAMA Surg. 2017 Out;152(10):944-50.
5. Conselho Federal de Medicina (BR). Resolução CFM no 1.483, de 11 de setembro de 1997.
Diário Oficial da União, Brasília (DF), 22 set 1997: Seção 1: 21075.
6. Lei nº. 13.700, de 19 de dezembro de 2018 (BR). Dispõe sobre a cirurgia plástica reconstrutiva
da mama em casos de mutilação decorrente de tratamento de câncer. Diário Oficial da
União, Brasília (DF), 20 dez 2018: Seção 1: 1.
7. Bezerra FJF, Moura RMG, Maia Neto JD. Lipoenxertia em reconstrução mamária. Rev Bras
Cir Plást. 2013;28(2):241-6.
8. Chaput B, Foucras L, Le Guellec S, Grolleau JL, Garrido I. Recurrence of an invasive
ductal breast carcinoma 4 months after autologous fat grafting. Plast Reconstr Surg.
9. Alharbi M, Garrido I, Vaysse C, Chavoin JP, Grolleau JL, Chaput B. Latissimus dorsi
flap invasion by ductal breast carcinoma after lipofilling. Plast Reconstr Surg Glob
Open. 2013 Nov;1(8):e68.
10. Skendelas JP, Lee C, Mangino A, Carson WE. Unusual recurrence of breast cancer in
a BRCA-variant patient after fat grafting. Clin Case Rep. 2018 Dez;6(12):2457-62.
11. Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde (SIH/DATASUS).
Portal da Saúde - SUS. Brasília (DF): Ministério da Saúde; 2020.
12. Fonseca A, Ishida LH. Censo 2018 análise comparativa das pesquisas 2014, 2016 e 2018.
São Paulo (SP): Sociedade Brasileira de Cirurgia Plástica (SBCP); 2018.
13. Kolasinski J. Total breast reconstruction with fat grafting combined with internal
tissue expansion. Plast Reconstr Surg Glob Open. 2019 Abr;7(4):e2009.
14. Sowa Y, Kodama T, Morita D, Numajiri T. Fat grafting with harvesting from zone IV
in the DIEP flap. Eplasty. 2019 Mai;19:ic14.
15. Fujiwara T, Yano K, Tanji Y, Nomura M. Staged prosthetic reconstruction with fat grafting
for severe depressive breast deformation after breast-conserving therapy. Plast Reconstr
Surg Glob Open. 2018 Mar;6(3):e1717.
16. Stumpf CC, Biazus JV, Zucatto FSAE, Cericatto R, Cavalheiro JAC, Damin APS, et al.
Reconstrução imediata com enxerto autólogo de gordura: influência na recorrência local
de câncer de mama. Rev Col Bras Cir. 2017 Mar;44(2):179-86.
17. Cheng L, Han XF, Zhang C, Lv LL, Li FC. Occurrence of breast mucinous carcinoma after
autologous fat grating for breast augmentation. Aesthetic Plast Surg. 2016 Fev;40(1):102-5.
18. Daye D, Conant E. Digital breast tomosynthesis findings after surgical lipomodeling
in a breast cancer survivor. J Radiol Case Rep. 2014 Set;8(9):9-15.
19. Howes BHL, Fosh B, Watson DI, Yip JM, Eaton M, Smallman A, et al. Autologous fat grafting
for whole breast reconstruction. Plast Reconstr Surg Glob Open. 2014 Mar;2(3):e124.
20. Hoppe DL, Ueberreiter K, Surlemont Y, Peltoniemi H, Stabile M, Kauhanen. Breast reconstruction
de novo by water-jet assisted autologous fat grafting - a retrospective study. Ger
Med Sci. 2013;11:Doc17.
21. Kim H, Yang EJ, Bang SI. Bilateral liponecrotic pseudocysts after breast augmentation
by fat injection: a case report. Aesthetic Plast Surg. 2012 Abr;36(2):359-62.
22. Mojallal A, La Marca S, Shiphov C, Sinna R, Braye F. Poland syndrome and breast tumor:
a case report and review of the literature. Aesthet Surg J. 2012 Jan;32(1):77-83.
23. Panettiere P, Accorsi D, Marchetti L, Sgrò F, Sbarbati A. Large-breast reconstruction
using fat graft only after prosthetic reconstruction failure. Aesthetic Plast Surg.
24. Rigotti G, Marchi A, Stringhini P, Baroni G, Galiè M, Molino AM, et al. Determining
the oncological risk of autologous lipoaspirate grafting for post-mastectomy breast
reconstruction. Aesth Plast Surg. 2010 Ago;34(4):475-80.
25. Salgarello M, Visconti G, Farallo E. Autologous fat graft in radiated tissue prior
to alloplastic reconstruction of the breast: report of two cases. Aesthetic Plast
Surg. 2010 Fev;34(1):5-10.
1. University of Vassouras, Medical Course, Vassouras, RJ, Brazil.
2. University Hospital of Vassouras, Plastic Surgery, Vassouras, RJ, Brazil.
Thaís Moreira Lara Rua Benedito Pereira Rocha, 304, Parque das Palmeiras, Angra dos Reis, RJ, Brazil.
Zip Code: 23906-485. E-mail: email@example.com
Article received: September 02, 2020.
Article accepted: April 23, 2021.
Conflicts of interest: none
TML Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Investigation, Methodology, Project Administration,
Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
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Data Curation, Final manuscript approval, Investigation, Methodology, Project Administration,
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LALP Conceptualization, Final manuscript approval, Project Administration, Supervision,
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