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Although autologous fat grafting is widely accepted for breast reconstruction, its indications remain limited to minor contour deformities after reconstruction and small deformities after breast-conserving surgery. The authors describe a case series of total or nearly total breast reconstructions treated with the perioperative use of a vacuum-based external tissue expander (i.e., the Brava device) followed by autologous fat grafting.The authors assessed the clinical outcomes and aesthetic results in six nonirradiated total mastectomy cases and eight severely deformed irradiated breast-conserving surgery cases. Total Brava wearing time and skin complications were also investigated.The number of fat grafting procedures required ranged from one to four, and the mean amount of fat grafted during each procedure was 256 cc (range, 150 to 400 cc). Postoperative fat lysis and cellulitis occurred in two cases (14.3 percent). Brava worked effectively for total mastectomy cases, and improvement in the total aesthetic score was significantly higher than that in the breast-conserving surgery cases. All patients wore the device for more than 8 hours/day. The most frequent skin complication was dermatitis [n = 11 (79 percent)], which occurred in all breast-conserving surgery cases.Brava was well tolerated by patients. Fat grafting with perioperative use of Brava is an alternative to total breast reconstruction in total mastectomy cases. However, for severely deformed breast-conserving surgery breasts treated with radiation therapy, the contracted skin was difficult to extend despite Brava use, and the results were less satisfactory. These cases also experienced a higher incidence of skin complications compared with the total mastectomy cases.Therapeutic, IV.