Reply: Subfascial Primary Breast Augmentation with Fat Grafting

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We thank Dr. Cucchiaro for his interest in our article1 and we are grateful for the opportunity to respond to his letter. First, the author highlights the low index of rotation and asks for the reason for the demise of anatomical implants. Even if 0.64 percent is a rare event, it is still too high. We believe that if we are able to obtain the same cosmetic results with round implants surrounded by fat, it would help in assuring our patients that there will be no risk of rotation. Moreover, as reported by Hidalgo and Weinstein, anatomical implants have a more aggressive textured surface, to avoid rotation. As evidence is growing about a correlation between macrotexture and anaplastic large cell lymphoma, it seems prudent to avoid texture, as this pathogenesis is not clearly understood, especially if the same aesthetic results are achieved without a macrotextured implant.2,3
Second, even if a subfascial pocket is a good way to ensure coverage of the implant, it can be insufficient, particularly in patients with a low body mass index. The mean body mass index in our series was 18.85 kg/m2, and fat grafting offers the possibility of avoiding suboptimal results caused by failure of the overlying soft tissue while avoiding dissection of the retromuscular pocket.
As we use nearly the same amount of fat for each breast, except in asymmetric cases, we did not observe any asymmetry during follow-up. The need for a second fat injection was rare if the patient had a stable body weight.
Third, we often remove fat in the prone position to collect a sufficient amount, because of the low body mass index. We do not believe there is an increased risk for contamination of the surgical field when strict asepsis rules are followed. Furthermore, fat is injected in a subcutaneous plane at the end of the surgical procedure, and thus it is difficult to see how it could be the cause of capsular contracture or any subclinical infection, as fat placement is not close to the subglandular pocket.
We totally agree with Dr. Cucchiaro that breast augmentation produces high satisfaction rates. However, we have to collect data and go further with evidence-based medicine in cosmetic breast surgery while striving to improve cosmetic results and enhance safety.
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