Background Autogenous fat grafting (AFG) is an established technique used as an adjunct to breast augmentation (BA) to redesign breast shape. Surgeons often use experience and intuition to estimate AFG volume, which can result in incorrect assessment of donor areas and unnecessary fat removal. Objectives This aim of this study was to develop a method based on a mathematical formula, which utilizes implant volume and projection to predict AFG volume. Methods Thirty patients (60 breasts) underwent primary hybrid BA. A software package (SketchUp) was used to simulate 3-dimensional AFG and implant volumes, which in turn were used to develop an equation for estimating AFG volume according to 3 different implant projections. The results for each group were compared, via Pearson’s correlation coefficient, with the results of the clinical series. Results All patients received Motiva Ergonomix SmoothSilk/SilkSurface implants, ranging in volume from 175 to 355 cc (mean, 265 cc), as well as an average AFG volume of 79.2 cc/breast (range, 50-110 cc). Twenty-nine patients (96.6%) were either very satisfied or satisfied during a mean follow-up of 18 months (range, 6-28 months). A high correlation was observed between the AFG performed in the cohort and predictions obtained from the formula (r = 0.938, P < 0.001). Conclusions The AFG volume in hybrid BA procedures can be estimated utilizing measurements based on implant volume/projection. This low-cost method can be applied to guide surgical decision-making in patients who are candidates for BA. Level of Evidence: 4

Background Simultaneous association of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA. Objectives This study presents the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluates its aesthetic benefits after primary/secondary BA. Methods 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant. Results Mean patient age was 34.6 years (range: 28–56), mean body mass index was 18.8 kg/m 2 (14.4–26.1). The most common implant (SmoothSilk surface Ergonomix style) volume was 255 cc (175–355), patients received a mean volume of 96 cc of fat (60–145)/breast in the subcutaneous tissue. Average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days post-procedure and 10 days to 18 months post-procedure respectively. Postoperative complications included subcutaneous banding in the axilla [n = 3 (7.1%)], small wound dehiscence [n = 1 (2.3%)], and hypertrophic scarring [n = 1 (2.3%)]. No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (6–32). Conclusions SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft-tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

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Background: Autologous fat grafting is a procedure indicated for breast augmentation to improve coverage of silicone implants and redesign breast shape. Different techniques are based on parameters that have not been systematically standardized. The authors present a method using breast zone standardization based on breast anatomy to achieve an anatomical composite breast. Methods: The authors performed this zone standardization in 76 breasts (38 patients) undergoing primary/secondary augmentation. The area between the implant and the clavicle and parasternal area was marked to receive fat grafting and divided into three zones. A mathematical formula [volume of autologous fat graft = (π × r2 × p)/4.8] was used to estimate the fat graft volume according to implant volume in the respective zones. Results: Implant volumes ranged from 205 to 375 cc (mean, 265 cc), and patients received an average fat graft volume of 105.3 cc per breast (range, 36 to 135 cc); the average fat volume in zones I/II and III was 78.28 cc (range, 0 to 100 cc) and 27.03 cc (range, 15 to 60 cc), respectively. Three minor complications were observed (5.2 percent) during a mean follow-up of 12.8 months. A high correlation was observed between the fat grafting performed in the cohort and predictions obtained from the formula (p < 0.001). Conclusions: Recognizing risky cleavage breast zones between the implant pocket and the upper and medial quadrants remains essential to attain satisfactory outcomes. Although experience and proper judgment are still important in the fat grafting technique, the data presented here offer plastic surgeons an additional standardized framework to help deliver predictable hybrid breast augmentation.  CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Summary: Advances in breast augmentation techniques have led to safety improvements and better aesthetic results. The concurrent combination of the axillary approach with a subfascial pocket has been suggested for augmentation procedures, because it avoids breast scarring and the limitations of submuscular positioning represented by breast animation when the pectoral muscle is contracted. With the improvement of autogenous fat grafting techniques, new implant coverage options and more natural results have been proposed with more superficial implant pockets; simultaneous autogenous fat grafting with silicone implants (defined as hybrid breast augmentation) has recently been evaluated as a promising technique. Combining these two procedures allows core volume projection and natural cleavage while camouflaging implant edges. Fat grafting is also useful in reducing intermammary distance and achieving a smaller and smoother transition between the breasts. This article and the accompanying videos provide a detailed, step-by-step guide to hybrid breast augmentation using a subfascial axillary approach, with a predictable and optimized surgical outcome.

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