Evaluation of the efficacy and safety of breast augmentation using implants combined with autologous fat grafting: a retrospective study of 219 cases

Introduction

Implant-only breast augmentation in women with a thin soft-tissue envelope is limited by a palpable implant edge, visible rippling, and a widened intermammary distance. To overcome these limitations, the silicone gel implant can be combined with autologous fat grafting—an approach known as hybrid or composite breast augmentation—which has become a widely adopted technique (1). It is particularly suited to slender women with a thin soft-tissue cover, in whom the fat graft camouflages the implant border and refines the breast contour; several variants of this concept have been described (2,3).

In the hybrid approach, the fat graft functions as an adjunct to the implant rather than as the primary source of volume. Standardization of the recipient zones—particularly filling of the cleavage—helps the surgeon control the three-dimensional form of the breast (4). Building on this principle, the “soft-weight hybrid” concept proposed by Munhoz and colleagues advocates pairing a smaller-volume implant with a measured quantity of autologous fat, thereby reducing the mechanical load on the overlying soft tissue, limiting long-term implant palpability, and improving the durability of the aesthetic result (5). Systematic reviews and an international expert consensus have similarly concluded that hybrid augmentation yields favorable aesthetic outcomes and that its complication profile remains within acceptable limits when established technical principles are followed (6-8).

Although the international literature has reported favorable outcomes, most large series originate from the groups that first described the technique, and detailed evaluation of the size gain, the safety profile, and the determinants of patient satisfaction from independent centers remains valuable. We therefore conducted a retrospective study of 219 consecutive patients with complete 12-month follow-up undergoing hybrid breast augmentation, with the aims of evaluating the change in breast size and aesthetic quality (assessed by the change in breast circumference, the BREAST-Q, and a surgeon-rated aesthetic score), characterizing the safety profile, and identifying factors associated with postoperative complications, and examining whether the magnitude of the size gain was associated with patient-reported satisfaction. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0389/rc).

Methods

Study design and patients

This single-center, retrospective study included 219 consecutive women who underwent primary hybrid breast augmentation—silicone gel implant placement combined with autologous fat grafting—at Sao Han Cosmetic Hospital between January 20, 2023, and February 25, 2025. All eligible patients treated during the study period were enrolled, and no a priori sample-size calculation was performed. Eligible patients had a thin soft-tissue envelope (a low pinch-test thickness) with sufficient donor-site fat available at the abdomen, thighs, or flanks; were aged 18 to 42 years; and had a body mass index (BMI) of 18.5 to 22.9 kg/m². Patients undergoing revision or reconstructive procedures were not included. All 219 patients completed the scheduled 12-month follow-up, with standardized assessment at 6 and 12 months postoperatively; there were no losses to follow-up.

Surgical technique

Preoperatively, each patient underwent assessment of glandular volume, soft-tissue thickness, skin quality, and thoracic morphology to guide implant selection (type, volume, and pocket plane) and to define the donor site and the volume of fat to be transferred. Under general anesthesia and sterile preparation, a submuscular (subpectoral) pocket was created in every patient and a nano-textured silicone gel implant (Motiva Ergonomix; Establishment Labs, Alajuela, Costa Rica), each device carrying the Q Inside Safety Technology identification transponder, was inserted through the selected incision (transaxillary, inframammary, or transareolar-perinipple) after meticulous hemostasis; implant position and symmetry were confirmed before closure. The transareolar-perinipple incision consisted of a transverse incision across the areola with a semicircular extension around the inferior half of the nipple base (9,10). Fat was harvested from the abdomen, flanks, and medial thighs by low-pressure liposuction at 300 mmHg using a 3-mm cannula to preserve adipocyte viability, and was purified with a Puregraft^® fat-filtration bag to remove oil, blood, and infiltration fluid. The purified graft was reinjected as microdroplets with a 1.4-mm cannula mounted on 5-mL Luer-lock syringes, using a multilayer, multidirectional technique to place it into the subcutaneous tissue surrounding the implant to increase soft-tissue coverage, soften the implant border, and refine the breast contour, with attention to even, low-pressure distribution.

Study variables

Continuous variables included age, height, weight, BMI, breast base width, sternal notch-to-nipple distance, nipple-to-inframammary fold distance, pinch-test thickness, implant volume (each side), grafted fat volume (each side and total), operative time, BREAST-Q score, surgeon aesthetic score, and breast circumference before and after surgery. Categorical variables included smoking, parity, breastfeeding history, degree of ptosis, drain placement, overall complications, fat necrosis, implant-edge rippling, and Baker capsular contracture grade.

Outcome assessment

The primary efficacy outcome was the absolute change in breast circumference from baseline to 6 months, with the 12-month measurement used to assess maintenance. Breast circumference was measured by a single trained observer using a flexible, non-stretch tape measure, with the patient standing upright and the arms relaxed at the sides. The tape was passed horizontally around the chest at the level of the nipple, corresponding to the point of maximal breast projection, and kept parallel to the floor; the value was recorded at the end of quiet expiration. To limit measurement variability, the same observer performed all assessments preoperatively and at each follow-up visit, and each circumference was measured in triplicate and averaged; this landmark corresponds to the standard bust-circumference measurement previously applied in breast augmentation series (11). Patient-reported outcomes were assessed with the validated BREAST-Q (12), using the Augmentation module (version 2.0); the Satisfaction with Breasts domain was administered, and its raw ordinal responses were converted to a 0–100 equivalent (Q-Score) using the instrument’s standard scoring procedure, with higher scores indicating greater satisfaction. This instrument has been applied specifically to evaluate quality of life after breast augmentation (13). Aesthetic quality was rated by the surgeon on a composite Likert scale combining breast symmetry, shape and fullness (particularly the upper pole), contour and implant-edge coverage, and nipple-areola position and orientation; individual items were summed into a total score, which ranged from 8 to 14 in this cohort. Safety was assessed by overall and type-specific complications, and capsular contracture was graded by the Baker classification.

Statistical analysis

Data were analyzed with SPSS version 26.0 (IBM Corp., Armonk, NY), with statistical significance set at P<0.05. Continuous variables are presented as mean ± standard deviation [range] and categorical variables as counts and percentages. The paired t-test compared pre- and postoperative breast circumference and BREAST-Q scores, and 95% confidence intervals (CIs) are reported for the mean change; exact (Clopper-Pearson) binomial 95% CIs are reported for complication proportions. Associations between candidate risk factors (smoking, BMI) and overall complications were examined with Fisher’s exact test and univariate logistic regression. The relationship between patient satisfaction (BREAST-Q) and the gain in breast circumference was assessed with the Pearson correlation coefficient, and the independent-samples t-test compared BREAST-Q scores between patients with and without complications.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by The Biomedical Research Ethics Committee of World Beauty Cosmetic Plastic Hospital (Approval No. 01/GCN-HĐĐĐ). All personal data were coded and anonymized before analysis. Written consent for the scientific use of clinical photographs was obtained from the patients whose images appear in this article.

Results

Patient and operative characteristics

The study included 219 women with a mean age of 28.2±5.2 (range, 18–42) years and a mean BMI of 20.6±1.4 (range, 18.5–22.9) kg/m². The cohort was characterized by a thin soft-tissue envelope, with a mean pinch-test thickness of 2.1±0.5 cm. A history of smoking was present in 33 patients (15.1%) and 88 (40.2%) had breastfed; 76 patients (34.7%) had grade 1 or 2 ptosis. The mean implant volume was 282±58 mL per breast, combined with a mean grafted fat volume of 59.6±15.5 mL per breast (total grafted fat volume of 119±21 mL), and the mean operative time was 119±20 minutes (Tables 1,2). The implant was placed through a transareolar-perinipple incision in 98 patients (44.7%), a transaxillary incision in 72 (32.9%), and an inframammary incision in 49 (22.4%).

Volumetric efficacy and aesthetic outcomes

Breast circumference increased significantly from a baseline of 78.2±4.5 cm to 90.7±4.6 cm at 6 months, a mean gain of 12.6 cm (95% CI: 12.4–12.7; P<0.001), and remained augmented at 12 months (88.5±3.7 cm; mean gain 10.3 cm; 95% CI: 10.0–10.6; P<0.001). Patient-reported satisfaction improved markedly after surgery, with BREAST-Q scores rising from a preoperative baseline of 54.4±5.9 to 80.9±5.7 at 6 months and 82.2±5.4 at 12 months [mean improvement from baseline +26.5 at 6 months (95% CI: 25.5–27.5) and +27.8 at 12 months (95% CI: 26.9–28.8); both P<0.001]. Surgeon aesthetic scores were consistently high across the follow-up period (11.2±1.8 at 6 months; 11.0±1.7 at 12 months) (Table 3; Figure 1). Representative outcomes are shown in Figure 2.

Figure 1 Mean breast circumference at baseline, 6 months, and 12 months. Circumference increased significantly from baseline and remained augmented at 12 months (paired t-test, P<0.001). Error bars represent the standard deviation.

Figure 2 Representative clinical outcomes after hybrid breast augmentation in five patients (A-E). Within each panel, the upper, middle, and lower rows correspond to the preoperative, 6-month postoperative, and 12-month postoperative appearance, respectively. (A) 32-year-old woman, 275-mL implant with 85/60 mL fat (right/left). (B) 30-year-old woman, 245-mL implant with 95/115 mL fat. (C) 26-year-old woman, 285-mL implant with 75/70 mL fat. (D) 35-year-old woman, 245-mL implant with 65/60 mL fat. (E) 22-year-old woman, 250-mL implant with 105/95 mL fat. Written consent for publication was obtained from each patient.

Satisfaction was not explained by the magnitude of the size gain. BREAST-Q showed no meaningful association with the increase in circumference at either time point (r=0.05, P=0.50 at 6 months; r=0.06, P=0.35 at 12 months), indicating that the degree of enlargement accounted for essentially none of the variance in patient satisfaction (Figure 3).

Figure 3 Relationship between the gain in breast circumference at 12 months and the BREAST-Q score at 12 months (r=0.06; P=0.35). The absence of association indicates that the magnitude of enlargement did not explain the variance in patient satisfaction.

Safety and complications

The overall complication rate was 5.9% (13/219; exact 95% CI: 3.2–9.9%), and all events were minor. Fat necrosis occurred in 3 patients (1.4%; 95% CI: 0.3–4.0%) and palpable implant-edge rippling in 8 (3.7%; 95% CI: 1.6–7.1%). Clinically significant capsular contracture (Baker grade III) occurred in 2 patients (0.9%; 95% CI: 0.1–3.3%), and no Baker grade IV contracture was observed (Table 4). The reported complication rate refers only to the prespecified, clinically detected complications that were recorded in this retrospective dataset; other adverse events—including seroma, hematoma, infection, implant malposition, and donor-site morbidity—were not separately catalogued and are therefore not reflected in this rate. No patient required reoperation or secondary fat grafting within the 12-month follow-up period.

No complication occurred among the 33 patients with a smoking history, and smoking was not significantly associated with complications (Fisher’s exact test, P=0.23); because no events occurred in this subgroup, however, the estimate is subject to small-sample separation and could not be adjusted for other covariates, and it should be interpreted with caution. On univariate logistic regression, BMI was not associated with the risk of complications [odds ratio (OR) 1.02; 95% CI: 0.69–1.52; P=0.92]. BREAST-Q scores at 12 months were lower in patients who experienced a complication (78.5±5.3 vs. 82.4±5.3; P=0.009), although overall satisfaction remained high in both groups (Figure 4).

Figure 4 BREAST-Q satisfaction score at 12 months in patients without (n=206) versus with (n=13) a postoperative complication (independent-samples t-test, P=0.009). Satisfaction remained high in both groups. Error bars represent the standard deviation.

Discussion

Hybrid breast augmentation—combining a silicone implant with autologous fat grafting—has become a favored approach for the thin-tissue patient, in whom an implant alone tends to produce a palpable edge, visible rippling, and an unnaturally wide intermammary distance (1). In this retrospective series of 219 women, the technique produced a substantial and durable increase in breast size, a high level of patient-reported satisfaction, and a low, exclusively minor complication profile. Two observations merit particular emphasis: patient satisfaction was largely independent of the magnitude of the size gain, and the safety of the procedure was not compromised by smoking or by BMI within the range studied.

The demographic profile of our cohort is consistent with that reported for hybrid augmentation elsewhere. Our patients were young (mean 28.2 years) and slender (mean BMI 20.6 kg/m²), with a thin soft-tissue envelope reflected in a mean pinch-test thickness of only 2.1 cm. This aligns with the populations described by Munhoz and colleagues and by Sforza and Spear (5,14), and reflects the clinical reality that the hybrid approach is most often sought by thin, younger women in whom soft-tissue camouflage of the implant is the central concern.

Our operative parameters reflect the prevailing philosophy of the technique, in which fat is used as an adjunct rather than as the primary source of volume. We combined a moderate mean implant volume of 282 mL per breast with a mean total fat graft of 119 mL. Consistent with the “soft-weight hybrid” concept (5), the implant provides core projection while the graft is deployed to soften the implant border, fill contour deficits, and thicken the overlying soft tissue—particularly across the cleavage and upper pole—rather than to drive absolute enlargement (4).

The most clinically instructive finding of this study concerns the determinants of patient satisfaction. BREAST-Q satisfaction improved substantially after surgery—from a preoperative baseline of 54.4 to 82.2 at 12 months (a mean gain of 27.8 points; P<0.001)—yet this improvement was not explained by the degree of size gain: BREAST-Q was not associated with the increase in circumference at either time point (r=0.05 at 6 months and r=0.06 at 12 months). Notably, satisfaction continued to rise between 6 and 12 months even as mean circumference settled slightly, a pattern consistent with maturation of the soft-tissue result and resolution of edema rather than with any further increase in size. This observation supports the principle emphasized by Munhoz and by Sforza and Spear (5,14)—that the contemporary goal of augmentation is a soft, natural, well-camouflaged breast rather than maximal volume—and provides measured, patient-reported evidence that enlargement alone is an incomplete surrogate for a satisfactory result. Several factors probably contributed to this dissociation. Baseline dissatisfaction was uniformly high and postoperative scores clustered near the top of the scale, producing a ceiling effect and a restricted score range that attenuates any linear correlation; the gain in circumference was likewise narrowly distributed, further limiting the variance available to detect an association. In addition, the Satisfaction with Breasts domain appraises the qualitative attributes of shape, softness, and naturalness rather than absolute size, so a weak relationship with a one-dimensional size metric is expected rather than anomalous.

The safety profile in this series was favorable and compares well with the published literature. The overall complication rate of 5.9% falls within the range reported for hybrid augmentation, and all events were minor. The overall rate compares with those reported by Trignano and by Maximiliano and colleagues (15,16), and the rate of fat necrosis (1.4%) is consistent with the low rates reported in systematic reviews (6,7). Clinically significant capsular contracture (Baker III) was rare (0.9%), with no Baker IV contracture observed. Palpable implant-edge rippling occurred in 3.7%, an expected consideration in this thin-tissue population and one that the fat graft is specifically intended to mitigate. Neither smoking nor BMI was associated with complications; indeed, no complication occurred among the 33 patients with a smoking history. Although experimental work suggests that cigarette smoke can impair fat-graft survival (17), grafting a moderate fat volume into a low-pressure recipient pocket—achieved by avoiding oversized implants—appears to limit the ischemic risk associated with fat transfer (18). Patients who experienced a complication reported modestly lower satisfaction at 12 months than those who did not (78.5 vs. 82.4; P=0.009); overall satisfaction nonetheless remained high in both groups, consistent with the minor and manageable nature of the events observed.

All implants in this series were nano-textured devices placed in a uniform submuscular plane, standardizing two determinants of capsular behavior across the cohort. This is relevant to the safety profile, as breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) has been linked predominantly to high-surface-area (macrotextured) devices, whereas smooth and nano-/micro-textured surfaces carry a substantially lower reported risk (19). The low rate of clinically significant capsular contracture observed here (0.9%) is consistent with this surface profile. Standardized graft-plane placement and imaging surveillance for fat-related sequelae (oil cysts and calcifications) should nonetheless inform both clinical practice and the design of future hybrid-augmentation studies.

This study has several limitations. It is a retrospective, single-center series without a comparison group, so the findings are descriptive rather than comparative and cannot establish the incremental benefit of the hybrid approach over implant-only augmentation. As a retrospective, single-arm study it is also subject to selection and information bias, and the absence of a concurrent implant-only or fat-only control precludes attributing the observed outcomes specifically to the addition of fat grafting; propensity-matched comparative data suggest that hybrid augmentation improves implant camouflage and upper-pole contour relative to implant-only augmentation (20), but such a comparison could not be made in the present cohort. Breast size was assessed by tape measurement of circumference, a practical but imprecise surrogate that is influenced by chest-wall dimensions, weight, and posture; it cannot isolate the grafted-fat component and does not capture the contour endpoints most relevant to hybrid augmentation, such as upper-pole fullness, cleavage, and implant-edge camouflage. Three-dimensional surface volumetry would provide a more accurate measure of breast volume and graft retention, and its absence is a limitation. Patient-reported satisfaction was captured with the BREAST-Q preoperatively and at 6 and 12 months; we report only the Satisfaction with Breasts domain, without additional BREAST-Q domain-level or Rasch-transformed subscale reporting. The surgeon-rated aesthetic score, although based on defined morphological criteria, has not been formally validated and was assigned by a single unblinded observer without an inter-rater reliability assessment. The 12-month horizon is too short to fully characterize capsular contracture, the evolution of rippling, delayed fat necrosis or oil-cyst formation, and the need for revision; no routine imaging (ultrasound or mammography) was performed to detect fat-related radiologic sequelae. Risk-factor analyses were univariate, were affected by separation for the smoking variable (no events among smokers), and were not adjusted in a multivariable model. Because all implants were nano-textured and placed in a uniform submuscular plane, implant surface and pocket plane could not be examined as covariates, and implant profile was not analyzed. Prospective studies incorporating standardized three-dimensional volumetry, a validated blinded aesthetic assessment, longer follow-up with time-to-event analysis, and an implant-only comparison arm would strengthen these observations.

Conclusions

In this series of 219 thin-tissue patients, hybrid breast augmentation produced a substantial and durable increase in breast size together with a low complication rate, all events being minor and none influenced by smoking or BMI within the range studied. Patient satisfaction was high but was largely independent of the degree of enlargement, underscoring that soft-tissue quality and natural contour—rather than absolute volume—are central to a satisfactory outcome. These findings support hybrid augmentation as a safe and effective option for patients with thin soft-tissue coverage and argue for prioritizing a soft, well-camouflaged result over volume alone. Because the series lacked an implant-only comparison group, these results describe outcomes after hybrid augmentation rather than demonstrating its superiority over implant-only augmentation or the independent contribution of fat grafting; comparative studies are needed to confirm these points.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0389/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0389/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0389/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0389/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by The Biomedical Research Ethics Committee of World Beauty Cosmetic Plastic Hospital (Approval No. 01/GCN-HĐĐĐ). Written consent for the scientific use of clinical photographs was obtained from the patients whose images appear in this article.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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