Long-Term Outcome in Implant Breast Reconstruction and Radiotherapy: The Role of Fat Grafting

<b>Background:</b> Capsular contracture remains one of the most challenging complications of implant-based breast reconstruction, particularly in patients undergoing postmastectomy radiotherapy (PMRT). Autologous fat grafting has been proposed as a regenerative strategy to mitigate radiation-induced damage, but long-term data are limited. <b>Methods:</b> We retrospectively reviewed women who underwent two-stage implant-based breast reconstruction followed by PMRT (50 Gy in 25 fractions) between 2010 and 2021 at Ospedale Sant'Anna, Como. Eligible patients subsequently received at least one session of autologous fat grafting after radiotherapy. Primary outcome was the incidence and severity of capsular contracture; secondary outcomes included the need for salvage autologous reconstruction, oncologic safety, and patient-reported satisfaction. <b>Results:</b> Thirty-two patients met inclusion criteria. The mean age was 56.1 years, and mean BMI was 23.8 kg/m². All underwent submuscular two-stage reconstruction with anatomically shaped implants (mean volume 336 cc). Patients received an average of 1.7 fat grafting sessions (mean cumulative volume 180 cc). At a mean follow-up of 7.7 years, capsular contracture occurred in 6 patients (18.8%): 4 with Baker grade III and 2 with Baker grade II. No cases of severe (grade IV) contracture were observed. Importantly, no patient required salvage autologous reconstruction, and no local recurrences were recorded. Minor donor-site complications (transient edema or ecchymosis) occurred in 18.7% of patients. Subjective satisfaction was uniformly high, with reported improvements in breast softness and contour. <b>Conclusions:</b> Fat grafting appears to be a safe and effective adjunct in maintaining implant-based breast reconstruction after radiotherapy. In this long-term series, lipofilling was associated with a lower incidence of capsular contracture compared with historical rates, absence of severe contracture, and no oncologic events. For selected patients who are not candidates for autologous reconstruction, fat grafting may represent a valuable strategy to preserve implant viability, improve tissue quality, and reduce the need for salvage procedures.