The Latest on Fat Transfer to the Breast

Intro

For as long as I have been a Plastic Surgeon I have been jokingly hearing the question, “Hey doc, can’t you just take some of the fat from here and put it there”?  Until recently, the answer had always been “No”.  However, as we are understanding more and more about the biology of fat we are now able to say “yes” to this frequent inquiry and are able to get good results.  I say “good” and not “great” because fat transfer does have limitations.

My Street Credit

In addition to being a board certified plastic surgeon and performing fat injections myself , through attending several meetings I  have had the chance to learn the latest in fat grafting science and techniques from the world experts. I have heard Dr. Sidney Coleman, of Manhatten, lecture extensively on fat grafting to the face, hands, breast, and body.  Dr. Daniel Del Vecchio of Boston, and Dr. Roger Khouri of Miami, the masters of large volume fat grafting to the breast, also imparted their vast knowledge and experience on fat only breast augmentation.  This blog is as credible and as current of information as you will find on the topic.

The Teachings of the Master of Fat Transfer to the Breast

Dr. Roger Khouri of Miami has the world’s most experience with breast augmentation with fat.  To date he has performed over 1000 fat grafting procedures to the breast and has published several articles on his techniques and outcomes.  He discovered that the keyfat ribbons to getting large volumes of fat to survive is dependant on the actual size of the particles of fat that are being transferred, the way the fat is distributed in the recipient site(breast), and the ability of the donor site to accept tissue.
Firstly, the fat droplets that are collected have to be very small, < 2 mm in diameter, for the fat to survive.  Next, when these fat droplets are introduced they need to be surrounded on all sides by healthy bleeding tissue.  This ensures that these small fat particles will receive oxygen and nutrients from the adjacent tissue before becoming incorporated.  Lastly, the recipient site, or breast in Khouri’s cases, has to be loose enough structurally to accept the fat.  In a nutshell, if too much fat is crammed into too small a space then it will die from too much pressure.

The Technique

First, the fat is harvested via liposuction. This fat is usually taken from the thigh or lower abdomen. It is then separated into its 3 components of  water, oil, and fat cells. It is the fat cells that we want. The next step is the tricky part. The breast has to be able to accommodate the fat.  In many women their tight breast tissue and skin limits fat placement.  In these cases, the breast tissue has to be expanded before surgery.  This is accomplished with the BRAVA device.  This device looks like something from a 70’s sci-fi film or an Austin Powers movie(One swedish made…), but it is real, and it works.  The BRAVA device is essentially a pair of breast suction cups that suck on the breast and stretch the skin.  This creates space for the grafted fat and as an added bonus also improves the breast blood supply.  This is worn intensely for 10 hours a day, every day, for 2 weeks prior to surgery and for one week after grafting.(see below)

BRAVA

Limitations/Caveats

1) Size – We are limited to grafting 250-300 cc(or ml) of fat.  This can move an A cup to a B cup, or a B cup to a C cup, but will ot jump an A to a C.  Therefore, results are still significant, but modest.  Fat grafting will not achieve what an implant can.

2) Shape – Again, we are limited.  Fat grafting adds volume and can do some shaping.  However, fat grafts are still subject to gravity and will not yield projection, or how far the breast sticks out from the chest.  Projection is still best achieved with implants.

3) BRAVA – Often the BRAVA device is necessary for pre-expansion prior to fat injection.  A patient has to be absolutely committed to wearing the device if surgery is to be successful.  Again, the device has to be worn every day,10 hours a day, for 2 weeks prior to surgery.  Then, the device is worn as much as possible, preferably continuously, for an additional week after surgery.

4) Cost – The BRAVA system alone costs $2500.  Then you add surgeons cost which is basically the cost of a breast augmentation + the cost of liposuction.  Then you add in anesthesia and hospital fees.  Lastly, you may need more than one injection procedure to get your desired results.  This additional procedure will also have a cost.  Overall, a breast augmentation is a cheaper option which accomplishes more.

5) Safety – Concern has been raised over the possibility of fat injection interfering with breast cancer screening.  Fat graft death can result in oil cysts and calcium deposits in the breast.  These findings can potentially affect mammogram interpretation. More concerning is that there has been research showing that when fat stem cells, which are abundant in transferred fat, are transplanted into mice containing breast cancer cells, that the cells become more aggressive and more likely to metastasize.

Conclusions

Overall, I think fat grafting is a good procedure that is here to stay.  Although it cannot accomplish all the things a breast implant can, it can yield “good” results with a modest and all-natural breast augmentation.  That being said, at this time I am holding off on offering fat grafting for breast augmentation. The animal studies are concerning for what these stem cell rich fat cells might do to any preexisting breast cancer cells.  As breast cancer occurs in 12% of the population, I am not willing to take the risk of worsening an undiagnosed breast cancer.

 

How Botox can Effect our Mood

Botox has long been utilized in the medical community for treating muscle spasms, excessive sweating, migraine headaches, and Botox-Logomost notably, facial wrinkling. However, over the last few years more and more research is revealing that by altering facial expression with Botox we can also alter mood.

First of all, let’s get a little background. For decades researchers have known that facial expressions can effect changes in mood just like mood effects facial expression. It began in 1989, when a psychologist named Robert Zajonc published one of the most significant studies on the emotional effect of producing a smile. During his study, subjects repeated vowel sounds that forced their faces into various expressions. To mimic some of the characteristics of a smile, they made the long “e” sound, which stretches the corners of the mouth outward. Other vowel sounds were also tested, including the long “u,” which forces the mouth into a pouty expression. Subjects reported feeling good after making the long “e” sound, and feeling bad after the long “u.” According to his hypothesis, the facial changes involved in smiling have direct effects on certain brain activities associated with happiness.

Several similar studies followed. One had subjects make the positive and negative expressions by holding a pen in their mouths,
either protruding outward for a pout or held lengthwise in the teeth to make a smile. This study yielded the same results. In another experiment, one group of subjects was shown pictures of various facial expressions; another group made those facial expressions and a final group made those expressions while looking in the mirror. The evidence all pointed toward smiling as a cause of happy feelings. Subjects were asked questions that pinpointed their emotional state before and after smiling, and they overwhelmingly scored happier after smiling. In the study involving the mirror, subjects who watched themselves smile saw an even more pronounced change in mood than those who smiled without the mirror, and the subjects who merely looked at pictures didn’t experience that change at all.

So now that we’ve established that smiling can actually make you happier, what would happen if we weakened the muscles that cause you to frown. This was the question that has been answered in more recent research. In 2006, Finzi et al. published a case series in the Journal of Dermatologic Surgery where 10 depressed patients were injected with botox into their vertical glabellarScowlfrown lines(ie. vertical lines that run between your eyebrows when you scowl or are angry). Within 2 months, 9 of 10 patients reported resolution of depression and the 10th had an improvement in mood. In 2012, Wollmer et al. published a paper in the Journal of Psychiatric Research where they conducted a randomized double-blinded controlled trial studying the effect of Botox injection on depression. Thirty depressed patients in each study group received either botox or placebo injected into their glabellar frown lines. At 6 weeks after treatment 47% of the botox study patients showed significant improvement in depression scores vrsus only 9% in the placebo group. In August 2014 an additional study by Wollmer et al again proved this Botox and depression relationship. Only in this more recent study, they showed additional positive psychiatric effects even after the cosmetic effects of botox wore off.

In conclusion, is highly likely that the effects of Botox, and maybe even other cosmetic treatments, may effect our psychology in more subtle ways than we realize. I can’t help but think in this era of selfies and increased personal visibility granted by social media sites such as facebook, twitter, and instagram, that we are looking in the mirror more often than ever. I hope that we’re smiling.

DG