The question is a big one, especially as we are now seeing teenagers considering things like breast surgery.  So I have some things for you to consider.

1. Are you done growing?  When did you have onset of puberty? Has your height changed at all?  Breasts and body are all about proportion.  You need to make sure your body isn’t still changing. 

2.  Is your weight stable?  Breasts can change with weight changes.  The breast is made up of breast tissue and fat.  The proportion of breast tissue to fat is different for every person.  For some, their breast size will go up and down with their weight.  For others, it won’t change at all.  Regardless, you seek a certain breast cup size to create an overall proportion with your body.  So make sure your weight is stable.  Especially when you go through life stage changes- college, new job, etc, it is common for your weight to change.  For example: you don’t want to put in implants which look proportionate to 150 pound body, which may look too large on a 135 pound body.  Another example: You don’t want to do a reduction and lift, and then lose weight, so then the lift loosens up and droops.

3. Babies? Anytime soon?  I know you are in your 20s, but pregnancy and babies change everything.  If you are on the cusp on babydom, wait to do surgery. 

4.  Think about the future.  Particularly for breast augmentation, consider future surgeries.  Fat grafting could potentially increase your breast size, and no future surgeries are needed, but there are issues with fat grafting (I am a fan, but it is not perfect- read my blogs) .  With implants, consider what size to do with the thought you will need to replace implants in the future and during pregnancies and breastfeeding your breasts will be bigger.  My general advice is don’t max out when you are young- leave yourself room to upsize down the road to tighten things up as you age.  With breast reduction, surgery can affect your ability to breastfeed. 

5. Why are you doing this?  Your body changes as you age.  There are things though which will not change with time- breast asymmetry, a funny shaped breast, no breast tissue at all.  These are usually good motivators.  Are you doing this for you? your self esteem? Or someone else?  If it is for a boyfriend, your implants will likely last longer than he will. If it is to get a boyfriend, wrong motivation.  Plastic surgery is not for others.  It really is for YOU.  Take this as a time to be introspective.  What are your expectations?

You can see my post on Quora as well: http://www.quora.com/What-should-I-consider-before-getting-a-boob-job

Breast reductions are a surgery I commonly perform.  It is great –not just from the lift and cosmetic perspective– it is great from a health perspective.  I have seen dramatic changes in neck pain, back pain, posture, and better body image.  Any woman who takes off her bra and watches her breasts plummet to her waist, can’t jog because of the bounce, or has deep digs in her shoulders from her bra knows of what I speak.

This study is out of Maryland, led by Dr. Shermak at Johns Hopkins.  In the introduction it states, “Despite the fact that complications after breast reduction surgery occur at a relatively high rate of 14-52%, breast reduction is one of the more commonly performed procedures in plastic surgery. ” 

She goes on to state, well known factors impair outcomes in breast reduction surgery:

• BMI (obese or greater)
• resection of 1000g
• smoking

But what about age?  So they did a study of 2156 breast reductions.  They looked at the different types of reductions: inferior pedicle / Wise pattern, superior pedicle with nipple graft, vertical lift (the one I do), and liposuction alone. 

What is considered a complication?  They included symptomatic scars, minor wounds requiring dressings, fat necrosis, infection, and seroma. 

Age groups were younger than 40, 40-50, and older than 50. 

So.  What did they find? 

•  Age over 50 is a “significant factor” impairing outcome, particularly with regard to infection and wound healing problems.
• Even 40-50 showed a trend toward complications

Why?

• They postulate due to lower estrogen levels.  They found women on hormone replacement therapy or birth control pills fared better, and those with ovaries removed did worse with regard to reoperation for postoperative wounds.
• Other theories include: decreased growth factors, diminished cell proliferation.

Of note: This conflicts with a study of Roehl et al who found complications were more common in the 30-39 year old group.  This paper postulates maybe the younger women in that study were different- high BMI, larger reductions- which made them get a breast reduction at a younger age.  They said in this study they controlled for factors affecting the outcome, so they could single out age alone.

So take home message?

Don’t wait to do the reduction.  If you are done with kids and breast feeding, and still have those hormones going, this study indicates it is better to do the surgery now. 

So I am now part of their IRB. 

Please see my other blogs on fat grafting.  I have patients at different stages of fat grafting for breast augmentation. 

http://www.laurengreenbergmd.com/category/breast/breast-augmentation-breast/fat-graft-to-breast/

The October 2011 issue of Plastic and Reconstructive Surgery has an article entitled (hold on- it is a long one-) “Sensitivity of the Nipple Areola Complex and Areolar Pain following Aesthetic Breast Augmentation in a Retrospective Series of 1200 Patients: Periareolar versus Submammary Incision.” 

They studied 1200 patients from 2004-2010.  It excluded any patients who had any other kind of surgery like a breast lift, inverted nipple repair, etc. 

Findings:

• 95% had unaltered postoperative nipple areola complex sensitivity at 6 months
• When pain occured it was always on one side only

For the 5% of patients who had pain, they found

• no differences for age
• no difference for implant positioning (in front of or behind muscle)
• there was a difference between where the incision was, with periareolar incision having a 2-3x difference

Issues: 

• retrospective study
• didn’t measure precisely using a pressure sensory device testing (as the other studies in the past have)

My thoughts?  The chance of having problematic sensitivity issues following breast augmentation is a low rate.  This study is not as elegant as others in the past, as it does not use a scientific tool to assess the change in sensation.  BUT it does have large numbers, and its results are statistically significant.

I do all the incisons.  The periareolar incision was a favorite of mine for years in the past.  I think it has many benefits: it is an easier to hide incision, particularly for my patients with darker skin tones; it can be reused if you have issues in the future; it is hidden under your bra; and it is where you will get a scar if you ever need a breast lift.  As for sensitivity studies, I have always relied on the original study cited by these authors which showed no change in sensation with where you put the incision, but rather how large you go.  This new study published this month indicates the prior study may be off, and attributes it to the small numbers in the study.  This is a valid criticism.  In educating my patients about incision choice, I will include this new study, coupled with what I have learned about capsular contracture rates, the periareolar incision, and biofilm.   The inframammary incision may be better.

Yes, yes, I know for many of my large breasted patients they want them off. Gone.  You are done with the whole breast thing.  I get that.  But there are two basic reasons you can’t or shouldn’t go super small.

1. Technically, the breast reduction is usually done with a breast pedicle.  In English, this means the blood supply to your nipple areola is coming from a chunk of breast tissue.  You don’t fully cut off the nipple and areola (phew!).  It stays attached to the underlying breast tissue. 

The droopier you are, the bigger and longer the pedicle.  You can’t make the pedicle too small- you need to keep the blood supply adequate, so your nipple and areola live. 

2. Aesthetically.  I find cup sizes are hard to talk about.  Getting slightly deep here (we are in California …) What is a B cup? A C cup?  When you say “B” and I say “B” are we picturing the same thing?  We know a 36 C versus a 34 C is not the same amount of breast tissue.  In fact, a 32D can look quite normal.

When you talk about size, it is hard to distinguish exactly what size you are currently and what size you want to get to.  A B cup is a pretty small breast.  I think the basic consideration is to think about proportion.  When you have been large breasted your entire life, you are used to the proportion it gives.  Your belly never has looked large because your breasts are larger. 

You may really want to be small in the chest.  I am happy to get you as close to where you want as safely possible.  Things to help you think:

• Find photos of the “ideal” size you like. 
• Look at your body.  Imagine your breasts are small. 
• Strap down your breasts in a really tight bra and imagine they are gone.  Do you like how you look? 

My advice is always to err too large, not too small.  We can always remove a little with lipo after.  It is hard to add some back.

So when is fat grafting to the breast not a good option?

• When you want to go a lot bigger. You likely can’t go from an A to a C  in one session.  Why is there a limit on the amount of fat you can move?  There is a limit on the amount of fat you can graft at one time due to the amount of space we have to graft into and just technical things.  If you are willing to do serial grafting procedures (multiple surgeries, spaced about 3 months apart) you could likely go larger.
• If you are young and/ or your breasts are small and tight AND you are not willing to do BRAVA.  BRAVA is the pre surgery breast expansion system.  It helps soften up your breasts and  open up the spaces to graft into.  If you do not do this, your tight skin will not stretch to accommodate the fat during surgery.  This tight skin will cause pressure which will cause the fat to die.  So you can do the surgery, but it just won’t be successful.  Can you get a preview of how you will look?  Dr. Khouri who champions the BRAVA system says you can’t add more fat and volume than how big you look in the BRAVA.  So the more you expand and open up the tissue ahead of doing the fat grafting, the better the fat will live and the more which will take.  Oh yes- you also need to wear the BRAVA after surgery as well.  It keeps increased blood flow and helps keep pressure off the newly transferred fat.
• If you have a strong history of breast cancer or are BRCA positive. There are new studies coming out showing radiologists can tell the difference from calcifications from breast fat grafting for cosmetic breast augmentation versus the calcifications seen from breast cancer, but if you have a strong family history, there is no reason to add issues to your cancer screening.
• You need to use BRAVA to preexpand, but you have a contraindication to it. Contraindications to BRAVA are easy scarring and hyperpigmentation, allergy to silicone, and others.
• You don’t have enough fat to graft.  Suprisingly, this is not as common as one would think- I just did fat grafting for breast augmentation on my typical skinny Bay Area woman and was still able to get enough fat for her desired size.  Should you gain weight before doing the surgery?  I am not a fan.  I think you should be the healthiest, best you.  Deferring to my favorite expert on fat grafting, Dr. Khouri does not recommend you go chow down on Ben and Jerrys to fatten up.  Why?  He believes you want to harvest the fat which is diet resistant- that way the transferred fat will survive better after transfer, even if you lose weight in the future.
• You are in the process of weight changes. Whether up or down, when your body is in flux is not a good time to do breast surgery.  You want your weight to be stable.
• You are going to have kids soon. Again, this is just another general reason not to touch the breasts.  Pregnancy and breast feeding change the breasts in a multitude of ways.  Have your babies.  Enjoy your time.  Add volume and fix what they did later.  If your timeline is years down the road, then it is okay to consider surgery now.  I will discuss the pros and cons with you.
• It is a new procedure. It is not terribly new.  Fat grafting has been gaining traction over the last decade.  But when compared to breast implants which have been around for 40 years, fat grafting for breast augmentation is the new kid on the block.  I get why this makes fat grafting a more difficult choice.  We don’t have tons of data on what it will be like 20 years down the road.  But unlike implants, the fat is your own tissue.  It is transferred to another area which is similar, as the breasts are primarily made up of fat.  It is very low tech- you are just using some simple cannulas and techniques.  I wish I could give you reassurance and statistics which had been gathered over the past 40 years, but I can’t.  Using your own fat makes sense to me.  I don’t see any glaring issues with it, and I have met with and studied those who have been doing it for 5+ years.  I have seen some fantastic results and spoken with patients who had rave reviews.  But if its newness makes you uncomfortable, I understand.

So for most of my patients, there are few reasons not to consider fat grafting.

As I have discussed before, BRAVA helps with this in two major ways.

• It helps expand the tissue to allow for new spaces for the fat graft to be placed.  Imagine your breast is a collapsed heap of chicken wire mesh.  We want to put a fat cell into each little opening in the mesh, which is hard to do when it is collapsed in a heap.  Now imagine we used something to pull on that mesh and lift it up and out.  The spaces in the chicken wire are now more accessible.  The thought is the better spacing and placement of the fat, the better the fat survival, the lower the issues like fat loss and calcification.
• The second way is to increase the vascularity, ie blood flow to the area.  More blood= more nutrition for the newly moved fat cells= fat cells live.
• I would also venture to say the BRAVA helps keep you from doing things like putting pressure on your new fat in your breasts (tummy sleeping with the BRAVA on just can’t be done) and serves as a reminder, “Hey! you just had surgery! Take it easy!”

So who needs BRAVA?

• Tight tissue.  This can be from having had a mastectomy and/or radiation; being 22 and having tight small breasts with great skin tone; or being 42 and having tight small breasts with okay skin tone (yes, these women do exist.)
• Poor blood supply to tissue.  Particularly seen in radiation patients. 
• Little fat to use to transfer.  Translation in English: for you super skinny women who have almost no body fat, it is tough to harvest fat on you.  We want to maximize the chances every little fat cell we get has a good chance of surviving after moving it.

So you either buy into the BRAVA thing or you don’t.  I know from our plastic surgical meetings some doctors who did not use BRAVA noticed improvements in their patients when they started to use it.  My own experience seeing pre and post op patients when I was in Miami was you could tell who was using it, and they seemed to get better faster results.  Yes, BRAVA is a pain.  But a good outcome from surgery is priceless.  After all of my research and mythbusting of plastic surgery products and procedures which are hype and not science, I think BRAVA really does something.

What is this thing?  BRAVA  is not new.  It has been out for over a decade.  Its original claim was to increase the size of your breasts without surgery.  Woo hoo! Sign us up!  If it works, why did this not catch on like wildfire?  It does work.  But it just doesn’t increase the size much.  The size ranged from 35-250cc of lasting increase in size.  It is cumbersome, takes a while, and requires dedication. 

How does it work?  It works by using gentle tension to cause growth.  Basically you put suction cups on your breasts (which are made to give a specific pressure) and you wear the cups nightly for months to cause the size to increase.  See this link for more information:  http://www.mybrava.com/the-science-behind-brava.asp

It was a good idea, but even with good compliance women usually only got about a 150cc improvement.  A lot of work for a small gain.

So what is causing a resurgence in BRAVA interest?   Fat grafting.  Transferring fat to the breast was the third rail of plastic surgery for a long time due to issues with calcifications and cancer surveillance or issues with losing the transferred breast fat volume and fat loss. We thought it just didn’t work. 

But our techniques and understanding of fat grafting have evolved.  We do more microfat grafting.  We treat the fat differently.  We have researched the ideal size of fat globules to survive, how to harvest them, how to process them.  In our new era of fat grafting surgery, BRAVA  is interesting.   BRAVAexpands the tissue to increase the area we can graft to, and it also increases the vascularity of the area. 

In simple terms, when you move fat from one area of the body to another, it is a free graft.  It is like moving a new plant.  You need a fertile bed and water so your new plant can grow.  BRAVA helps with creating fertile space and improving the blood flow.

I spent time with Dr. Khouri in Miami a few weeks ago.  I saw BRAVA and its effects.  Particularly for the breast reconstruction patients after breast cancer, I could see those patients who had been compliant with the BRAVA and those who were not.  And those who were using BRAVA diligently had better results.

More blogs to come. Until then, check out BRAVA’s website:http://www.mybrava.com/home.asp

I just finished time in Miami with Dr. Khouri where I was able to see breast reconstruction using fat grafting.  The results are amazing.  Soft, natural breasts.  Jiggly.  Sensate.  All you, your fat, moved from where you don’t want it to where you do.  It works in radiation fields and improves the skin quality after radiation.  The skin discoloration and firmness reverses back to near normal.  Indented tethethered scars can be released. 

This is not magic.  It uses basic science and “low tech” instruments.  It is part of what I love about it.  This technique makes sense to me. 

Wow what you can do.

Who is a candidate?

• Anyone who has had a mastectomy defect. 
• First stage can be done with your mastectomy (immediate reconstruction) or delayed (after you are done with all of your treatments).
• You can have had radiation.  This makes the grafting harder, so it takes 3 surgeries to get to the point you would have been at if you had not had radiation.
• You can  have had prior reconstruction with an implant.  Women who have failed implant reconstruction for capsular contracture, infection, migration, “implant cripples” are good candidates.

How?

Fat grafting for breast reconstruction is not a one surgery operation.  I know the idea of multiple surgeries is offputting for many, but those who know breast reconstruction know tissue expander implant reconstruction is not a one stage thing, and usually free flap reconstruction has small touch ups (or big ones if needed). 

• It takes multiple steps over months.  This varies if you have had radiation, if this is immediate or delayed, how much volume you need, etc.
• There are usually 3 -5 surgeries, spaced 2-3 months apart.
• Only the mastectomy is an in patient procedure.  The rest are done outpatient. 
• The patients I saw were mobile and returning to life faster than what I see with implant reconstructions.
• You need to do some prep work.  See my upcoming blogs on BRAVA.  From what I have seen with patients in various stages of reconstruction, the more compliant you are with BRAVA, the faster you get to your reconstruction being done.

I just got back from my second training session with Dr. Khouri. My journey started two years ago when I attended his fat grafting course. He along with a handful of other doctors (Rigotti, DelVecchio, Coleman) is a foremost expert in fat grafting to the breast. They have many published papers on fat grafting. Khouri is the guy asked to lecture all over the country (and world), showing his work and teaching plastic surgeons how to breast surgery without breast implants and free flaps. And he is someone who did a micro fellowship and used to do all the big free flaps. Fat grafting for breast cancer reconstruction isn’t something he is doing because he couldn’t do a TRAM- he is doing it because it is better.

I went again to see him in action this time- in the operating room- where women fly in from all over the country to have him perform his magic. Most of the patients are breast cancer patients. Some of them had been reconstructed with implants and had issues: hardening, poor matching, poor sensation, migration, etc. Others had never done a reconstruction for a multitude of reasons. Some had radiation, some did not. And over the past week I saw back to back surgeries and post operative patients in all stages of repair.

Fat grafting makes sense to me. Why not use your own tissue to make a breast after you lost it to cancer, or use your own fat to make your breast larger? Why not move fat from where we don’t want it (yahoo!) and put it where we do?

So why did I not start two years ago after the first course I attended? Why? I am wary of anything “new.” I am never the first to jump on a bandwagon. I am critical of any doctors who are trying to make a new technique. Is this real? or is this a marketing gimmick? But I am impressed by everything I saw. What these doctors are doing is low tech- this does not need fancy lasers and instruments. They have studied it well, over years with serial MRIs to look at the architecture, volume, and changes, and they honed their techniques to improve fat survival. These are not doctors who are trying to make me buy a super-cool-fantastic-ultrasonic-laser which is going to make a breast with no downtime or scars and I only need to buy the machine for $$$$.         

                                                                                                                                                                                                                                                 Dr. Khouri is a doctor who reminds me why I wanted to become a plastic surgeon.  He is a thinker and tinkerer with great surgical training.  The work he is doing with fat grafting and a technique called PALF is amazing.  He is applying his fat grafting techniques and scar releasing  (with small tiny releases to mesh it) to burn scars and hand surgery for Dupytrens contractures.  The results are amazing and scarless.

.

I am a smart girl. These plastic surgeons are thoughtful innovators. For the past decade they have been refining their technique on how to do fat grafting. What size cannula? fat droplet? Do you centrifuge the fat or not? What speed, for how long? Do you use BRAVA pre expansion and post surgery? Are there patients you can’t reconstruct? What are the limitations?

Instead of me trying to invent this wheel, I decided to go learn from the best. They have tried every permutation and studied it. There are some limitations and issues, and I will address these in future blogs.

I am a convert.

I left Miami excited to get home and start. As I said before, I am critical or new things. I have been dancing around this idea of fat grafting to the breast for a few years.  Fat grafting is not new.  The refinements and technical points for breast augmentation and reconstruction are what I needed to hone.  I got it.

Sign me up.