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.

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.

For the Palo Alto women with too much to do today and need the down and dirty synopsis:  Avoid the implant if you can.  If you need it for volume, then you need it.  If you are doing an implant just for shape, particularly if you are a full C cup or more, there are things you need to think about.

Why? 

First let me say the old school teaching was you always needed an implant.  “You won’t get good shape without an implant.”  ” You need it for fullness.”  yadda yadda.  This was likely true for some of the lifts, particularly the periareolar lift (donut) which tends to flatten the breast, and the inferior pedicle (anchor scar pattern) lift.  I don’t think this is as true for the lollipop vertical lift.  It is true there is not as much fullness in the tip of the upper part of the breast without an implant. (Mostly seen when you are naked. With a bra on, this fills out.)

Breast lifts are great to reshape and lift the breast.  If you have a sizable amount of natural tissue (read C cup and above), gravity will cause your breasts to age over time.  Even if I lift it and make it super shapely– and you wear bras 24 hours a day, you are done with kids and breastfeeding, and you promise never to jog–you can’t stop gravity. (Sorry! I have applied for a magic wand.  Still not here in mail.)

So due to this gravity stufff , if you use an implant, things which will happen:

• The weight of the implant adds to the weight of your breast.  Heavier breast= more aging with time/gravity= more droop.
• Your natural breast tissue will age faster and more than the implant.  This means in 10 years or 20 years your implant will still be up there, but your natural tissue will hang low, kind of hanging off the implant.
• You have all the risks of the implant: infection, malposition, migration, capsular contracture and hardening, and implant deflation. 
• You guarantee yourself a second surgery at some point to fix it all.  That surgery may be in 10-20 years.   How is your current health? How old are you? How will you be then?

If you are an A/B cup and want to be a C/D, then you need an implant for volume.  That is a different story.  My patients who are naturally a C or more tend to want the implant for shape.  Maybe they do want to be a little larger, but when deciding to go larger you need to consider the negatives I discussed above.

I do breast lifts with implants, but I discuss this in detail.  Think about your ideal now, in 10 years, and in 20 years.  What are you willing to do for it? Is another surgery down the line okay? If you don’t go larger will you be unhappy?  If more volume is a must, then do it.  If more volume is a I-would-kinda-like-it, maybe-it-would-be-fun, I don’t advise the implant.

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.

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.

Bacteria in biofilm grow as communities, not single cells.  They are very resistant to our body’s defenses.  One of the first defenses your body sends in to attack an intruder is the phagocyte.  It is a white blood cell which comes in and finds the intruder.  It will bind to it, engulf it, release enzymes to attack it.  It calls in its friends to let them know your body is under attack. 

Phagocytes can’t get rid of biofilm.  The scientists discuss something called “frustrated phagocytes.”  They try and try to get rid of the bacteria in the biofilm.  And they get madder and madder.  And they release more enzymes.  Many think this is what leads to bone breakdown around prosthesis.  We know injecting steroids can help sometimes with this.  Why?  It is calming down those angry, frustrated phagocytes.

Biofilm bacteria are colonies of different bacteria which are LINKED.  (This is the scary part.)  They have intercommunications which share cytoplasm- so they exchange DNA, including resistance to antibiotics.  There are also electrical connections.  They showed a study where one end of a biofilm was exposed to an antibiotic, and within seconds the whole biofilm reacted, even those parts far away from where the antibiotic was.

Eek.

When you do cultures, you can’t culture the biofilm.  It is stuck like tape onto your body.  Cultures only can get the one or two bacteria which have been shed off and are floating in your blood or saliva.  The biofilm scientists believe cultures are misleading us.  They can only detect the floaters.  And the dose of antibiotic which kills the floaters is much less than that needed to kill the biofilm.  1000X less. 

Egads.

This whole thing is much more complex.  We need bacteria.  We have good bacteria.  Somehow, with all of this stuff we are discovering, we are still walking around talking, eating, dancing, and working.  Somehow we are still here.  And we get a bad cold or sinus infection, and we heal.  Sometimes with antibiotics, sometimes without.  We have a lot to learn.  As I have discussed in other blogs, we need to separate out which bacteria are bad and make us sick, and which ones are okay.

Biofilm is interesting.  I think it will be a integral part of improving how we treat infections, and how we approach implantable devices in our bodies- from hip replacements to cardiac valves to breast implants.

Yes, this is another blog from my favorite meeting, the TIPS Plastic Surgery meeting in San Francisco.

Cultures- skin cultures, swabs, blood cultures- are likely going to be replaced.  A study came out showing chronic wounds are polymicrobial.  They had a study of 1400 wounds.  They did cultures and found staph aureus, pseudamonas, and enterococcus were the main offenders. 

But are these the real offenders?  I have been taught since I was a wee medical student skin infections are almost always staph and strep.  But at this meeting with biofilm experts, they postulate staph and strep are big offenders in infections, but they are not the only ones.  We attribute their being the primary offending bacteria because they grow in culture.

But what if our cultures are wrong?  What if the cultures have a bias towards those bacteria which we can grow on agar plates? 

So new technology has evolved where we don’t have to grow bacteria out in culture to assess what bacteria are there.  It is PCR technology.  IBIS PCR got the gold medal award in the Wall Street Journal 2009 technology innovation award.  Haven’t heard of it?

What this technology does is it analyzes a sample of blood, tissue, whatever, and it tells you what bacteria are in it.  As it does not need to be grown out, it will detect the anaerobic and hard to grow bacteria better.  It also detects the bacteria if you are on antibiotics (for those MDs out there reading this, this could be an end to “cultures will be negative since they are already on antibiotics.”) 

They found interesting things: Bacterioides was in 100% of the surgical site infections.  All cultures on these wounds had come back negative.  Bacteroides just couldn’t grow in cultures or labs.  They found fungi in 23% of wounds.  They found a lot of cornybacterium (not thought to be a usual culprit in wounds) and found it was tenacious and hard to treat.

The PCR test gives an initial report in 6 hours.  It includes information on antibiotic resistance, particularly MRSA and the like.  The final report is in 3-4 days.  For those MDs who have ever sent cultures, what a change to get more information back so quickly. 

It is new technology, and not in most centers.  Again, it is likely important for the chronic nonhealing wounds or very sick patients with infections.  A challenge to this new information is determining which bacteria are bad? pathogenic? making us sick? versus which ones are just standing by?

We don’t want to treat all bacteria.  We need bacteria in our body and on our skin.  It reminds me of a freind who tented their house to get rid of termites.  It got rid of all the bugs, not just termites.  For a year after there were no spiders and other bugs, and they had big ant problems.  Somehow the bug population of the house normalized again, and the ants were not a problem.  So how do you get rid of just the termites? How can you get rid of just the bugs which are harming your house but leave the good ones?

And we need to beware of resistance.  We hear it all the time now.  No antibiotics unless you really need them.  The superbugs- bacteria resistant to our normal antibiotics.  Biofilm has been shown to be a very integrated organism, where they can share resistance.  If we treat all bacteria with equal force, will we make bacteria which aren’t so bad into bacteria which can hurt us?

NOT ALL WOUNDS NEED THIS.  If you fall off your bike and get a scrape, you do not need to rush out and diagnose your wound bacteria and go on special antibiotic gels and treatments.  This is for wounds or issues that don’t heal and go on for months. 

You can create a window to treat it by debriding the wound.  In English, debriding means getting rid of the top layer, that waxy exudate on your skin, the dead cells and tissue.  As they say on TV shows, YOU SHOULD NOT TRY THIS AT HOME.  Other physicians refer to us plastic surgeons to do this.  Why?  Because there is a fine line between removing what should be removed and removing too much.  If you remove too much you will get scar, contour deformities, and ickiness.

So how to treat biofilm?

• Debride.  Frequently.  You will be seeing your doctor to do this every couple days.
• Selective biocide.  In English, that means  you can use a treatment which helps get rid of bacteria, but not the normal good cells.  An example of a nonselective biocide is peroxide- it kills bacteria, but it also kills your normal healthy cells. 
• Antiobiofilm.  These are enzymes and gels which help break down the biofilm
• Antibiotics.  These are personalized antibiotics tailored directly to what they found on your test.  What bugs you have and what they are susceptible to cannot be gotten from a culture.  This is done by PCR.  You have to treat usually “long and strong,” and you have to reassess and potentially rotate agents if resistance is growing.

So if you have a nonhealing wound, that has gone on for months, you should look into diagnosing the biofilm.  Some of the results they showed for diabetic foot ulcers and other what seemed to be “impossible to heal wounds” was amazing.

When I mentioned biofilm to my doctor friends, no one had heard of it.  Is it some new scar treatment?  Is it an environmental thing?  It sounds good- bio, green, high tech.  But it is not good.  It is bad and causes some of the issues plaguing surgeons and patients who have any kind of implant. 

First, lets start with why you should care.  Wounds are a huge issue in our society.  Chronic nonhealing ulcers, diabetic feet, osteomyelitis infections.  You, healthy Palo Alto reader, are sitting at home, thinking “Well, that is not me.”  No, maybe.  Not yet.  But as you age and your tissue breaks down faster and is harder to heal, it can become an issue.  And if any of you have hip implants, knee implants, chin implants, breast implants- any foreign object placed in your body, biofilm is incredibly important. 

I spoke with a friend recently who had a broken ankle as I was excitedly relating the information I got at this meeting, and she said, “My doctor told me my foot is not infected.”  I would think she is wrong.  There is a big difference between active infection- that rip roaring, red, pus filled infection, and biofilm.  Biofilm is subtle. Low grade.  But affecting you.

Also, many think the biofilm of chronic wounds acts just like cancer does.  It operates outside of host immunity. (In english that means that our body’s defenses don’t attack it.  We let it stay there).  It hijacks our body to do its work.  And it grows and mutates. So understanding biofilm may lead to advances in how to treat cancer. 

Biofilm is so exciting there is an institute dedicated to it.  This is a new fronteir of infection control and medicine.

So that is why we care.  WHAT IS BIOFILM?

There are two basic ways bacteria affect your body. 

• Infection.  This is where bacteria attacks you, it comes fast, and there are lots of symptoms.  As I stated before, this is what you think of when you think of infection.  Red, tender, swollen, pus.  It responds to antibiotics and gets better.
• Biofilm.  This is where bacteria attacks you but you don’t really know it.  It colonizes.  It hijacks your cellular functions, but does so in a less aggressive way.  Biofilm allows your body to keep operating, but not as well.  This is thought to be why people have those nagging wounds that won’t heal.  It is implicated in capsular contracture for breast implants.  And it is hard to treat.

Why does biofilm stay? Why doesn’t your body break it down? Why don’t antibiotics treat it?

Ah.  The stuff for another blog.