oh my.

They don’t know what this person was injecting, but being a foreign substance, it 1. got infected and 2. the body didn’t like it so it spit it out. 

There are more and more of these cases popping up: a NY woman injecting free silicone, the Florida injections of super glue, tire sealant, and cement.   I don’t have a lot of patients seeking to enhance their bottoms.  If you want a larger or curvier bottom, the best way in my opinion to get more curve is to 1. take down the surrounding areas like the love handles and outer thighs using liposuction, to help define the buttock area more, and 2. fat graft into the buttock to give more volume.  (This is a surgical procedure, and in my view should be done by a board certified plastic surgeon well versed in liposuction and fat grafting.) 

I cringe when I read these stories.  I get these hotel room, back room injections are cheaper.  But are they?  When you get infections and ER visits and operations to try to fix things… and the likely irreversible scarring and disfigurement which comes with it…. I don’t understand.  In this age of computers and information, please do your homework. 

• Safe surgeon.  Look at their credentials and training.  Research them.
• Safe technique and substance.  Research it.  Free silicone has issues which are well known.  And who would ever think cement and tire sealant are good things to inject?
• Safe place. When doing a large scale injection, you need sterile technique.  Otherwise you can get infections. 

http://abcnews.go.com/GMA/WaterCooler/wireStory/nc-woman-charged-buttocks-injections-bad-15114376

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.

Many of the stores in Town & Country Village in Palo Alto will give 10% of your purchase from stores and restaurants to BCC. 

• For those of you not in the know, this little shopping mall has become a haven for cute stores and nice restaurants.  So dine at Calafia Cafe, or get a burrito from Lulus, or an ice cream from Cold Stone Creamery… Buy some baby gifts at Day One, take your daughter to create it ceramics, or get kids hair cuts at snip its. 
• Many of the stores are also giving YOU 10% off in addition.

Also Keplers Books in Menlo Park will donate 6% to BCC if you mention “BCC” at the register.  For a complete list of events click here.

Breast Cancer Connections is a wonderful FREE center for those with breast cancer and their families.  For anyone who has had breast cancer, it is amazing how your world is turned upside down in a day.  It can be overwhelming for the patient and family when you have a new diagnosis of breast cancer. 

 I speak at their open house on their informal discussion rounds with doctors on Thursday nights.  For more information on BCC of Palo Alto, please click the link.

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.

Fat is a magical substance.  We are the tip of the iceberg in understanding it.

Fat is full of stem cells.

Stem cells seem to be magical too.  Many think they can help repair our bodies.  Who wouldn’t want to repair our old worn out middle aged body parts?  I can only imagine how damaged a poor NFL quarterback is after years of getting hit by men the size of a truck. 

People have claimed stem cells can do about anything.  My ASPS society has a position paper stating “stem cells are promising” but there is little hard scientific research to back many of the claims.

I have seen fat grafting improve things.  I have seen the overlying skin get softer, scars fade.  I have talked to women who after breast cancer had neuropathy of their breast skin or into their arm which reversed after they had fat grafting to the breast and armpit area.  So the fat somehow is nurturing these hurt areas back to health.  Most think it is the stem cells in the fat which does this. 

I don’t know what Peyton Manning’s goal was with the stem cells.  Was it to help with nerve pain? Was it to try to heal the bone?  To avoid a surgery?  Was it like putting fairy dust in the wound and you hope it does something good?

As I have said in my many prior blogs, stem cells are great.  They have some issues we already know about.  They have benefits we already know about.  I think my society has it right- Stem cells are promising.  Let’s keep researching to figure out how to use them.

I am sure the sport world will update us on Peyton and if the stem cells are working…He sure brought a lot of attention to stem cells.

So at my favorite TIPS Plastic Surgery meeting in San Francisco in June we discussed many of the new things out there.  What I am repeating here is what I learned there. 

• platelet rich plasma.  Good stuff, may help fat survive, BUT you need a large amount of blood to get enough to help.  Likely not feasible.
• stem cells.  Studies showed if you supplement fat with stem cells you can increase survival.   Again a feasiblity issue- you need a lot of fat for a tiny plug of stem cells.  Many women seeking fat transfer don’t have much fat to transfer, much less extra liters of fat to spin down for a small plug of stem cells.

There is still a lot of controversy.  Yoshimura out of Tokyo has looked at stem cells a lot.  He focuses on the face.  He published a study in the Aesthetic Plastic Surgery Journal in 2008 showing adipose stem cell enriched fat showed increased transfer efficacy.  (IN NON DOCTOR TALK= When you move the fat, if you add stem cells to it, more of it lives.)  The ratio of stem cells to fat he used was high.  An issue remains – in order to get that amount of stem cells you need to harvest a lot of fat and distill it down to get the little tiny amount of stem cells.  Again, as I alluded to above, maybe stem cell enriched fat is better for smaller areas, where you are grafting less fat.  For large areas, it can be hard just to get enough fat to transfer, much less get extra liters of fat to spin down for stem cells to enrich the fat.  And many in the plastic surgery field say you don’t need to enrich the fat with stem cells, as fat is a rich source of stem cells in itself.  They argue when you transfer fat, you are transferring stem cells already in the fat.

And there are other basic questions about fat grafting which we don’t fully understand yet.  (This gets into more science-y stuff, so some of you may tune out)

• Do the cells you transfer live?  Or do the cells die and release something the neighboring cells like? 
• When he looked at the cells 4 weeks out, he found a lot of cells are dead, but there were new cells from the progenitor cells.  (It was like you tranferred a mommy cell which gave birth to new baby cells and then the mommy cell died.)
• At 3 months he found no more new fat.  At that point you could see oil cysts. (So things tend to stay stable after 3 months.  Until that point there is more flux with fat cells- some which have died are bdisappearing and the new cells which formed are growing)

From his research he hypothesizes during the first 3 months you see tissue repair, then for the next 9 months you see stabilization, oil absorbtion, or oil cyst formation.  Understanding what happens to the fat when we move it will help us be better at helping it survive in its new location.

All good stuff to help us make fat grafting techniques improve.

There are all sorts of claims out there of ways to increase fat survival.  Which of these are necessary?  How much do they help?  What are the issues with them?  I love the analogies to gardening and new plants.  If you think in this way, the whole fat transfer and graft thing makes more intuitive sense.

We are still at the beginning of our new era of fat grafting.  We know some basic really low tech things:

• Time is critical.  Fat cells do not last well outside of the body.
• We need to prep the recipient site to make it a more fertile bed.  We know that preexpansion and volume maintenance may help with this.
• How we harvest is important.  There is an ideal fat globule size- if the fat globule is bigger than this, we get increased fat loss, as it can’t get enough blood supply so it dies.
• The processing of the fat is important- what pressure are we removing the fat at?  Hand held syringes seem less traumatic, but a study showed that how much you pull the syringe has an effect.  So a teeny tiny 10cc syringe when pulled back to 10 cc has 600mm of pressure. (!)  This is more than a liposuction machine at low or medium setting, and too much to not damage the fat cells.

We get some feedback on how we are removing the fat.  The more oil we see, the more cell damage there is.  When the cell wall is hurt, there is release of LPH, triglycerides, and increased enzyme activity.  These all indicate damaged fat cells.  Damaged fat cells don’t live. 

So. Be gentle to your newly moved plants.  Remove them gently, handle them with care, put them in a new fertile bed, and water them well.

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.