This month’s October 2011 issue of PRS (our plastic surgery journal) looked at a new kind of tissue expander breast implant to use for breast reconstruction.  A new system “AirXpander system” out of Palo Alto provides “controlled, gradual and comfort guided tissue expansion in breast reconstruction.”  This would eliminate the need to do the expander fillings like we have traditionally done (every 2-3 weeks you come into the office for an almost pain free injection of saline into your breast tissue expander.) 

The article is titled “Patient Activated Controlled Expansion for Breast Reconstruction with Controlled Carbon Dioxide Inflation: A Feasibility Study.”  Please note key words in the title: FEASIBLITY STUDY.  This is not out yet in your local hospitals.

Benefits of this?  Smaller, more frequent expansions.  You don’t need to go through the skin, so likely a lower risk of infection and capsular contracture/biofilm.  The system involves a dosage controller which is outside of the body.  It wirelessly tells the implant to administer carbon dioxide into the expander.  This can be controlled by the doctor and by the patient.  There is a lockout period, and other things.

Findings? Time to full expansion was a mean of 15 days.  It was 1/3 of the usual time needed to do expansion normally. 

So can you get this yet? No.  There were issues: if you leave the expanders in,  you need to redose the carbon dioxide.  If you need to remove any of the carbon dioxide, you disable the device and would have to remove it.  Also there is a change in altitude restriction, causing discomfort, so the patients were not allowed to do air travel.

But it is interesting.  Oh brave new world.  Who would have thought we may have wireless devices with internal tracking to help us inflate our breast tissue expanders?

BRCA is high in certain ethnic groups, particularly

• Ashkenazi Jewish  (Eastern European) women.  Risk of being a carriers  is estimated at 7-10%.  Your insurance may cover your testing if you have
• Any first-degree relative with breast or ovarian cancer.  (parent, sister, child)
• Two second-degree relatives on the same side of the family with breast or ovarian cancer.(aunts and uncles, nieces and nephews, and grandparents)
• If you are not of Ashkenazi Jewish descent, you may want to get tested for BRCA if you have: 
  • Two first degree relatives with breast cancer, one of whom was diagnosed before age 50
  • Three or more first- or second-degree relatives with breast cancer, diagnosed at any age
  • Both breast and ovarian cancer in the family
  • A first-degree relative with cancer in both breasts
  • Two or more relatives with ovarian cancer
  • One relative with both breast and ovarian cancer
  • A male relative with breast cancer

Know though that even women at risk may not meet the “insurance criteria” to get tested, and the test itself is not cheap.  So what do you do if you want to get tested and don’t meet criteria?  You can pay for the test with or without insurance.  Another method would be to do your own genetic testing.  Groups like 23 and me do genetic testing.  The cost is about $200 ($99 for the kit and then a monthly fee of $9/mo for a year).  They test for 3 specific parts of the BRCA genes.  To get more information please go to their website.  Please note:  BE PREPARED TO KNOW YOUR RESULT.  This is not something I recommend to do without the advice and counseling of a genetic counselor or doctor.  Knowing you are BRCA positive will definitely have an effect on you, your family, what you choose to do, and possibly your insurance. 

As for how it may affect insurance, please see GINA synopsis as summarized by 23 and me. 

“The Genetic Information Nondiscrimination Act, or GINA, is U.S. federal legislation with bipartisan support that protects Americans from discrimination (in health insurance and employment decisions) on the basis of genetic information. GINA has passed through Congress and was signed into law by the President on May 21, 2008. As a result, American insurance companies and health plans (including both group and individual insurers, as well as federally-regulated plans) will be prohibited from:

• looking at your predictive genetic information or genetic services before you enroll;
• “requesting or requiring” that you or your family members take a genetic test;
• restricting enrollment based on genetic information;
• changing your premiums based on genetic information.

GINA also prohibits U.S. employers (including employment agencies, labor organizations, and training programs) from:

• discriminating against who they hire or how much they pay on the basis of genetic information;
• “requesting or requiring” that you or your family members take a genetic test;
• disclosing your genetic information in their possession except under specific and specially controlled circumstances.

GINA does not cover life or disability insurance providers.”

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.

Wow.  Heavy stuff. 

This is your reality check time.  If you are in your 40s or older, YOU NEED TO GET A MAMMOGRAM.  I don’t care if work is busy, you are traveling, it is hard to get in to see your doctor, or how many kids you have with soccer practices and girl scout meetings.  BREAST CANCER AFFECTS 1 in 8 WOMEN. 

• You should be doing self exams.  Your significant other can help.  Even if you are just doing a little extra soap time in the shower, feel for lumps, bumps and changes, including up into your armpit.
• You should have a professional clinical breast exam of your breasts every 2-3 years before age 40, and every year after age 40. 
• You should get a mammogram.  No excuses.  Just do it.  Women over age 40 should get a mammogram every year.  If you have implants, you need to go to a place familiar with how to do additional views.
• If you have risk factors, you should talk to your doctor about how often and how (mammogram, MRI, etc) to evaluate your breasts.   Some risk factors are BRCA positive, strong family history, personal history of ovarian cancer, late menopause (after 55), no children or first child after age 35 (many of us in the Bay Area fall into this one), high density on mammogram, radiation exposure (at work, treatments for other illnesses like Hodgkins, etc). 

More blogs to come.  For those interested, you can see my other posts at

http://www.laurengreenbergmd.com/category/breast/breast-cancer/

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.

When?  Aug. 30-31.

Why?  The hearing is to evaluate the studies which were mandated when silicone gel implants returned to the market in 2006.  (gel implant patients who had breast augmentation when silicone gel implants came back to the market enrolled in the study.)

What are they evaluating?  They want to figure out new ways to gather data for these post approval of silicone studies.-approval studies.  How do we figure out “effectiveness” of the device?

“The breast implant post-approval studies have provided us with an excellent learning opportunity,” says ASPS President Phil Haeck, MD. “At roughly the midpoint of the studies, we know that the pre-market data supporting safety and efficacy have been largely verified. The 2006 decision by the FDA to allow women to choose between silicone and saline implants was a sound decision supported by science.”

Dr. Haeck further notes that numerous studies have demonstrated a high level of patient satisfaction with silicone breast implants and no established relationship between silicone breast implants and connective tissue disorders, one of the primary reasons these studies were implemented.

What may come out of this?  As many of you know, the style 410 “gummy bear” implant is not approved in the US.  As these “next-generation” silicone implants look for approval, they likely will have their own studies.

Back in June the FDA issued an updated white paper looking at the safety of silicone  breast implants.  The paper stated “silicone gel-filled breast implants have a reasonable assurance of safety and effectiveness when used as labeled.”

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.