Fat grafting is not new. It has been something gaining popularity over the past decade. It started first with Syd Coleman’s work in NYC. More recently it has expanded to breast augmentation and reconstruction surgery. Doing fat transfer to fill areas is something I have been doing for years. I started by taking a course with Dr. Coleman. And then I started fat transfer: the back of the hands, liposuction defects, the cheek, and the buttocks are common areas to graft.
But the breast is different. The breast needs additional techniques. I went years ago to my first meeting to learn how to do fat grafting specifically for breast augmentation and reconstruction after cancer. As I said, fat grafting is not new. What is improving is our knowledge. There are increasing numbers of scientific studies to refine our techniques. How can we maximize fat survival? Reduce the number of calcifications? Reduce the loss of fat? After my first training course for breast fat grafting, even with my excitement for the technique and additional insights, I still didn’t start doing fat transfer breast augmentations in my practice.
I then spent additional time in 2011 training with Dr. Khouri in Miami to learn from him, as he is one of the surgeons with the most experience. He has been thoughtful in his study of fat grafting and how to improve the results. He published a prospective trial paper in the May 2012 Plastic and Reconstructive Surgery Journal putting some scientific proof behind his results.
I love that Dr. Greenberg gave me all of my options and helped me come up with treatment that would get me the result I want..
– P.B., San Carlos
Fat grafting involves doing liposuction of your body to harvest the fat we need to transfer. The fat is removed by small cannulas. It is then centrifuged to help separate the liquid from the fat. We want to use healthy fat cells in the transfer.
The fat is then injected using small special cannulas into the breast. I use a pattern which looks like a clock. There are no big incisions for the fat injections- it is done through small openings I make with a needle. The fat is placed in small droplets, called micro fat grafting. I fan out the level and where the fat is placed, to create a kind of matrix.
Surgery takes a little longer than traditional breast augmentation due to the harvesting of the fat. Pain tends to be less, and I find my patients are back to full speed faster than with traditional implant breast augmentation.(Most breast implant augmentations go under the muscle, which causes the pain, and fat grafting is on top of the muscle.)
Brava is a system of suction cups which you apply to your breast. You use the system ahead of surgery to help create a space and matrix for the fat graft. Imagine your breast is a compressed heap of chicken wire mesh. New fat needs a good blood supply, space, and no pressure on it so it can grow in its new position. It needs to be protected. The Brava helps stretch out the internal breast tissue and skin, to expand the chicken mesh, so there are spaces to graft into.
**PLEASE NOTE: AS OF JANUARY 2016, THE BRAVA COMPANY NO LONGER EXISTS, SO DOMES ARE NOT AVAILABLE. This is a big issue for those of you who are young with good skin tone. Fat transfer requires we have space to graft into, and the domes stretched the skin to allow for space and less pressure on the newly transferred fat. If you have tight skin, I will not be able to graft.
Dr. Greenberg measures you for the system at your initial consultation. She orders the domes. You then come into the office and are oriented on how to use the domes and the ins and outs of Brava wear.
You expand prior to surgery for 4-6 weeks. The Brava wear is done at night.
Why do Brava? If you are young, have tight skin, and have never stretched out your breast (by time, gravity, pregnancy, or breastfeeding), you need to create space to graft into. If you do not, the skin tension creates pressure on the newly transferred fat. It would be like stepping on newly seeded lawn- you will kill the new blades of grass. I can see the skin tension as I graft. I cannot “overfill” the breast- if the tension is too great, it will kill all of the fat. Studies have clearly shown fat dies off precipitously when you reach a certain pressure.
Does Brava work? Dr. Khouri started the Brava company, so clearly he has a bias. I can say from my personal experience those patients who are compliant with Brava allow more space for me to graft into. More space to graft= more fat transferred = bigger end result. There also was a paper in May 2012 which analyzed breasts done with Brava using volumetric MRI data from pre and post surgery (the post being 6 months out to show real survival of graft.) They found an average 82% take when using Brava, versus historical 55% take when fat transfer was done without Brava. There is also thought to be an effect by increasing the blood vessel supply to the area.
This is a complex topic and still a “new” procedure for plastic surgeons. Please read my many blogs on the topic. I was impressed by what I saw in Miami. There are issues with breast implants. They can turn hard, migrate, thin the overlying tissue, have biofilm or infection, and need to be replaced. Many of my patients want small augmentations and would like to avoid implants. It is with all I have learned and seen, the impressive results and thoughtfulness of those doctors I studied with, and understanding my patients and their desires that I have started to offer this procedure to my bay area patients. I am pleased with the results I am seeing.
Fat grafting can have issues. Again, I would reference my blogs. Fat grafting to the breast for breast enlargement is not for everyone. There are limitations. Of note I would counsel those who are looking into fat grafting to find someone thoughtful and trained in fat grafting. Using the BRAVA system, knowing the techniques on how to maximize fat survival, and good counseling are important for you to figure out if you are a good candidate, and if you are, for you to get the best result. If you have a history of smoking it will affect your results. Active smokers are not candidates.
If you have a low BMI, you will not have enough fat to do transfer.