New study on fat grafting to the breast

It's seems like a perfect answer - "take a little off down here, put some a little more up here". But fat grafting to the breasts has been controversial. A problem, known as fat necrosis, has been the #1 concern. Lumpy deposits of injected fat, which may feel exactly like a breast cancer, can result if the fat does not survive the transfer, and goes on to form calcified scar tissue within the breast.

Previously, back when radiologic imaging of the breast was less advanced, sorting these lumps of scar out from early breast cancers was a real problem. Surgical biopsies were sometimes needed to make the determination. Over the last decade, though, a lot of work has been done on fat grafting, reappraising its role as a reconstructive tool. Here in the U.S., Drs. Coleman and Khouri, two plastic surgeons who have been independently making major contributions to this area, deserve a lot of credit.

In this month's issue of the Aesthetic Surgery Journal is an important study looking at the safety of fat injection to the breast. This work, from Lyon, France, summarizes 880 procedures over 10 years, and mainly looks at the application of fat grafting for reconstructive applications - following mastectomy reconstruction, and for breast asymmetries and other developmental problems.

The French group in the study used Dr. Coleman's technique (low-pressure small cannula liposuction of the fat from the donor area, purifying the fat with a centrifuge, then injecting it in very small volumes into the target area). None of the more advanced techniques that have been recently reported to enhance fat grafting success were used -i.e. no addition of stem-cells, or use of the external BRAVA suction device.

Very careful breast imaging was mandatory - both pre-op and at one year post-procedure, using mammograms, ultrasound and MRI. The French radiologists "signed off" on the normal status of the exams before the patient underwent surgery. (I wonder if any lawsuit-averse U.S. radiologists would be willing to do that!) While all patients had some post-surgical changes in their post-op mammograms, the radiologists were, in general, able to sort out these changes with the use of the more advanced imaging methods and a lot of experience.

Ninety percent of the results were rated as either "good" or "very good". As expected, the surgeons found that about 40% of the injected fat melted away. Fat necrosis - formation of lumpy scar tissue - was seen in 15% of the authors first 50 cases, decreasing to about 3% after that. In some cases, a needle biopsy of the lumps in the breast was still required.

Overall, good improvements in the breast contour and degree of symmetry were reported, and the authors felt that fat grafting represented a very good technique for "touching-up" results after a complex breast reconstruction, or avoiding a more-complex reconstructive method. They also showed nice results for breast asymmetry and cases of Poland's syndrome, a developmental breast problem.

Bottom line: fat-grafting to the breast is a procedure which, while very promising, is still under development. Guidelines about timing, indications, pre-op and post-op MRI imaging, and important details regarding the best technique are still being sorted out. I can not yet recommend it for cosmetic breast enlargment at this stage, outside of a carefully controlled clinical trial.

Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries - say, a tummy tuck with a breast operation.

To answer this, we have to look at things from 2 different angles:
1) legal - what do the Florida regulations permit, and
2) medical - what do the studies looking at surgical complications find.

First of all, the applicable Florida regulations for office-based surgery state that the "maximum combined duration of anesthesia shall not exceed 8 hours."
Longer procedures can be performed - in a hospital.

From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, somewhat of a mixed picture, when it comes to plastic surgery operations for healthy people.

Data against long surgeries:

- increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.

- increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT's.

- increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions.

- increased rate of surgical site (wound) infections with longer surgeries.


Data supporting combination surgeries

- no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.

- no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this study, all surgeries were less than 6 hours in length.

The bottom line: Combination surgeries can be performed safely, but that doesn't mean we should throw caution to the winds and have a marathon surgical make-over. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating.

I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients. I feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this number.

So, going back to the original question: I will combine a breast augmentation (approx. 1 hour procedure) with a major abdominoplasty (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a big tummy tuck, as I feel the lengthy anesthesia / surgery time is worrisome.

As always - safety first.

Saline breast implants: pros and cons

Today's chapter is about saline breast implants.

Prior to 2006, saline implants were the most commonly used implant in the U.S. Now, with FDA re-approval of the silicone gel implants, that figure has fallen significantly, down to about 20% in our practice.

Here are the more common reasons that my patients give for picking a saline-filled breast implant.

1. Cost. Saline implants aren't as expensive.

2. Adjustability. For women with major breast asymmetry issues, the adjustability of the size of a saline implant at the time of surgery can be helpful to fine-tune the correction of volume differences between the two breasts. Essentially, we can "put a little more" on the smaller side. With silicone gel implants, the implants are not adjustable - so one has to go to the next size implant, a difference of 25-30 cc.

3. No need for follow-up scans. When a saline implant leaks, the saline is simply absorbed by the body. The implant deflates quickly - and making the diagnosis of an implant deflation is easy, without requiring fancy diagnostic tests. There are no recommendations for follow-up MRI scans, as there are with the gel filled implants.

4. Lingering anxiety about silicone gel. Despite the large number of carefully performed, large-scale scientific studies disproving many of the "urban legends" about health issues and silicone, some women are just more psychologically comfortable with the saline option.

5. Age. If you are younger than 22 years old, silicone gel implants may not be available under the FDA guidelines, unless you happen to have other issues, like rib cage asymmetry, scoliosis, and so forth.

6. Wanting the "very rounded" look. This can be achieved, if desired, by over-inflation of a saline implant, creating a more spherical shape and increased upper breast fullness.


Disadvantages of saline implants:

These were discussed in the previous blog chapter, during the discussion of silicone gel implants. The main issues are:
- a less realistic "feel" to the breast

- higher percentage of ripple / wrinkle issues, particularly in slender women.

While some surgeons will try to over-fill the implant in an attempt to reduce ripples, that may cause a different set of problems, such as creating excessive roundness of the upper breast, causing excessive firmness, or creating tension bands around the edge of the implant. Over-filling also potentially voids the manufacturer's warranty.

The choice of implant - the size, the shape, and the type of fill - are all issues that we discuss at the time of a consultation. Hopefully, the information in this blog will help you to become a more "informed patient" prior to your consultation and surgery, and will answer some preliminary questions for you.