Hot off the Presses: BRAVA DOES make breast augmentation with your own fat even better!

Between working on the book and doing my day job as a plastic surgeon, I’ve had to take a vacation from blogging for the last couple of weeks…But I was so inspired by this article in the May issue of Plastic and Reconstructive Surgery (Our plastic surgery Bible) that I had to make time to share it with everyone. In layman’s terms 🙂

Most of you who know me are aware that I have been performing autologous fat transfer for breast augmentation (liposuctioning your fat from wherever you want to get rid of it and putting it in your breasts instead of an implant—yes, it’s a dream come true) for over two years and that I think it is an amazing procedure. (See my previous blog, “When fat is your friend.”) My patients have been thrilled with their results and I have had tremendous support from Doctors Lebovic, Schwimer and Goldberg–a very prestigious group of radiologists in town who specialize in breast imaging. So far the fat injections have not interfered with any of my patients’ mammograms.

If you have been seriously researching this procedure for yourself, you have most likely heard of the BRAVA. Developed by Dr. Roger Khouri in Miami, it is an external soft tissue expansion device that looks like a “Madonna Bra.” When you’re wearing it, it literally suctions your breasts out like a giant suction cup would, temporarily enlarging them. The theory is that wearing it before and after the procedure will increase the percentage of fat that “takes.”

Breast augmentation with fat grafting is probably the hottest new topic in plastic surgery, but the multiple variables involved with the technique still leave a lot of unanswered questions:

1)    Does it matter where we take the fat from (ie, is back fat better than thigh fat)?

2)   Does centrifuging it (spinning it down before injection to separate out the blood and fluid) really select out precious fat cells or just destroy them? There are two opposed camps on this topic.

3)   What type of system should we be using to harvest the fat? Hand-held syringes or suction machines with the pressure turned down? Two opposed camps here as well.

4)   What type of system should we be using to inject the fat?

5)   Does Dr. Khouri’s BRAVA thing really work or is it another marketing gimmick?

6)    Is selecting out stem cells with an expensive machine and calling the procedure a “stem cell breast augmentation” necessary for the fat to take? (The plastic surgeons who own the stem cell machines will say it is, but see my blog “What is a ‘stem cell breast augmentation’ or a “stem cell facelift” and is it worth the extra money?)

There have been multiple conflicting reports on this topic without real scientific data. Most of the plastic surgery journal articles are like second grade classroom show-and-tells: “This is what I did, and this is how it looks, Ta Daa!!!” As of yet the only thing that everyone agrees on is that there is no standard way of doing this procedure to give the optimum results.

But at least now we have an answer to question #5:

 According to this new study, yes, wearing the BRAVA seems to increase the fat volume “take” from about 50 to 80 percent.

 There is a strong possibility that this is accurate information. Last summer I was able to compare notes with Dr. Scott Spear on this topic. Since Dr. Spear is the chairman of plastic surgery at Georgetown University and one of the renowned breast surgery experts in the world, I felt validated to learn that my experience and results have been identical to his. We agreed that the most important determinant of success with fat grafting to the breast is the “skin envelope.” So, whether it’s from breastfeeding or age, in this situation, “sagginess” of the breast skin is good news. It gives the transplanted fat more room to live comfortably and survive better. I like the analogy in Dr. Khouri’s paper: when planting crops, the most important thing to a farmer is not the seeds, but what kind of soil he is planting the seeds into. If it’s crappy soil, the seeds won’t do well, no matter what kind of magic potion (ie, stem cells) they are mixed with.

This is why the BRAVA makes sense. It stretches the skin and tissues—and by doing so may also increase blood supply to the area–to allow for a more accommodating “home” for the fat grafts.

Other “pearls” that can be taken away from the results of the article are that:

1)    when done correctly, the fat injections really do not interfere with the reading of mammograms as much as we first thought they would

2)    spinning it down fast in a centrifuge is probably a bad idea.

 So what does this mean?

 In the past, when my patients have asked me about whether or not the BRAVA was worth the extra money (It’s about $800 at cost) I told them that it probably helps, it couldn’t hurt, and that the patients who used it seemed to have more of the fat volume survive, though I couldn’t guarantee it. I do not like “selling” things to people if I can’t justify it. I still can’t guarantee anything, but now at least I can quote this paper, that the patients who wore the BRAVA had about 80% retention of volume as opposed to about 50%.

However…

 The results of this study may make more patients more motivated to wear the BRAVA, but most still won’t be able to do it. Logistically, it is quite difficult.

For one thing it looks like this:

 

Okay, sorry–I had a picture of someone wearing it here but I guess it got remove by the people that own this blog server for “porn” so I am working on a censored version of it with my IT guy–hopefully it will be up later today. How annoying is that? I mean, really. So you can see the shadow of a woman’s breast underneath it–so what? For now, just imagine big plastic domes that project about ten inches in front of your chest.

So, unless you’re okay with people staring at you for reasons other than being famous or impossibly gorgeous, you can’t wear it in public. Your regular clothes won’t fit over it. And the protocol calls for wearing it ten hours a day for a month before the procedure (with 24 hours a day for the last few days) so unless you work from home, you have to learn to sleep in it. The logistics are even challenging for “stay-at-home” moms, because most of them don’t really “stay-at-home.” You can’t show up to school drop-off wearing a BRAVA unless you have tinted windows, and forget about making the rounds at Whole Foods/Costco/the drycleaners unless you’re okay wearing a tent.

But at least I can assure my patients who are dutifully wearing it in preparation for their surgeries that yes, it does work.

 Again, for all of you BRAVA-wearers out there, here are some inspiring before and afters:

 

Before, an A cup

 

One year after BRAVA and fat-grafting, a C cup

 

Here is the link if you would like to read the full article:

 http://journals.lww.com/plasreconsurg/Fulltext/2012/05000/Brava_and_Autologous_Fat_Transfer_Is_a_Safe_and.25.aspx

 

One more thing I would like to add:

 

In his video discussion of the article, Dr. Spear mentions that we must “respect the donor sites” (the places where the fat is being taken from) and that is EXACTLY what I tell my patients. I often see patients who have been told by someone else that they are candidates for the procedure. But as a surgeon who has performed thousands of liposuctions for over ten years—and someone who understands how a woman wants her body to look—I have turned some of them away because I felt that I could only get the fat out at the expense of causing deformities at the donor sites. MAKE SURE that your plastic surgeon understands that you CARE what your legs/arms/abdomen/back are going to look like after the fat’s been removed (unless, of course you don’t.) And make sure that your doctor is GOOD AT LIPOSUCTION, which is not as easy as it sounds, especially when the patient is thin to begin with.

For example, if someone looks like this to start with:

…she should look like this when you finish:

XO

LQ

35 comments
  1. Leigh Ann Z said:

    Oh really? It makes me wonder if BRAVA would help me in my situation.

    • No because you can’t put it on with implants underneath 😦

  2. chicorybreath said:

    Have you heard of the Brava/fat transfer procedure working for extreme asymmetry (Small B/Large A vs. Full D)? I was told by one surgeon, who specializes in fat transfer, not to “complicate the situation” when i inquired about using the Brava system. i can’t seem to find any info on the success to failure rate of the Brava.
    It’s a traumatizing situation and if this could actually work it would change lives.
    Do you think a MRI is necessary prior to going to a consultation for breast augmentation?
    And is it normal to pay in full for a surgical procedure prior to the operation?
    THANKS.

    • Hi There! You know, the article I referenced in this post shows evidence that the BRAVA does help with the percentage of fat retention (80% of the volume vs. 50%) however, none of this is really hard science yet. It certainly won’t hurt. But even with the BRAVA you really can’t get an A/B up to match a D cup. It sounds like you are describing a “tuberous” breast, and the smaller side usually has tighter skin, so even with fat injection, to get symmetry the surgeon is most likely going to have to reduce the other side. I personally would recommend using the BRAVA in this situation, as my patients who have used it have definitely had better retention of the grafted fat, but again, in this situation, fat transfer alone is not going to be enough if you are concerned about shape.
      I usually just require a pre-operative mammogram for all patients over thirty undergoing breast procedures. Unless you have certain risk factors for breast cancer, or there is something unusual on the mammogram you probably don’t need an MRI before the surgery, but this would need to be clarified with your doctor.
      Unfortunately, yes, it is “normal” to pay in full for a surgical procedure prior to a cosmetic operation. It’s like purchasing a luxury item. Compare it to buying a Louis Vuitton bag on Rodeo Drive–you can’t take the bag out of the store and make payments on it, or promise to pay them next week. There are plastic surgery financing companies like “Care Credit” that you can look into. I understand that this is frustrating, because it seems like severe breast asymmetry should be covered by insurance. In rare situations it is, and you can find out by looking at your insurance company’s website. Hope this is helpful!

      • chicorybreath said:

        Your information was very helpful! thank you!
        I want to also inquire about your knowledge or professional opinion of Dr. Kamran Khoobehi in Metairie, La. I am told he performs the highest number of fat transfer procedures in the country. I am curious if you, or any of your colleagues, might know more about his success rate or reputation.
        thanks again!

      • Hello!
        I have been to one of Dr. Khoobehi’s meetings and he seems to be very experienced and offhand I would say that he has a very good reputation amongst our colleagues. I don’t know personally about his success rate but I am sure that it is as good as anyone else’s. If you live in the New Orleans/Metaire area I would definitely have a consultation with him and see if it’s a good “fit” for you. Hope this is helpful and let me know if you have any further questions.
        Thanks for writing!
        LQ

  3. Jenny said:

    Hi!
    Im a 28 year old girl. Im 5.10, 9st 1.9lb, I believe my body is ok shaped; don’t have fat in some areas or loose skin etc. But I would like a bit bigger breasts. Im a small B cup and would like to be a full B. Could never do implants. Would you not recommend to do the fat transfer since there a possibility my hipsters, thighs, stomach etc would be misshaped, since there is not much fat there? I also wonder if the small scars after fat transfers are big and/or visible after a year post op? Would really appreciate your answer! Thank you!
    Jenny

    • Hi Jenny,
      I’m sorry but I didn’t understand your weight “9st 1.9.lb”? Regardless, your plastic surgeon would have to evaluate you in person to see if there are “donor sites.” You need to make sure that you go to a plastic surgeon who not only knows how to do the fat transfer but is good at liposuction and respects the donor sites. If you are not in Southern California, if you let me know where you live I can see if I can think of someone I would trust in your area. Or, sometimes I do a phone consult with patients from out-of-state–they usually email their pictures.
      Usually after a year the small liposuction incisions are no longer visible, but if you have darker skin they can be.
      Hope this helps! Thanks for writing!
      XO,
      LQ

  4. Jenny said:

    Hi LQ!
    Thank you so much for your answer. I live in Scandinavia..that´s why I wrote the weight thing all wrong:) I´m 58 kg/127lb. Does that sound more right? Im going to NYC for a couple of months this autumn, so if you could recommend me a surgeon there I would be really grateful! If one is quite skinny, is there still a possibility the skin in the donor sites can get baggy / loose it´s smooth surface and flexibility?

    • Hi Jenny,
      The surgeon who is well known for the fat transfer to the breasts in NYC is Sydney Coleman, but I do know a couple of female surgeons who might be more sensitive to your concerns (and probably less expensive, since his prices are reportedly outrageous). I am not sure if they do the fat transfer, but they could certainly evaluate you for the lipo at the donor sites, and give your their honest opinion. Try Dr. Sharon Geise and Dr. Michelle Zweifler.
      Good luck and let me know if you need any more info!
      LQ

  5. Jenny said:

    Hi! Thank you!

    I will definitely contact them. What are the prices I can expect?

    Jenny

    • It depends…usually if I am doing a small lipo on someone thin to harvest fat to transfer for a breast aug it runs around $10 G (U.S. dollars) and then it goes up if I’m going to be doing extra contouring. Things might be a little more expensive even in NYC than they are in BH, but I think for what you’re describing, $20G would be way too much.

  6. Jenny said:

    Ok, thank you so much for all your info!

  7. ramzie said:

    Hi,

    Thanks very much for all this info, very helpful and appreciated!!

    i have a couple questions I was hoping you could answer…

    1) Is it possible to just wear one cup of the Brava system? Or is it designed so that you have to wear both? I want to correct/reduce my breast asymmetry of about 1-1.5 cups, and don’t want the bigger breast to grow at all!!

    2) Could you recommend anyone in Austin or Dallas/Fort Worth, Texas who does the fat grafting and breast augmentation procedure?

    Thanks!!!

    • Hi Ramzie,

      I’m glad you’re finding the info here helpful! To answer your questions:

      1) Yes you can wear just one Brava cup 🙂 I have had several patients do that–breast reconstruction patients as well as those who have exactly your situation. The Brava coach from the company can explain how you plug off one side if you decide to get one.

      2) Ironically, I actually spent a year of my training in Dallas at UTSW and I know a lot of really fantastic plastic surgeons in that area, however…I have checked out some of their websites and none of them seem to be doing the fat grafting. I wish they were because I have to tell you, it’s been amazing! Maybe check out Dr. Christine Stiles in Frisco? I will look again when I have more time. Meanwhile what I recommend is that you research it this way: find a board-certified plastic surgeon who does a lot of liposuction first, as this is someone who is likely to be doing this procedure. If you find some names, let me know and I will check them out for you!

      Good luck!

      XO
      LQ

  8. Christine said:

    Hi, I have lupus and am scared to have breast implants because of all of the horror stories surrounding reactions to foreign bodies related to my autoimmune disorder. I read on a comment of a different thread that fat grafting would be okay. Would you agree with that? I have breastfed my kids and went from a C cup to DDD cup. My breast are now softer and sag a little. Will I be a good candidate? Would you recommend anyone in t he Carolina’s? Thanks!

    • Hi Christine!
      My opinion is that the main thing for any procedure that you undergo, the physician monitoring your lupus and the surgeon need to be in communication about the stress on your body, the chances that it could cause an autoimmune flare-up, the need for perioperative stress steroid doses, continuation or temporary discontinuation of your current medical regimen (if you have one.) Basically what we used to call a “medical clearance” but now the term is “physical optimization for surgery.” That is, the physician managing your medical condition evaluates you, and determines whether or not you are in “optimal condition” for the procedure, and if not, he “tunes you up” with whatever medication you are taking (if you are taking something.) Then he determines the risks for your undergoing the procedure (low, medium, high), gives recommendations for the surgeon and anesthesiologist on how to treat you before, during and after the surgery, and how to keep to “optimized” and then it’s the surgeon’s and your decision, weighing out all the risks and benefits, whether or not to proceed.

      While it sounds like you are physically a good candidate–as far as your breasts and of course assuming you have the fat deposits to spare!–you need to discuss the procedure with the physician taking care of you. Since Lupus is an autoimmune disorder, I am not sure if you would have a reaction to your own fat even more so than a foreign body. Just a thought. I haven’t seen any literature on this but I will look into it. In the meantime, discuss with your doctor.

      As far as a plastic surgeon, I do not know anyone personally in the Carolinas (I went to UVA med school but haven’t been in that part of the country for a long time!:)) but you could start by looking on the American Society of Plastic Surgeons website with “find a surgeon” to get someone board-certified. If you come up with some names I can look into it for you.

      Meanwhile, let me know what your doctor says about the procedure. I’m curious, as I haven’t been asked this question before. I will be attending the annual Breast and Body Contouring meeting in Santa Fe next week, so I am going to ask around there.

      Best Regards,

      LQ

  9. Celeste Brown said:

    Hello, luv ur blog. I have under the muscle, 10 year old saline implants with some recent rippling n hollowness in cleavage area. I would like them removed n replaced wit autologous fat. I live in Mass n have been unable to find anyone -like u- who proficiently does this proceedure. Wondering if u could steer me in the rite direction… Pleeeeze! Thanx.
    Celeste

    • Hi Celeste!
      Glad you are are enjoying the blog–thanks for reading! Actually Dr. Daniel DelVecchio is one of the pioneers of the procedure in this country. He practices in Boston. I’ve seen some results of his that look great.
      Let me know how it goes!
      XO
      LQ

  10. jamie said:

    I am looking for a female board certified surgeon who will perform a very good liposuction respecting the donor sites, like you mentioned, and the fat transfer to the breasts. I am 5’8″ about 120lbs and would not want the liposuction to cause any disfiguring in my body as I dont have too much fat. I didn’t catch where you practice, since you mentioned you perform these procedures. Can you give me some recommendations, I live in southern California. I would like the most experienced reputable surgeon in doing this for me. Im willing to drive/fly longer distances in Cali. Thank you Lipo Queen!

    • Hi Jamie!
      Well of course I would recommend that you come see me in Beverly Hills 🙂
      We just launched the new website drtrott.com so there aren’t many pictures on it yet, but I have many more in my office that we can look at together, especially women with your body type. I see a lot of women with your physique–tall and thin with small isolated areas that could use contouring.
      Look forward to meeting you!

      Best Regards,

      LQ

  11. Bonni said:

    I’m looking for qualified surgeon who can do this procedure in Ala, Ga or Fl. I am 65 yrs old, good health, work out, nice muscles, but had silicone implants removed 6 yrs ago and it left me deformed. The implants had erupted for some time and I got very sick. The surgeon had to remove much of my breast tissue to get all the escaped silicone that was damaging my health. I look like I had mastectomy in my right breast and left one has areas of tissue removal also. I want to feel positive about my body again, but even with weight training, the tissue is just not there. I never want to go back to implants, and am hopeful about the fat transfer with Brava, but am concerned about the percentage that would stay and if it could even out my form with the severe loss of tissue.

    • Hi Bonni,
      Actually, Dr. Roger Khouri in Miami is the creator of the BRAVA and gets good results in situations like yours, from what I have seen in his pictures, and when I spent time with him in the operating room a few years ago. It sounds like a reconstruction with fat and no implants for you would require at least a couple of transfers. I would think that if anyone in that geographic region could help you, it would be Dr. Khouri. Good luck!
      XO
      LQ

  12. Ggua said:

    Hi, I’m only 22. Is an MRI necessary before using Brava?

    • I do not believe that MRI is necessary prior to BRAVA use no matter what age you are.
      XO
      LQ

  13. Ana said:

    Do you know of anyone in the Virginia Beach or DC area who is good with this type of procedure. I am 5’7″, 140 in good shape, right now a 32A want to end up a full B.

    • Hi Anaestasia,
      Sorry I don’t know anyone personally in that geographic area…the best way to start your research for this kind of procedure is to go to the ASPS (American Society of Plastic Surgeons) and ASAPS (American Society of Aesthetic Plastic Surgeons) websites and search for a board-certified plastic surgeon in your area. Yours is quite a cosmopolitan area, so I am sure you will come up with at least a few good physicians. Then you can visit their websites, look at pictures, set up consults, etc.
      Here are the links to the two websites where you can search by zip code:

      http://www1.plasticsurgery.org/find_a_surgeon/

      http://www.surgery.org

      Good luck! Let me know if you find anyone you like so we can share with the next person who asks. 🙂 If you come up with some names I would be happy to look them up for you. Depending on how tight your breast skin is, based on the information you are giving me, you probably would have an improved result if you were able to wear the BRAVA for at least a few weeks before the procedure.

      XO
      LQ

  14. Amanda said:

    Dear LQ,

    Great article! I am 6’2″ and have asymmetrical small breasts (A+B). I want to end up a plump C. I have plenty of love handle/butt to harvest from. I’m in central jersey but in Ohio for the summer. I’m looking for a surgeon for brava + fat transfer below 10G$. Any recommendations?

    • Hi Amanda,
      Glad you found the blog useful. Honestly I don’t know anyone in Ohio or New Jersey who does the procedure. As far as the price, I have no idea what they charge in Ohio but it is probably less than in Beverly Hills (Here it is definitely more than $10G). What I can tell you is that even with the Brava, if you are trying to achieve symmetry and a full C cup, you will very likely need two rounds of fat grafting. That is my honest experience.
      I recommend that you start with the American Board of Plastic Surgery website and find a board certified surgeon in the region that you will be staying, and then if you can’t find one who does the fat transfer, find a good liposuction surgeon–chances are that they will also be doing the fat transfer.
      Hope this is helpful!
      Good luck!
      XO
      LQ

  15. LX said:

    Hi!

    I am very interested in fat transfer to breasts in the Pittsburgh, PA area. Do you know of any good doctors who specialize in this procedure in my area?

    I am 27 years old, no kids, 5’7″, 150 lbs and a size 6-8. You mentioned that on average patients who used BRAVA had 80% fat retention compared to 50% without it. If I am already a C-cup and just want to be a more full, contoured C (possibly don’t need a high volume of fat transfer?), then do you think it is necessary? Is it more beneficial for patients who want to transfer a higher volume of fat?

    Thanks in advance for your help and advice!

    • Hi Lil,
      Thanks for reading! I do not know anyone in Pittsburgh, but I do highly recommend Dr. Louis Bucky in Philadelphia (I know it’s far, but not as far as California :)). He’s given talks on the procedure and worked with Dr. Daniel DelVecchio, who is one of the pioneers in the field.
      The increased fat volume retention rate with the BRAVA is reported in the studies done by Dr. Khouri and Dr. DelVechio–I haven’t personally had enough patients be able to wear the BRAVA so I can’t say that I have seen this myself, though BRAVA most likely does help the fat retention.
      The BRAVA is mostly beneficial for women with tight skin envelopes of the breast, where there isn’t a lot of room to put the fat. It stretches out the skin to help provide a looser skin envelope. When the skin is too tight, the fat is kind of “squashed” and doesn’t live as well. This is why women who have had children are usually good candidates even without the BRAVA because they have looser breast skin envelopes.
      Regardless, it sounds like you are a good candidate for the procedure, given your expectations and body proportions. The BRAVA is probably not “necessary” in your case, but I would be better able to advise you with a formal phone consultation. If you are interested, my patient coordinator, Nadia can set this up for you. She can be contacted through the website drtrott.com or by phone 3102753990.
      Hope this is helpful!
      XO
      LQ

  16. Elena said:

    I’ve been reading about fat grafting for breast reconstruction. I had a lumpectomy for atypical ductal hyperplasia and am now asymetrical. Is fat grafting safe or feasible for my situation?

    • Hi Elena,

      Yes fat grafting is absolutely safe and feasible! It is now a widely well-accepted way of dealing with any post-lumpectomy breast deformities. Even the general oncologic surgeons talk about it at their meetings.
      However, I would strongly suggest that you see a Board-Certified Plastic Surgeon for this procedure.

      Hope this is helpful!

      XO
      LQ

  17. Athena smith said:

    Hi!
    Thanks for your blog, I was wondering if you know of any doctors in the houston Texas area or if you know of Dr. Young cho? And where are you located?
    Thanks

    • Hi Athena,

      Sorry about the delayed response here–we had some maintenance issues with the blog. I am located in Beverly Hills, CA but there should be many great board-certified plastic surgeons that can take care of you in Houston as well. I don’t know anyone in particular in Houston. Dr. Young Cho looks good–he is board-certified.
      Is there a particular procedure that you are looking for?

      XO
      LQ

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