January 2013 Marie Claire
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%.
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:
Here is the link if you would like to read the full article:
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:
I get this question from every patient I see in consultation for a breast augmentation, and even from those who have come to see me for something else.
“By the way,” they say, “I should talk to you about my breast implants. I need to get them changed out.”
“Do you like the way they look and feel?” I say.
“Yes, they’re great. But I have to switch them out every ten years, right?”
The short answer is: “No, you don’t HAVE to.” So where did this “replace every ten years” myth come from?
1) The implant companies used to offer a ten-year warranty on replacing your implants if they ruptured.
They offer this because even if your health insurance kicks in for the capsulectomies (removal of the scar tissue surrounding the implant), they will not cover the replacement implants if the first procedure was done for cosmetic reasons. The only exception here is if the initial augmentation was authorized for reconstruction, such as after a mastectomy in breast cancer, or for a congenital breast deformity such as tuberous breasts or Poland’s Syndrome.
If your implants are ruptured and you are relying on your health insurance to pay for the rest of the breast implant removal surgery, be prepared to have a Breast MRI or mammogram documenting the rupture before you see your plastic surgeon. Most insurance companies will demand proof of implant rupture before they will pre-authorize the removal.
Also, Insurance companies like Anthem and Aetna usually will not pay for removal of saline implants, even if they rupture. And while silicone implants could theoretically last you the rest of your life (although nobody will go on the record saying that), after ten years all bets are off with a saline implant. The shells really do start to weaken after ten years to the point where you could just wake up with one of them deflated and completely flat. Don’t worry—it’s psychologically traumatizing but not dangerous. The implants are filled with sterile physiologic saline that will just absorb back into your body. You should also know that saline implants deflate on their own about one percent per year, so if your implants seem to be getting smaller, that could be why. For instance, if you have implants filled to 500 cc, That’s fifty cc after ten years, which is about half a cup size.
But now, the two main implant companies in the U.S.—Mentor and Allergan—offer “lifetime” warranties on their implants. I’m sure this new company Sientra will do the same to keep up, since these guys always have to be neck-and-neck with their promotional deals. (See the First New Implants FDA-Approved post)
All of Allergan’s Natrelle® silicone implants automatically come with a Confidence Plus® lifetime warranty of the implants including $1200 toward out-of-pocket surgery expenses for whatever your insurance company won’t cover, for the next ten years. And, if you give Allergan an extra $100 within forty-five days of the your first breast augmentation, you are enrolled in the Confidence Plus Premiere® program, which gives you up to $3500 and a free implant for the other side if only one is ruptured for up to ten years.
Mentor® offers a similar program for their Memory Gel® implants—the Lifetime Product Replacement Warranty–and the comparable upgrade is free.
I realize that if you’ve read this far it’s just because you have implants and you’re trying to figure out what frequent flier plan you’re on. The bottom line is that if you got your implants in 2009 or later, they are lifetime guaranteed, but the extra money is only available for ten years after the first surgery.
See the following links for more information:
http://www.cppwarranty.com/warrantyInfo.aspx (for Allergan.)
2) The second part of my theory has to do with the typical “timeline” of a breast augmentation. Many women undergo breast augmentation in their early twenties, so by their late thirties-to-forties, after child-bearing and breast-feeding, they have developed capsular contractures, rippling or further sagging and need a lift, or want them bigger/smaller/looking “perkier” again. So they get them switched out because of the way they look, not because they have to.
Multiple studies have proven that there is no significant association with silicone and autoimmune disorders (see link http://www.ncbi.nlm.nih.gov/pubmed/18090815, Breast implant rupture and connective tissue disease: a review of the literature, Plastic and Reconstructive Surgery Journal, 2007 Dec;120(7 Suppl 1):62S-69S.)
So even if you find out that an implant is ruptured, it is not an emergency. The silicone isn’t going to leak all over your body and cause Lupus or connective tissue disorders. In fact, lots of women are walking around with old ruptured silicone implants and don’t even know it. The only thing that could happen is if the liquid silicone (and now we’re talking the second generation of silicone implants from the seventies and eighties) gets outside the capsule (the shell of scar tissue that your body makes around the breast implant) and into the breast tissue, you could develop hard little nodules called siliconomas. But even these will not hurt you. At the worst they can local inflammation and discomfort.
Siliconomas are rarely an issue anymore, since the third generation of silicone implants have been around for more than a decade—they don’t really leak since they have the consistency of Jell-O® (See my previous New Implants blog)
Okay, I think this is more than enough information for the rest of the week, but I hope it’s been helpful for at least some of you out there.
This is an easy one. I’ll go out on a limb here and say pretty much, yes. Men like breasts, period. Real and fake. All men are “breast men.” They just won’t tell you they are if you don’t have them.
How do I know this? I’ve lost count of how many times I’ve witnessed the following scenario:
A woman comes in to discuss breast augmentation. She’s not asking to look like a stripper. (Though most men find absolutely nothing wrong with that, either.) Generally she’s in her late thirties/early forties, since we’re in Los Angeles she weighs about ten pounds less than the average woman her height in the United States, and exercises about twice as much. She doesn’t even like big breasts. She just feels that hers are starting to make her look old. They’ve deflated and sagged after childbearing and breastfeeding and she wants to replace the volume and regain the youthful shape. She just wants to look like she’s wearing a bra, without wearing a bra.
She’s keeping this first meeting a secret from her husband or significant other because he would “kill her” or “die” himself if he found out she was even considering breast implants. He would never understand. Even though she has to wear painful push-up bras with two inches of padding all of the time just to get back to square one, he thinks her body is perfect the way it is.
So back to this first meeting in my office. She’s wearing a wife-beater and she’s got small Allergan® silicone implant sizers tucked into the try-on bra. Finally, after about half an hour of staring wistfully from all angles at her reflection in my full-length three-way mirror, she hands back the sizers and sighs. Oh, well. She loves how they look but her husband/significant other would never be okay with this. He doesn’t believe in breast implants, like we’re talking about the Easter Bunny. That’s fine, I tell her. I absolutely understand. But we’re here if you change your mind.
Fast forward about a month and now we’re having a second meeting, with the husband/significant other in tow. Her fortieth or forty-fifth or fiftieth birthday is coming up and she’s decided she really wants to do this. Since I am so good at explaining things and making her feel comfortable, she wants me to explain it to her husband, convince him that it’s not really such a crazy idea. Especially since he’s going to fund it.
The husband turns out to be much less opinionated and controlling than the picture she’s painted of him, especially when it comes to a discussion about making her breasts artificially bigger. There she is, standing in front of the mirror again with a pair of 210 cc style 10’s under the wife-beater (my go-to implant for the “natural look”), asking for his opinion. He’s trying to appear uninterested and neutral about the whole thing, staring at my blank white wall, down at the floor, out the window at the view of the side of a brick building. Again he recites his mantra: “This is totally up to her. I don’t think she needs it. She’s beautiful, perfect the way she is.” But when he is finally forced to give an opinion, the tell-all words slip out of his mouth as he tries to keep his expression as objective as possible, “Well, if you’re going to do it, you might as well go a little bigger.”
Together they pick a size and she schedules the procedure. Her husband arrives to get her after the surgery and again he is expressionless and objective, overly focused on how to take care of her that night, when she can take what medication, what position she should be sleeping in. He averts his eyes from her tightly wrapped, newly-enhanced chest.
At the post-op visit when her new rack is unveiled for the first time, I can detect a smile flicker across his face, but he’s trying to keep it under wraps. “They look great, honey,” he says, as objectively as possible, like he’s admiring a new set of dining room chairs.
At her visit a week later she reveals to me with genuine shock in her voice: “He loves them.” And then after a month she tells me how he demands to see them every night when he comes home from work, and that their sex life has improved dramatically.
So is it possible that all of his earlier talk about “hating breast implants” and saying that you’re “perfect the way you are” is just political and safe? I mean, your husband is not stupid enough to agree with you when you say, “My breasts look deflated and old and I need implants, what do you think?” It’s like asking if a pair of jeans makes you look fat. Unless he’s a total fool and wants to sleep outside, he’s never going to tell you, “Yes, your muffin-top looks disgusting. You should change into something loose-fitting.” He does love you the way you are, and he does still find you attractive, but he doesn’t care enough about the little details to get into trouble over them.
I am absolutely not advocating that we all go out and get breast implants (although I know that my husband would be thrilled if I did.) All I’m saying is that if you really want them, and the reason you’re holding back is because you’re afraid your husband would be horrified at the mention of them, you might be pleasantly surprised. I’ve just never had a patient come back after her breast augmentation and say, “My husband is repulsed. He won’t touch me. He is demanding that I take them out.”
Food for thought! Happy Sunday!
This is huge news. I first heard about this new company, Sientra when they sponsored a St. John’s Hospital Plastic Surgery Division dinner meeting about a year ago. The speaker bragged about how their implant line was already going strong in Europe, but I ignored their threats to become FDA-approved in the U.S. I figured the company as a whole was delusional and I actually felt sorry for them for spending so much money on all the free food and alcohol at the four-star restaurant. I mean, it’s nearly impossible to get anything FDA-approved in this country, especially something as invasive as a silicone breast implant. (Which, as I tell my patients should make you feel better about having the ones that are approved.) But Mentor and Allergan have pretty much been the Coke® and Pepsi of breast implants for as long as I can remember. (Actually, Allergan started out as McGhan, then became Inamed and then really pulled ahead when it got taken over by Allergan and the sales reps started bundling our breast implant purchases with free Botox® and Juvederm®.)
So why is this such a big deal?
Most of the implants from this new company Sientra will probably not be significantly different from the ones already offered by the other two giant manufacturers. (I’ll let everyone know what they feel like in comparison to the others as soon as the company brings by samples, which I imagine will be as soon as all of the plastic surgeons in town open their doors for business on Monday morning.)
But the big story here is that this new company, Sientra has in its available armamentarium, a teardrop-shaped implant comparable to the “gummy bear” one that Allergan and Mentor have been trying to get approved for nearly a decade.
So what is this “Gummy Bear” implant, anyway?
All of the silicone implants that are available today are “third generation.” They are made of a cohesive gel, which means that if you cut one in half it will just stay the way it is, and the silicone won’t run out all over the place:
Truthfully, their consistency is more like Jell-o® than a Gummy Bear, but it’s the same idea.
The implants that have been nicknamed the “Gummy Bear” implants are the fourth generation silicone, which are made of an even more ”cohesive” gel. This means that not only do they not leak, they barely move(think stiffness of Jell-O® vs. Gummy Bears.) The difference is that they are teardrop-shaped, and to keep their shape they are firmer and don’t move at all, even if you lie down. This is what is known as “form stable.” There has been a lot of hype about how “great” they are–especially by the small number of plastic surgeons who have access to them through the Mentor and Allergan clinical trials.
Except now everyone’s going to be able to get them from Sientra.
But the FDA tends to keep things fair and square. Seven years ago Mentor and Allergan both got approval for silicone implants on the same day. If form-stable Gummy Bear implants by Sientra are getting approval, the same thing will probably happen for Mentor and Allergan by the end of the week.
However, don’t let the supply/demand thing fool you. Just because they’re less accessible doesn’t mean they’re necessarily better for everyone. The way I like to think of it is that instead of the implant taking the shape of the breast, with these “form stable” implants the breast takes the shape of the implant, which is most useful in a case of reconstruction after mastectomy or in a tuberous breast. In fact, these implants were initially intended for breast reconstruction patients, and somehow became another marketing tool for the plastic surgeons who not only have access to them, but get paid to use them and talk about them.
I have personally seen results with these form-stable implants, and while they definitely have advantages in breast reconstruction (both in congenital breast deformities and mastectomy patients) my opinion is that the third-generation ones that feel more like Jell-O® are better for most primary cosmetic procedures, and these are the ones that I would choose for myself. By the way, the form stable implants require a bigger incision in the breast (pretty much always at the inframammary crease) because you can’t manipulate them as much to insert them. (They were obviously developed by a man.) So don’t be upset that you missed out on something if you just got breast implants a few weeks ago and you suddenly hear about this “superior new Gummy Bear implant” fresh on the market.
Regardless, I also predict that along with everyone else in Beverly Hills, I will be getting a call (if not a knock on my door) from the Sientra sales rep on Monday morning. So for all of you considering breast implants, imagine that every plastic surgeon in town is probably going to be getting at least one free pair to try from Sientra, and then Mentor and Allergan are going to have to up the ante, get off their laurels, and give us each at least one complimentary pair. Whether or not your plastic surgeon decides to pass the savings on to you is up to them, but I think it’s a good time to get a breast aug…I’m just saying…;-)
Have a great weekend!
P.S. Here’s a link to one of the newsflashes if anyone is interested:
We’ve all heard about stem cells. They’re like the millenium’s new “black.” But why, again?
Stem cells are progenitor cells. Think of them as generic cells that can morph into whatever type of cell that surrounds them, as well as enhance the existing cells with extra hormone-type substances—called “growth factors”—that they secrete. There is promising research being done right now that gives us hope that one day adult human stem cells will be used to restore injured tissue after heart attacks, or even spinal cord injuries.
So how did plastic surgeons get involved with something that started out as a potential “magic cure” for heart failure and paralysis?
One of the most exciting discoveries has been that the same fat we’ve been discarding in the hazardous waste containers after liposuction cases (and no, it’s not Fight Club and we don’t make soap with it, as every guy seems to think is the most hilarious question to ask me) is chock full of stem cells. And most of us have at least some of that to spare.
So what does it mean when your surgery is enhanced with your stem cells?
Usually it is a procedure that already involves fat injection. Then it means that your plastic surgeon is additionally using an expensive machine to isolate out an even more concentrated number of stem cells from the fat, and injecting it all back in together wherever the fat is going—usually the face, breasts or buttocks. It also means that you are probably paying extra because the plastic surgeon has to pay off the loan on the machine, and for whatever expensive Google marketing they’re doing to sell their “stem cell” surgeries.
So is it worth the extra money?
There has been promising data regarding the positive effects of fat injection. I have seen it firsthand not only in my “natural breast augmentation” patients, but in cases where it has softened radiated tissue and improved pain and sensation in my breast reconstruction patients. And the science points toward the stem cells and their growth factors as the main reason for this success. However, there is no hard data to prove that isolating out some of the stem cells and then mixing it up with the fat to give you “supercharged stem cell” fat injections is superior to just injecting the fat with its regular stem cell concentration. But the term “Stem Cell” has become as much of a marketing buzz-word as “SmartLipo™” did four years ago (See my Smart Lipo post) and this is where it gets confusing.
My main concern has always been whether or not the additional stem cells are helpful in the “take” of the fat in a natural breast augmentation, as this is a procedure that has become a big part of my practice. I have taken an informal poll of the experts at the meetings, and I have found that it is basically a split camp. In general, many of the plastic surgeons in Japan and the ones here in the U.S. who have stock in the stem cell companies like Cytori are huge stem cell advocates. However, I’ve spoken personally with fat-grafting pioneers such as Dr. Gino Rigotti, Dr. Mel Bircoll and Dr. Roger Khouri, all who disagree.
So far I am personally getting great long-term results in my natural breast augmentation patients without supercharging the fat with more stem cells. In fact, one of my first “guinea pigs” just emailed me some pictures, bragging about how much appreciation her breasts were getting. I believe the direct quote was: “Oh my God, Boobs are so great! They do all the work for you—I don’t even have to open my mouth anymore! I wish I’d done this sooner. When I was younger I used to feel sorry for the girls who had to show off their boobs to get attention, but let me tell you—they were onto something!”
I also did spend a spa day with another one of my first volunteers and although there were no pictures allowed–I can only tell you that she is thrilled and looks amazing; she still weighs 106 pounds and wears a size zero, but she gained two pounds over the holidays and it all went to her boobs.
So could they be better if I used the stem cell machine? Maybe. I have access to stem cell-enhancing technology if the patients want to pay for it, but I don’t feel comfortable pushing it as a “superior” method.
I am a member of both The American Society of Plastic Surgery and The American Society of Aesthetic Plastic Surgeons and the two groups just issued a joint statement, essentially saying that there is not yet any scientific evidence that this expensive extra step of stem-cell enhancement is beneficial.
So what is the take-home message?
If you have been sold a “Stem Cell” procedure, you should understand that what you are getting is fat grafting and while the “stem cell enhancement” may help, there is no proven benefit to the use of additional stem cells in fat transfer. As of now, it is really more a “throwing everything into the pot” approach to getting the fat to take.
In case you are interested, I have copied and pasted the points made in the ASPS/ASAPS January 2012 advisory statement on “stem cell” surgeries:
“…growing concerns have emerged regarding advertising claims and/or clinical practices using stem cells that have not been substantiated by scientific evidence. These concerns include:
* Use of the term “stem cell” in aesthetic surgery procedures, such as the “stem cell face lift,” with the implication of improved results.
* Claims that skin quality can be improved from stem cell treatments, and that outcomes from fat grafting can be improved with stem cell therapy.
* Widespread marketing, evidenced by a Google web search using the search terms “stem cell face lift” yielding 197,000 results and “stem cell breast augmentation yielding 302,000 results, respectively.
* A lack of consistency in how these procedures are performed and how stem cells are incorporated into the procedures.
* Instructional courses, some “for profit,” that have emerged which are designed to teach methods of stem cell extraction for aesthetic procedures.
* Many procedures being advertised by practitioners who are not board certified plastic surgeons or members of other core specialties with formal training in aesthetic procedures. Such “noncore” practitioners have not been trained in an approved residency program designed to teach the physician safe and careful evaluation of cosmetic patients or a working knowledge of the full range of aesthetic procedures.
* Specialized equipment being marketed to physicians for use in “stem cell procedures.”
* Specialized equipment to extract stem cells, including devices, may fall under FDA regulations. Some devices, including automated machines to separate fat stem cells from fat tissues, are not yet approved for human use in the United States.
* Claims of purifying or activating stem cells through techniques that have not been fully verified and tested for safety and efficacy in current, peer-reviewed medical journals, or claims of improved outcomes as a result of these therapies…”
For the full statement you can go to:
If we’re taking bets on a woman who is at least partially clothed, without X-ray vision even a plastic surgeon has to admit, “No.” But that doesn’t mean there’s not some help going on. There’s all kinds of smoke and mirrors out there. The bionic push-up bras aside, I’ve had patients go down two cup sizes in the exam room once they remove the Victoria’s Secret water bags. And even though they’re just meant to try on in the office, I swear that my supply of sample “try-on” breast implants has definitely dwindled down over the past few years.
Don’t even try to decipher the ones you see in magazines. Even the implants are photo-shopped, and if you go back a few posts there’s a lovely video about that.
Of course, there are the obvious ones, like the ninety-five pound woman sporting a DD cup, or the one who looks like she has melons pushing up to her chin.
But those are obvious to everyone. So maybe a better question to ask is:
“Why do some breast jobs look fake and others don’t?”