More data on Brava-assisted fat grafting for breast augmentation

In the upcoming issue of Plastic and Reconstructive Surgery, Dr. Roger Khouri and associates give us an update on their experience with fat transfer to the breast for the purposes of breast augmentation. The bottom line: as long as you use the Brava system for several weeks beforehand, fat transfer works pretty well.

In the study, 81 patients used the Brava for 4 weeks before surgery, then had their own fat transferred with liposuction harvesting to the breast. They then wore the Brava post-op for at least a week. An average of 277 ml per breast was used - which, compared to typical breast implants, is a pretty conservative volume. The patients were followed for an average of 3.7 years postoperatively.

Based on MRI data, they found about 82% graft survival, which was much better than earlier studies in which the Brava system was not used, where the average fat graft survival was 55%. Also, the better the pre-expansion was with Brava prior to surgery, the better the results. There were no suspicious breast masses or nodules during the follow-up period.

These results are pretty much the same as what Drs. Khouri and delVecchio presented at last year's breast surgery conference in Boston. But now the data has gone through the formal peer review process.

I'm a fan of this technique. As a plastic surgeon, it's exciting to build something out of nothing - or in this case, build a breast out of otherwise unwanted fat. Plus, the patient gets the benefit of the contouring from the liposuction at the fat donor site. We're still working on methods to streamline and standardize the operation, but it does work. Wearing the Brava really does help the fat to survive, and our early experience with this method has been very promising.

But wearing the Brava system isn't easy or comfortable - it certainly does require a solid commitment from the patient, to wear it 10 hours a day, every day for the required time - so it's not for everybody. The surgery is more expensive than an implant surgery. Also, if you want more than a cup size increase, or the high-profile implant look, implants are currently still the better choice. With fat grafting, however, there's no worries about implant deflation or capsular contractures - and that can be pretty appealing for the right patient.

New meaning to the term "drug bust"

According to the Daily Mail newspaper (London), a 33-year-old woman was charged in December with international drug trafficking, after she was found carrying more than five and a half pounds of cocaine - with an estimated value of £250,000 - that had been molded inside some artificial breast and buttocks inserts ("falsies").

The woman, a model identified only as MFM, was detained by security personnel at Rome's Fiumicino Airport after a flight from Buenos Aires, Argentina.  "She tried to distract them with a plunging neckline and tight outfit, but they (security personnel) stopped her for questioning because she was so alluring," Fiumicino Airport Police Chief Antonio DiGreco said.

"Once she was questioned, she actually became quite aggressive and was taken away for more detailed questioning by two female officers," he added.  Authorities began their search of the suspect after she failed to adequately explain the reason behind her trip to Argentina, the newspaper reported.  

That's when the drugs were found hidden in the plastic breast and buttock inserts that were responsible for her curvy shape.

....Talk about a drug bust.

Photo credit:  drugfree.org

Botox versus Dysport

This month, in the ASJ, comes another study looking at the Botox versus Dysport battle.  Patients are always wondering - "which one is best?".  Some patients swear they do better with one medication compared to the other.

In this paper, a randomized, controlled study, 53 patients had Botox on one side of the face, and Dysport on the other.  They were then followed for 150 days to see how they did.  The usual conversion ratio of 2.5 units of Dysport to 1 unit of Botox was used, in equal volumes of solution.

Results:  no difference - in this trial, both sides were totally comparable and equal, from day 2 out to 150 days post-injection.

As I've  said before, it's a bit of the "Coke versus Pepsi" situation... pick your favorite, as both Botox and Dysport are both equally effective.  And of course, we offer both here at our Orlando office.

Want smoother, firmer skin? And less cellulite?

There's a lot of machines in the medical marketplace that claim to be "the answer" for non-surgical skin tightening.  Many of them work...a little bit.  But I wanted something that would give my patients real and measurable results.

In addition, it had to be painless, have no side effects, and be FDA cleared.

Now, I'm pleased to tell you that following a lot of comparison shopping, it's now here, sitting shiny and new, in my Orlando office.  Although you've probably never heard of the "Venus Freeze" before, I think it's going to be a name that you'll want to know.  It's proven to firm and tighten skin, reduce fat, and improve cellulite.  And it's painless - unlike the Thermage, the Accent, and a number of previously hyped gadgets.

You'd guess, with a name that has "Freeze" in the title, that the machine would work by cooling the tissue, much like the Zeltiq machine does.  Nope.  It actually works by heating the dermis and subcutaneous tissue, using something called radiofrequency energy, or RF for short.

Turns out this RF heating process activates the production of new collagen and elastic fibers in the skin, which is a good thing.  It also activates a lipase enzyme - a fat melter - and so it can be used for modest contouring improvements, too.

Now this RF technology has been around for a number of years.  There are couple of unique things that make this machine better than previous efforts, like the design of the handpiece.  Instead of only 1 or 2 electrodes (as in earlier designs), the Venus Freeze uses an 8 electrode design.  This divides up the treatment energy more evenly, achieving uniform heating (good!) and avoiding painful heat spikes.  This makes the treatment safe, painless and pleasant.  The new design and higher power output allows the RF energy to go about an inch into the tissues - much more than previous designs on other machines.

Also, unlike laser or IPL, this kind of treatment can be safely used whether you are tanned or not, and on skin of all shades and types.  Almost all areas of the face and body can be treated.  Typically, treatments are done once a week, 6-8 times for the face and 8-10 times for areas on the body.  Depending on the area, treatments take about 25-45 minutes.

Our test patients have commented on smoother, firmer feeling skin, an improvement in their cellulite, and even a loss of about an inch around the waist and bra fat area....and that's after 3 or 4 treatments, not even the whole series.  Three benefits in one!

Of course, this isn't a magic wand.  It doesn't compare to what can be done with surgery, such as a facelift, tummy tuck or liposuction.  But it very favorably compares with any other non-surgical machine currently on the market.  I predict that it will become very popular in our Orlando office - already, all my staff have told me they want a treatment!

Come on in and give it a try.  We've got a special introductory package available for the next 3 months.

Timing of surgery doesn't affect complication rates

Did you ever wonder whether a surgery on Monday or Friday was riskier than one during the rest of the week, or whether surgery in July, when there are new interns on the wards in teaching hospitals, was riskier than a surgery in May? Well, a new study has analyzed this...and there's no difference in the rates of post-surgery death.  So, while you might not buy a car made on a Monday, it's perfectly fine to have elective surgery then!

Here's the rest of the story, from Cosmetic Surgery times....

*****

Cleveland — Results of a recent study suggest that the timing of surgical procedures — afternoon versus morning, Friday versus Monday — has no effect on the risk of post-surgery death.

Researchers from the Cleveland Clinic analyzed the outcomes of 32,001 elective surgeries performed from 2005 to 2010. The risk of death within 30 days after surgery was analyzed according to time of day (6 a.m. to 7 p.m.), day of the week and month of the year. As much as possible, emergency and urgent surgeries were eliminated from the study.

Researchers found that the overall risk of death within 30 days after surgery was 0.43 percent, and that after adjustment for other factors, mortality risk was not significantly different for patients operated on at different times of day. The same was true for operations performed later in the workweek. The study also shows no increase in mortality in July and August, when new residents begin work.

According to a report in Medical News Today, the findings help to alleviate concerns that fatigue may contribute to higher rates of safety problems for operations performed later in the workday or workweek.

The study appears in the December issue of the journal, Anesthesia & Analgesia.

Tightening up Florida liposuction requirements - it's about time!

According to the Sun-Sentinel, there is a bill working its way through Tallahassee which will make some improvements to safety standards for office-based liposuction.  Honestly, it's about time!

The bill would require liposuction of more than 1000 cc of fat to be done in surgery suites inspected by the state, and would require doctors to have life-support training.  Currently, many low-cost providers perform liposuction in unregulated physician offices, and lack ACLS training.

I think this is definitely a step in the right direction!  All surgery, in my opinion, should be performed in an accredited setting, with appropriate anesthesia, monitoring, and emergency equipment.  For example, we are inspected and certified by AAAASF.  In addition to myself, an MD anesthesiologist, two registered nurses and a surgical tech are present for all surgeries.  Everyone has an up-to-date ACLS certification.  We have hospital-grade anesthesia monitors and a crash cart with an AED and emergency medications.  Thank goodness, we've never had to use all of this emergency equipment - but we sure are prepared, "just in case".

The bill last week cleared the Senate Health Regulation Committee and now goes to the Senate Budget Committee, where it is expected to pass. This would close the loophole in current Florida surgery regulations that permit physicians to do procedures in an unregulated, non-inspected office setting if they are only using local anesthesia, and the patient is not sedated.

And often, these same practices have the nerve - the sheer audacity - to claim that they are "safer", despite the fact that they have not passed a safety inspection, lack emergency equipment, don't have an ACLS-trained staff member, and don't have the benefit of a trained anesthesiologist present in case of an airway problem!  Talk about spin and marketing B.S!

While this bill is an improvement for Florida patient safety, it could certainly be a lot stricter.  There's still a lot of unregulated med-spa type offices out there that do other surgical procedures, and these are not covered by this bill.

Happy Holidays!

I'd like to wish our friends, family, patients and staff every happiness this holiday season and throughout the coming year.

The best part of this season is remembering those people who make the holidays meaningful. May your holidays be filled with joy and peace.

All the best,
Dr. Fiala

More trouble with PIP, the French implant company

Although this doesn't apply to us here in the U.S., you might remember hearing about some troubles with the French implant maker PIP.  The news initially broke last year that PIP had been using a cheaper industrial grade silicone in their silicone gel breast implants, rather than medical grade silicone.  They were promptly shut down by French regulators.  Now, there's some more news...

This week, the French health ministry said that these PIP brand implants were much more prone to rupture and leakage than normal, and recommended implant removal (and replacement with new, better implants) as a precautionary measure.  They stated there was no evidence of a cancer link due to these implants.  The French government says it will cover part of this cost for patients under their healthcare plan.  (They'll pay to have the implant removed - but not to replace it.)

It is thought that some 30,000 French women, and even more in other parts of Europe and South America have these PIP brand implants.  That's a lot of patients who are potentially going to need surgery.  PIP, now bankrupt, was once the world's #3 manufacturer of breast implants.

The implants we use in our practice, made by Allergan and Mentor, are FDA-approved, and have an excellent track record.  I've been to the Mentor manufacturing facility in Texas, and it is a top-notch facility run using ultra-sterile "clean rooms" with the employees in those "Intel-inside" type sterility suits.

Fortunately, PIP implants were not used in the United States.  However, if you happen to have had your breast implants done in Europe or South America, check to see if you have PIP brand silicone implants.  If you do have them, please come and talk to us about an implant exchange.

Valeant Pharmaceuticals buys Sculptra

In a $425 million deal, Valeant Pharmaceuticals has purchased the dermatology unit of Sanofi-Adventis.  For us, this means that Valeant will now be in charge of marketing Sculptra, the facial injectable filler agent.

Sculptra is different than other dermal injectable fillers, like Restylane or Juvederm. It stimulates your body to produce some lost collagen, which can gradually improve the quality of the skin and reduce wrinkling and deep hollows. It also lasts up to two years. It's been quite helpful in restoring hollow cheeks and temples, as well as improving deep naso-labial folds. It's quite popular here at our Orlando office.

According to our Sculptra rep, we may be seeing more direct-to-consumer marketing of Sculptra with the new owners, but little else will change.  So far, we haven't heard about any pricing changes, either.

Sanofi, apparently decided to divest its dermatology business with the intention to further concentrate on its core products.

How can we get upper pole fullness without using breast implants?

Upper pole fullness is the term plastic surgeons use to describe the desired shape of the upper part of a breast.  Many women like the look of some upper pole fullness.  The challenge for us is how to make this shape during surgery, and have it stay there.

Certainly, breast implants are a proven way to get upper pole fullness.  Moderate and high profile implants, whether they are saline or silicone gel filled, clearly create that fullness and roundness.  I  call this "the implant look".

Fact is, it is a real challenge to get the uplifted "implant look" without using breast implants.  Not that surgeons haven't tried:  if you look at the literature on breast lifts and breast reductions, there are literally dozens of strategies that have been tried.  There are the "internal bra" methods, the internal suture methods, internal tissue re-arrangments, and many more.  These may very well work for the first month or two, especially while the breast is still swollen from surgery - but the real question is, do they last once the swelling has gone?

Dr. Elizabeth Hall-Findlay, the talented plastic surgeon from Canada and author of a textbook on surgery of the breast, did her own experiment on this problem.  She tried virtually every sensible method during breast lift surgery to try to solve the mystery of how to get persistent upper pole fullness without an implant.  She presented her results at a recent plastic surgery conference.  She found that, although the results looked promising initially, by 6-12 months after surgery, the shape of the breast returned to what it was pre-operatively, and that the fullness was lost.  Nothing really worked; all of the methods she tried failed to give lasting upper pole fullness.

This month, in PRS, comes a new study reviewing 82 major previous publications in breast lift surgery.  Careful photometric analysis was done of the techniques.  Once again, it's a disappoinitment.  With the possible exception of fat-grafting to the breast, the author found that  upper pole fullness "was not increased by any of the mastopexy / reduction techniques, or by the use of fascial sutures or autoaugmentation techniques".

In other words, all the methods touted for upper pole fullness failed to work.  So put internal lifting sutures, auto-augmentation, and the "internal bra" on the scrap-heap of discredited methods.

What does this mean for patients?  Simple:  if you want the "implant look", you have to have an implant.  Fat grafting might be an option, too - but we're still waiting for the studies on that one.