Fat grafting to the breast

Recently, there has been a resurgence of interest in the idea of using a person's own fatty tissue to enhance the breast. It seems like the ideal combination: "take a little off there, and put a little bit more up here".

The truth is: it's still a work-in-progress. Until recently, fat grafting to the breast had been considered a bad idea. Lumpy breasts, with oil-filled cysts, could occur. And worse, the scar tissue which sometimes formed after fat injections could exactly mimic the appearance of a breast cancer on a mammogram, leading to needless anxiety and additional biopsies.

Lately though, there has been a re-appraisal of this idea, both here in the USA and abroad. A breakthrough study from Japan found that the key factor to making the fat injections work in the breast seems to be the addition of stem cells.

By "turbo-charging" the injected fat with the person's own adult stem cells (also found in fatty tissue), the combination of fat cells and stem cells worked much better, successfully surviving the move from the donor site to the new location in the breast without the problems listed earlier.

Some pretty clever machinery is used to harvest, centrifuge, and purify the stem cells from liposuctioned fat. Some far-sighted biotech companies have already submitted automated versions of this machinery for FDA approval.

The Japanese group made fairly modest changes in the patient's breast size - averaging about 200 cc, which is small compared to the typical breast implants that we use here (commonly 300 - 500 cc), but their results show that the technique is promising. The fat-grafting surgery also takes much longer than a typical breast augmentation: about 6 hours of anesthesia time, compared to about 1 hour when implants are used.

Nevertheless, it's an exciting surgical innovation that someday (I hope) will be in common use. Currently, the technique is not FDA-approved, and is still in the "experimental" stage.

Trends in Breast Augmentation in Orlando

With a practice that is about 50% breast surgery, we are well-versed on the current trends in breast augmentation. Here are some of the patterns that we've noted.

1. Return of silicone gel: Three years ago, 90% of the implants we used were saline-filled. With the FDA re-approval of silicone gel breast implants, we've been offering our patients a choice of saline or silicone gel. Now, easily 75% of the implants that the patients want are silicone gel ones, due to their "more natural" feel and their lower rate of post-operative rippling in slender patients. The remaining 25% of our patients select saline implants due to their adjustability, their lower cost, or their desire to avoid anxieties about silicone gel altogether.

2. Credit crunch: Prior to September 2008, many younger patients were using third party financing to pay for their surgery. With the meltdown in the credit markets, these loans are more difficult to get, especially for people with marginal credit. Some are taking advantage of our cash-only discounts, but many are holding off on surgery for the moment.

3. Lack of interest in the "gummy bear" implants: Despite the buzz in the American plastic surgery societies about the impending FDA approval of form-stable silicone gel implants (commonly known as "gummy bears" due to their thick gel formulation) patients seem unimpressed. Once I describe the significantly bigger surgical incision required for their placement, patients seem to rule out that choice, despite their potential advantages. Our patients also don't seem to care for the tear-drop shape, either - the majority of our patients specifically ask for some fullness in the upper portion of the breast. This reflects the American sensibility for breast shape, which interestingly, is different than what is popular in Europe or South America. (More on than later!!)

Lipodissolve & Mesotherapy: the low-down

Here's a hot topic: can you melt fat by injecting certain active substances into it, and is this safe to do? Those are the key questions to be determined when in comes to injection lipolysis, also known as Lipodissolve, Flab-jab, and a number of other proprietary names.

Currently, the two most commonly used drugs, the soybean-derived phosphatidylcholine (PC) and a bile-salt derivative called deoxycholate (DC), are not FDA-approved for this purpose. These are injected, sometimes with a cocktail of other ingredients, into the fat, using a grid-like pattern. This is typically repeated at intervals, until the desired results are seen, or the patient gives up, or runs out of money!

While this procedure is poorly-understood and needs a whole lot more research to determine the best way to do it, here's what we do know from the scientific studies:

1) The injections don't "melt" fat - they cause the fat cells to rupture, killing the fat, which is then replaced by scar tissue;
2) The DC seems to be more effective in causing the effect, compared to the PC;
3) Some studies have found no benefit whatsoever; others have seen a measurable effect, with a reduction in fat;
4) We don't really know the optimal dosage and mix of ingredients;
5) We don't know where the "melted" fat goes, and whether this process has side effects;
5) Some people have reactions to the injections, with pain, swelling and lumpiness. Fortunately, most of these reactions are usually transient;
6) Some people have no response to the treatment, other than the inevitable thinning of their wallet. These people usually come to me later, for actual liposuction.

So far, I feel that injection lipolysis should be classified as an experimental procedure. Although I'm very interested in it, I don't offer it to my patients. I feel that the details really need to be worked out first. Liposuction is still the undisputed standard for fat removal.

Regulatory approval would also help me feel better about this technique. When the FDA, Health Canada, the UK's Medicines and Healthcare Products Regulatory Agency (MHRA), and the Brazilian version of the FDA all speak out against this procedure, that should tell you something. It's probably not "ready for prime time" yet.

The research wing of ASAPS (American Society for Aesthetic Plastic Surgery) has a study going on this right now. I'll post the results as soon as they are available. Personally, I'd like for this technique to work - it would add another useful method to those we use currently, and would be minimally-invasive, as well. We'll have to wait and see...

Which TV Doctor would you pick?

Here's a bit of fun: according to a recent survey conducted by the American Board of Medical Specialties (ABMS), Gregory House (from the FOX-TV series "House") is simultaneously America's most loved and most hated TV doctor, and the medical professional most people would want as their own doctor. Go figure!

Apparently, Americans respect and want his brilliant diagnostic abilities, but don't care for his gruff manner and lack of people skills.

The other favorite TV doctors were: Marcus Welby, Hawkeye Pierce (M*A*S*H*), John Carter ("ER"). On the other end of the scale, the TV docs that people least wanted to have were: Doogie Howser, Gregory House (as stated above) and Frasier Crane ("Frasier").

The results of the survey suggested that the qualities people value most in a physician are bedside manner and communication skills (95%) and board certification (93%). Curiously, only 45% of these same survey respondents had ever checked to see if their doctor is board-certified. (Go to www.ABMS.org if you ever want to look up your doctor's board credentials.)

Consumer tip: Remember, with the new "Truth in Medical Education" laws passed here in Florida last year, it's not enough for your doctor to say he/she is "Board Certified". They also must tell you the specific name of the ABMS Board as well. That means a "wanna-be cosmetic surgeon" who trained in gastroenterology or OB/GYN, would legally have to tell you those very relevant details.

Does taking Vitamin E supplements prevent prostate cancer?

In the mid-1990's, two medical studies that were looking at the effects of vitamin and mineral supplements on cancer rates came on a finding, quite by happenstance during the post-study data analysis. It seemed that men who took Vitamin E supplements had a lower rate of prostate cancer. While neither study was particularly designed to investigate prostate cancer issues, the finding generated a great deal of excitment, as prostate cancer is very common in middle-aged and older men. Suddenly, men everywhere were taking Vitamin E and selenium, for prostate health

In the latest issue of the Journal of the American Medical Association (JAMA)are two major studies, which were designed to look specifically at this issue. The first study, known as "SELECT", looked at 35,000 men in the U.S., Canada and Puerto Rico, and compared the effects of 400 units per day of Vitamin E and/or Selenium supplements versus placebo. The second study, "PHS-II", looked at 14,600 American physicians over a 10 year period, and was also a randomized, double-blinded, placebo controlled study.

Bad news: unfortunately, neither of these two new, powerful studies found any significant reduction in prostate cancer rates due to Vitamin E, Vitamin C or Selenium supplements in the dosages given.

It seems that the positive results of the earlier studies were a chance occurrence - a fluke, if you will. Sometimes that happens - which is why scientists always double-check their initial findings with further studies. Given the large size of these two new studies, and their careful design, it is unlikely that an effect of the supplements, good or bad, would be missed.

So, it's back to the drawing board...guys, you can stop taking the selenium and Vitamin E now.

Surgery after Massive Weight Loss

As gastric bypass procedures have become more common, patients who have lost a large amount of weight following gastric bypass, who now have significant laxity of their skin have also become more common in our office. As you'd expect, the areas that are commonly affected after massive weight loss (MWL) include: the abdomen and trunk, the breasts, the arms, and the inner and outer thighs.

While plastic surgeons have long had operations to fix these problem areas by removing the excess skin, we've learned through experience that the MWL patients are a little different than regular non-MWL patients when it comes to wound healing, complications and results.

For example, problems like anemia (from iron or vitamin B12 malabsorption) and certain other vitamin deficiencies are much more common in someone who has had a previous gastric bypass, compared to a non-bypass patient. Also, poor protein absorption caused by the effects of bypass surgery can result in low protein reserves and subsequent troubles with slow or impaired wound healing.

MWL patients are also more prone to have a higher rate of certain post-surgical complications. These include: wound separation, fluid accumulations under the skin known as seromas, and scars that may be more obvious in color or size compared to the non-MWL group.

Also, the MWL- patient's skin tends to stretch out more over time, due to decreased elasticity. So, even though we pull the skin as snug as we safely can, some relapse of the lifted area can occur.

Overall, this makes surgery for MWL patients more of a challenge - but the results are usually very gratifying for both surgeon and patient alike when it is completed. We'll discuss this topic in more detail in future blogs.

Celebrity Plastic Surgery

Recently, I got a e-mail from a former employee, an attractive young nurse who had moved out to the West Coast. In it, she comically mentioned "not wanting to look like some Hollywood-style bad plastic surgery victim", and asked me for some recommendations about who to see out there. But it got me thinking...

I spent some time looking at "bad celebrity surgery", and started to notice some patterns. I think it boils down to a combination of facial distortion, loss of one's distinctive initial appearance with reduction of recognizability, and the "stigmata" of poorly performed or ill-advised work.

Here is my highly opinionated list of "problems to be avoided", if at all possible.

1. Excessive botox - particularly in the glabella and medial forehead area, when it can drop the position of the inner portion of the eyebrows, giving a diabolical or "vulcan" look.

2. Excessive lip fillers. While a full, pouty lip can look youthful and pretty - there is a limit. The upper lip should certainly not be larger than the lower lip. Respect the anatomic details of the lip - the lip should not look like a sausage. In general, straight men should avoid lip augmentation, as it can feminize the appearance.

3. Facial fat removal. As we age, we naturally lose our facial fat. Removing it surgically with liposuction or direct excision, in order to give a more "sculpted" appearance, can be a set-up for a skeletal, gaunt appearance in the future. And it's hard to fix.

4. Cheek implants - are not a substitute for a facelift, and do not make a good replacement for loss of facial fat. Poorly performed cheek augmentation can distort the facial width, or look like a chipmunk storing nuts in its cheeks. Cheek & chin implants can work wonders for people that don't have good underlying bone structure - if they are properly sized, and meticulously placed by an expert.

5. Overdone rhinoplasty. An excessively thinned, pointy nose, with distortion in the nostril area or visible irregularities. Celebrity gossip pages are full of these.

6. Unfortunate facelift results. We'll talk more about this in future posts - but "pixie ears", loss of hair in the temple area, peculiar direction of cheek wrinkles, visible scars, the "tight face-loose neck" combination....these are all tip-offs that a facelift didn't work out very successfully or had some technical problems.

7. "Tan-orexia" - when your skin tone is the color of pumpkin pie from the over-use of self-tanning products, it's not good.

8. Too much of everything / too young / too many operations. Trying to slow aging is one thing. Starting to look like someone else is another.


Best wishes for 2009!