Thursday, March 31, 2011

Blindness After Blepharoplasty (Eyelid Surgery)

Can Blindness Occur After Blepharoplasty
Losing one's eye sight would be the most devastating complication after a blepharoplasty procedure for both the patient and the surgeon. Fortunately, blindness after an eyelid procedure rarely occurs (1 in 10,000 cases.)  Before one undergoes an eyelid procedure, one should be cognizant of its potential complications, such as blindness.  It is also very important to recognize the symptoms of an impending visual loss after a blepharoplasty procedure so that your plastic surgeon will be able to address this problem in a timely manner.

Fast Facts about Blindness after Blepharoplasty
  • Permanent visual loss after blepharoplasty was estimated to occur in 1 in 30,000 in a new study.
  • Temporary visual loss after blepharoplasty was estimated to occur in 1 in 50,000.
  • Majority of patients developed symptoms within 24 hrs of the procedure.
  • History of hypertension is the most common risk factor associated with blindness after a blepharoplasty procedure.
  • Postoperative vomiting and a history of vascular disease occured more frequently in patients who developed permanent visual loss.
  • Most common cause of blindness after blepharoplasty is retrobulbar hemorrhage (bleeding behind the eyeball).
The Blind Beggar by Jules Bastien-Lepage (File courtesy of Wikimedia Commons)
Symptoms to Look for an Impending Visual Loss after a Blepharoplasty 
  • Severe pain (41% of patients)
  • Pressure sensation (36% of patients)
  • Blurred vision (not common)
Preventive Measures to Reduce the Risk of Vision Loss after Eyelid Surgery
  • Good control of high blood pressure before surgery
  • Minimize postoperative nausea and vomiting
  • Minimize physical activity after surgery
  • Any medication that can increase bleeding, such as aspirin, ibuprofen, or certain supplements like garlic pills, gingko biloba, vitamin E, omega-3 fatty acids, should be suspended two weeks before surgery and should not be taken for at least one week after surgery.
It behooves the astute plastic surgeon, as well as the educated patient, to be aware of this potential complication.  It is imperative  for one to recognize the symptoms of an impending visual loss after an eyelid procedure so that vision can be preserved.   I recommend to always ask your plastic surgeon information about blepharoplasty prior to undergoing this procedure.

Hass AN,  Penne RB, Stefanyszyn MA, Flanagan JC. 
Incidence of postblepharoplasty orbital hemorrhage 
and associated visual loss.  Ophthal Plast Reconstr Surg
Lelli GJ, Lisman RD. Blepharoplasty complications. Plast 
Reconstr Surg 2010;125:1007
Mejia, Ergo and Foad Nahai. Visual Loss After Blepharoplasty: Incidence, Management, and Preventive Measures.  Aesthetic Surgery Journal.  January 2011;31(1): 21-29
Wolfort  F, Vaughan T, Wolfort S, Nevarre D. Retrobulbar hematoma and blepharoplasty.  Plast Reconstr Surg

Tuesday, March 29, 2011

BOTOX for Migraine Headaches

BOTOX for Migraine Headaches:  Is it Effective?

Migraine headache is a disabling medical condition that affects 11 out of 100 people in the United States.  Majority of these patients are women (3 out of 4 people with migraine headaches.)  With the serendipitous discovery of BOTOX reducing the frequency of migraine headaches in women who underwent BOTOX treatment for their forehead wrinkles, the idea of using BOTOX to treat migraine headaches seem promising.  Does BOTOX really treat migraine headaches?  

Migraine Headache Symptoms
  • Throbbing pain on one or both sides of the head
  • Stiff neck
  • Visual hallucinations such as zigzag lines and flashing lights
  • Nausea and vomiting
  • Irritability 
  • Mood swings
  • An episode of migraine can last from 3 to 72 hours

    Photograph courtesy of
    Fast Facts about BOTOX for Chronic Migraine Headaches

    • BOTOX was approved by the FDA on October 2010 for the prevention of chronic migraine headaches for adults.
    • Chronic migraines are defined as migraine headaches that occur more than 15 days a month for more than four hours per day.
    • A study involving 1,384 adult patients revealed that patients who received BOTOX injections for migraine headaches experienced 7.8 and 9.2 fewer days of migraine than they had before the studies started. Those who received  placebo injections (sugar pill) experienced 6.4 and 6.9 fewer headache days.
    • Patients who received BOTOX for chronic migraine headaches experienced 107 and 134 fewer hours of headache, versus a reduction of 70 and 95 hours for those on placebo.
    • Patients were also found to have reduced consumption of migraine headache medications, such as sumatriptan, after BOTOX injection for chronic migraine headaches.
    • About 1% of patients who received BOTOX injection for chronic migraine headaches found that their migraine headaches worsened after treatment.
    • Most common side effect was transient cervical pain (neck pain) according to one study.
    Unfortunately, BOTOX is not the panacea for migraine headaches.  It can reduce the frequency of migraine headaches in patients who have chronic migraine, but does not completely cure it.  I recommend seeing your physician (especially a Neurologist) to determine if you have chronic migraine headaches, and to evaluate if you are a good candidate for BOTOX to treat this disabling medical condition.

    Emmanuel De La Cruz M.D.

    US FDA: FDA approves Botox to treat chronic migraine. October 15, 2010
    Cady et al.  A multi-center double-blind pilot comparison of onabotulinumtoxinA and topiramate for the prophylactic treatment of chronic migraine. Headache. 2011 Jan;51(1):21-32. pp1526-4610
    Diener et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial.  Cephalalgia. 2010 Jul;30(7):804-14
    Dodick, et al.   OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program.   Headache. 2010 Jun;50(6):921-36  
    Oterino, et al.  Experience with onabotulinumtoxinA (BOTOX) in chronic refractory migraine: focus on severe attacks. Journal of Headache Pain.  February 2011.(Epub Ahead of Print)  

    Monday, March 28, 2011

    Dermal Filler Injections for Breast Augmentation?

    Dermal Filler Injection for Breast Augmentation:  Is it Safe?
    Research has shown that many women have shown significant interest in having a breast augmentation.  However, only a small percentage of women who contemplated about breast enhancement opted to undergo surgical intervention.  The advent of minimally invasive procedures for breast enhancement, such as fat transfer and hyaluronic acid injections, has garnered increasing attention from the media, and significant interests from women who are seeking a minimally invasive procedure for breast augmentation.  Hyaluronic acid dermal fillers being used for facial rejuvenation is now being extensively promoted for breast augmentation in 17 countries throughout Europe and Asia. The hyaluronic acid filler, Macrolane, was developed by Swedish scientists to be used for breast augmentation, as well as for buttock augmentation.  Because of the increasing popularity of this new procedure for breast enhancement, safety issues are now being raised, especially in the United States.
    Sunlight By Julius Leblanc Stewart (Photo courtesy of Wikimedia Commons)
    Fast Facts About Breast Augmentation Using Macrolane (Hyaluronic Acid Dermal Filler) Injections
    • Macrolane is a hyaluronic acid gel that is both biocompatible and biodegradable in nature.
    • Macrolane used for breast enhancement are injected either subglandular (above the pectoralis muscle) or submuscular (below the pectoralis muscle.)
    • Larger volumes are required for breast enhancement as compared to facial rejuvenation.  A maximum volume of 100 ml of Macrolane per breast was used in a study conducted in Sweden.
    • Macrolane injections are temporary and lasts for 1-2 years.
    • The study conducted in Sweden showed that in women who underwent Macrolane injections, 78% of the hyaluronic acid filler remained at 3-months; 57% remained at 6-months; and 34% remained at 12-months based on the breast MRI evaluation performed after the procedure.
    • Capsular contracture (85% with Baker Scale III) was the most common complication after Macrolane injection for breast augmentation (25% of patients.)
    • No serious adverse events or inflammatory reactions were found after 1 year of injection.
    • Macrolane injections for breast augmentation is NOT FDA-approved, and is not available in the United States.

    The minimally invasive nature of Macrolane injections for breast augmentation seems to be promising for those who seek an alternative solution for breast enhancement.  However, due to the limited clinical studies available regarding its safety, as well as the unknown effects for mammographic detection of breast cancer, one should proceed with caution regarding having this procedure done, especially in the United States.  I recommend asking your  plastic surgeon regarding the different alternatives for breast augmentation if one is interested to have their breast enhanced.

    Emmanuel De La Cruz M.D.


    Hedén, et al.  Macrolane for Breast Enhancement: 12-month Follow-Up.  Plastic Reconstructive Surgery.  2011. February; 127(2): 850-60.
    Hedén, et al.  Aesthetic breast surgery: Consulting for the future—Proposals for improving doctor-patient interactions. Aesthetic Plastic Surgery. 2009;33:388–394
    McCleave.  Is Breast Augmentation Using Hyaluronic Acid Safe?  
    Aesthetic Plast Surg. 2010 Feb;34(1):65-8; discussion 69-70. Epub 2009 Dec 5.
    Nahabedian, Maurice.  Discussion: Macrolane for Breast Enhancement:12-Month Follow-Up. Plastic Reconstructive Surgery.  2011. February; 127(2): 861-862.

    Sunday, March 27, 2011

    Buttock Augmentation Using Silicone Implants

    Buttock Augmentation Using Silicone Implants

    The desire to have a firm and sensuous buttocks, like that of Beyonce or Kim Kardashian, has sprouted over the past several years.  Unfortunately, exercise alone is not sufficient to acquire this voluptuous buttock that some women desire.  During the past decade, buttock augmentation has gained popularity in the United States.  Before one contemplates on having a buttock augmentation performed, whether with the use of silicone implants or with the use of fat grafts, one should be fully informed about these various procedures.  

    Buttock Augmentation Techniques
    • Buttock augmentation using a solid silicone elastomer implants
    • Brazilian butt lift with the use of fat grafts
    • Augmentation with autologous tissue by rearranging the tissues in one's buttock.  It's the typical procedure used for body contouring surgery after a massive weight loss.
    Photograph by Paolo Brandao from Caldas de Reis, España (Courtesy of Wikimedia Commons)
    Fast Facts about Buttock Augmentation Using Silicone Implants
    • Associated  with a higher risk of dehiscence (wound separation) of the midline low sacral incision ~14-30%.  However, a recent study has shown a 1.5% risk of wound dehiscence.  
    • Most common complication of buttock augmentation using silicone implants is formation of seroma (19-28%).
    • Overall re-operation rate is ~13% in one study. 
    • Infection rate is approximately 6.5% (subfascial and intramuscular implants.)
    • One study showed that placing the buttock implants below or above the muscle did not show any significant difference with regards to complications.
    •  If a patient has inadequate fat available, buttock implants may be the only choice available.

    Disadvantages of Buttock Augmentation using Implants placed Sub- or Intramuscularly
    •   Risk of sciatic nerve injury
    •      Inability to enhance the lower buttock or lateral buttock since     the implant can only be placed in the upper to mid buttocks
    •      Wound dehiscence/separation rate with implants which typically occur 1 to 2 weeks after surgery
    •   Recurrent or chronic seromas around the implant (2-4%)

    Emmanuel De La Cruz M.D.
    The Woodlands Plastic Surgeon

    Bruner, et al. Complications of Buttocks Augmentation: Diagnosis, Management, and Prevention.  Clinics in Plastic Surgery2006, Vol 33 (3): 449-466
    Gonzalez R. Augmentation gluteoplasty: the XYZ method. 
    Aesthetic Plastic Surgery 2004;28:417-425
    Mendieta CG. Gluteoplasty. Aesthetic Surgery Journal. 2003;23:441-455.
    Senderoff, Douglas. Buttock Augmentation With Solid  
    Silicone Implant.  Aesthetic Surgery Journal. 2011;31(3): 320

    Date updated:  March 31, 2011

    Tickle Liposuction

    Does "Tickle Liposuction" Really Tickle?

    Several liposuction techniques/machines, such as the VASER and Smart Liposuction, have been developed during the past decade which has drawn significant attention from the media.  Recently, a new liposuction technique, the "Tickle Liposuction", has emerged.   Does the "Tickle Liposuction" really tickle?  That is the question.


    Fast Facts about the "Tickle Liposuction"    
    • Tickle liposuction is FDA-approved in the United States.
    • It's a variation of the power-assisted liposuction (PAL).
    • "Tickle liposuction" has a cannula that rotates through a small conical arc of motion.  This rotation of the cannula produce a "tickling sensation" that patients feel during the process of liposuction.  
    • The patient is aware of this "tickling" sensation only when the patient is awake while the liposuction is being performed.
    • Currently, there is no published clinical data or trial comparing this liposuction method with other techniques.
    Is It Safe to Have Tickle Liposuction done in an Office Setting?
    • A safe surgical facility for liposuction must be able to minimize the risks of surgical infections that may occur after your procedure.  These kind of procedures should be done in operating rooms that maintain high standards for cleanliness. All surgical instruments should be steam-sterilized since cold sterilization of liposuction instruments is below the standard of care.
    • Your physician should maintain competency in Advance Cardiac Life Support (ACLS) when this procedure is being performed for safety reasons.
     Are there different levels of Office-Based Anesthesia?
    • Yes.
    Level I Services: Delivery of analgesics or anxiolytics by mouth, as prescribed for the patient on order of a physician, at a dose level low enough to allow the patient to remain ambulatory
    Level II Services: Delivery of analgesics or anxiolytics by mouth in dosages greater than allowed at Level I and tumescent anesthesia, as prescribed for the patient on order of a physician
    Level III Services: Delivery of analgesics or anxiolytics other than by mouth, including intravenously, intramuscularly, or rectally
    Level IV Services: Delivery of general anesthetics, including regional anesthetics and monitored anesthesia care

    What is the Standard of Care for these kind of Services?
    Level I services:
    1.      at least two personnel must be present, including the physician who must be currently certified at least in AHA-approved BCLS; and
    2.      the following age-appropriate equipment must be present:
    1.      bag mask valve;
    2.      oxygen;
    3.      AED or other defibrillator; and
    4.      pre-measured doses of epinephrine, atropine, adreno-corticoids, and antihistamines.

    Level II services:
    1.      at least two personnel must be present, including the physician who must be currently certified at least in AHA approved ACLS or PALS, as appropriate;
    1.      another person must be currently certified at least in AHA approved BCLS; and
    2.      a licensed health care provider, who may be one of the two required personnel, must attend the patient, until the patient is ready for discharge; and
    2.      a crash cart must be present containing drugs and equipment necessary to carry out ACLS protocols, including, but not limited to, the following age-appropriate equipment:
    1.      bag mask valve and appropriate airway maintenance devices;
    2.      oxygen;
    3.      AED or other defibrillator;
    4.      pre-measured doses of first line cardiac medications, including epinephrine, atropine, adreno-corticoids, and antihistamines;
    5.      IV equipment;
    6.      pulse oximeter; and
    7.      EKG Monitor.

    Level III services:
    1.      at least two personnel must be present, including the physician who must be currently certified at least in AHA approved ACLS or PALS, as appropriate;
    1.      another person must be currently certified at least in AHA approved BCLS;
    2.      a licensed health care provider, which may be either of the two required personnel, must attend the patient, until the patient is ready for discharge; and
    3.      a person, who may be either of the two required personnel, must be responsible for monitoring the patient during the procedure; and
    2.      the same equipment required for Level II;

    Level IV services:
    Physicians who practice medicine in Texas and who administer anesthesia or perform a procedure for which anesthesia services are provided in outpatient settings at Level IV shall follow current, applicable standards and guidelines as put forth by the American Society of Anesthesiologists (ASA) including, but not limited to, the following:
    1.      Basic Standards for Pre-anesthesia Care;
    2.      Standards for Basic Anesthetic Monitoring;
    3.      Standards for Post-anesthesia Care;
    4.      Position on Monitored Anesthesia Care;
    5.      The ASA Physical Status Classification System;
    6.      Guidelines for Non-operating Room Anesthetizing Locations;
    7.      Guidelines for Ambulatory Anesthesia and Surgery; and
    8.      Guidelines for Office-Based Anesthesia.

    I recommend to ask your plastic surgeon about different liposuction techniques when one is interested in liposuction.  Not everyone would be a candidate for liposuction.  The results of liposuction is not dependent on the machine but would be dependent by the skill and level of training of your plastic surgeon.  Remember that your safety is extremely important, and one should be fully informed before one undergoes any procedure.

    Friday, March 25, 2011

    Smile Train of the Week ~ Philippines

    With the emigration of physicians and lack of plastic surgeons in the Philippines treating children with cleft lip and palates, the need for surgeons performing this life-changing procedure becomes magnified when one visits the Philippines.  Non-profit organizations, like the Smile Train and Operation Smile, help millions of children all over the world who are born with cleft lip/palate.  Please visit Smile Train and "help ensure a child born with a cleft lip/palate has the same opportunities as one born without."

    Emmanuel De La Cruz M.D.
    The Woodlands Plastic Surgeon

    Tuesday, March 22, 2011

    Brazilian Butt Lift ~ Houston Plastic Surgeons

    The Brazilian Buttock Lift  

    With the popularity of Jennifer Lopez, and Kim Kardashian's shapely buttock curvature, buttock augmentation has been reported to be one of the top cosmetic procedures predicted to increase in 2011 according to the American Society of Aesthetic Plastic Surgery.  Recently there has been an increasing demand of having a youthful, prominent and perky buttock to obtain a more sensual body profile. The classic hourglass shape (full buttocks, narrow waist) of the female body has been thought to be aesthetically pleasing, and is what men universally find most attractive according to one study.  Several types of augmentation, such as the breast and that of the buttock, have sprouted demand to help create this hourglass figure.  

    L'Etoile Perdue: painted by William A. Bouguereau
     (File courtesy of Wikimedia Commons)
    The buttock has been an important element of sexual attraction in essentially all cultures throughout recorded history.  Buttock augmentation can be performed by using several methods such as the insertion of silicone buttock implants; by rearranging muscle and fat from your buttock; and by injection using fat grafts.  The so-called "Brazilian Butt Lift" has been increasingly popular in the United States, especially since this buttock augmentation procedure does not involve placement of a buttock implant.  This particular procedure involves the harvest of fat from areas with excessive fat (such as the lower abdomen, flank and hips) by performing liposuction.  These fat grafts are then subsequently injected in areas of the buttock desired to be augmented in order to produce a more attractive and sensuous body profile.  Before one decides to partake and undergo this increasingly popular cosmetic procedure, one should be fully informed about this particular plastic surgery.

    Fast Facts about Fat Grafting for Buttock Augmentation (Brazilian Butt Lift)

    • Liposuction is first performed in areas where there's excessive fat, such as the abdomen, flank, and hips (iliac crest area).
    • After the fat graft is harvested, it is then injected both intramuscularly (into the muscles) and subcutaneously (underneath the skin) at the desired area of the buttock to be augmented.
    • Approximately 300 to 400 mL of fat is injected on each side of the buttock.
    • The average fat injected may depend on the ethnicity of the patient (~205 mL in a petite Asian patient; 400 to 1430 ml per side in a Caucasian patient; 400 to 1478 mL per side in a Hispanic patient; and 400 to 1880 mL in an African American patient.)
    • The volume of fat that will be injected will depend on the amount of donor fat available.  Thus, patients with minimal fatty tissue may not be a candidate.
    • 50 to 75% of the fat grafted remains long term according to a clinical study involving 566 patients.
    • There may be lesser pain and faster recovery associated with the procedure, as compared to buttock implant placement, according to one study.

    Potential Complications of Fat Grafting for Buttock Augmentation
    • Wound infection/Cellulitis (<2%)
    • Seromas/hematomas
    • Asymmetry
    • Fat necrosis
    • Fat embolism (rare)
    • Partial reabsorption of grafted fat
    • Transient sciatic paresthesias (numbness)

      Plastic surgery is a rapidly evolving field.  It is imperative to have a plastic surgeon, who have solid mastery of clinically relevant anatomy in aesthetic gluteal body contouring surgery, perform these emerging procedures of aesthetic plastic surgery.  Buttock augmentation using fat grafts may seem to be a simple procedure, but like any procedure, potential complications and adverse events may occur.  I recommend seeing a plastic surgeon in your community if one is interested in getting the "Brazilian Butt Lift."

        Emmanuel De La Cruz M.D.

        Recommended article:

        American Society of Aesthetic Plastic Surgery: 10 Cosmetic Plastic Surgery Predictions for 2011 
        Bruner, et al. Complications of Buttocks Augmentation: Diagnosis, Management, and Prevention.  Clinics in Plastic Surgery. 2006, Vol 33 (3): 449-466
        Centeno et al. Clinical Anatomy in Aesthetic Gluteal Body Contouring Surgery.   Clinics in Plastic Surgery. 2006, Vol 33 (3):347-358
        Roberts, et al. “Universal” and Ethnic Ideals of Beautiful Buttocks are Best Obtained by Autologous Micro Fat Grafting and Liposuction.  Clinics in Plastic Surgery. 2006, Vol 33 (3): 371-394
        Roberts, et al.  Augmentation of the Buttocks by Micro Fat Grafting. Aesthetic Surgery Journal. 2001, Vol 21: Part 4, pp311-319
        Singh, Devendra. Universal Allure of the Hourglass Figure:  An Evolutionary Theory of Female Physical Attractiveness.  Clinics in Plastic Surgery. 2006, Vol 33 (3): 359-370

        Friday, March 11, 2011

        The Effects of Smoking and Nicotine on Your Plastic Surgery

        The Effects of Smoking and Nicotine on Your Plastic Surgery

        Not only smoking been known to increase one's risk of developing lung cancer, chronic lung disease and coronary artery disease, but it also been found to hasten aging.  The risk of development of wrinkles at an earlier age is two to three times greater in smokers than non-smokers.  So does plastic surgery reverse the effects of aging among smokers?   Does smoking has any effects on your plastic surgical procedure?
        Fast Facts on Smoking and Plastic Surgery
        • Smoking one cigarette may cause the small vessels in your skin to constrict (vasoconstriction) for up to 90 minutes.  Thus, patients who undergo facelifts and other plastic surgery procedures, such as a breast lift, are at risk for necrosis of the skin.
        • Smoking a pack of cigarettes per day will remain tissue hypoxic (oxygen deprived) for most of the day.  Thus, it is critical to stop smoking before and after your plastic surgery procedure.
        • The nicotine in cigarettes causes constriction of the small blood vessels of your skin.  This leads to decreased delivery of oxygen to your skin.  
        • Thus, taking nicotine for smoking cessation would still have an adverse effect on tissue oxygenation after your plastic surgery procedure.
        • Nicotine impairs wound healing.
        Jessica Biel states that she does not smoke.  She'll likely maintain her youthfulness.

          Scientific Evidence of the Effects of Smoking on Wound Healing
          • Nicotine is associated with thrombosis of small vessels by interfering with prostacyclin activity.
          • Nicotine also retards the rate of wound epithelialization.
          • Nicotine decreases the proliferation of fibroblasts, which is an important part of wound healing.
          Smoking and Plastic Surgery
          • 40% of patients who smoke before and after breast reduction surgery had impaired wound healing in one study.
          • After breast reduction surgery, the risk of developing complications, such as inverted T-incision site necrosis, among smokers is doubled (odds ratio 3.1).
          • After breast reduction surgery, the infection rate (OR 3.3) was significantly elevated among active smokers.
          • In patients who undergo a facelift procedure, smokers present a 13-fold risk of skin necrosis.  
          • Smoking is also associated with an increased risk for the development of hematoma (bleeding) after a facelift surgery.
          • In patients who undergo transverse rectus abdominis myocutaneous flaps (TRAM flaps) for breast reconstruction, smoking is associated with significantly higher flap necrosis rates for smokers than nonsmokers (19% vs 9%, P=0.005). 
          As a physician and surgeon, I do not advocate smoking and highly recommend smoking cessation, especially if one is to undergo a surgical procedure.  One should avoid nicotine and smoking at least one month prior to undergoing plastic surgery in order to minimize potential complications that can occur after your surgical procedure. 
            Emmanuel De La Cruz MD

            Bartsch et al.  Crucial aspects of smoking in wound healing after breast reduction surgery. Journal of Plastic  Reconstructive Aesthetic Surgery. 2007;60(9):1045-9. Epub 2007 Mar 9.
            Grover, et al.  The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts.  British Journal of Plastic Surgery.  2001 Sep;54(6):481-6.
            Knobloch, et al.  Nicotine in Plastic Surgery: A Review.  Chirurg2008 Oct;79(10):956-62.
            Koh JS, et al. Cigarette smoking associated with premature facial wrinkling: Image analysis of facial skin replicas. International Journal of Dermatology. 2002;41:21.
            Krueger J, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plastic  Reconstructive  Surgery. 2001 Sep 15;108(4):1063-1073. 
            Mosely, et al. Nicotine and its Effect on Wound Healing. Plastic  Reconstructive  Surgery. 1978 Apr;61(4):570-5.
            Siana JE, Rex S, Gottrup F. The effect of cigarette smoking on wound healing. Scandinavian Journal of Plastic Reconstructive Surgery & Hand Surgery. 1989;23(3):207-209

            Date Updated:  April 1, 2011

            Saturday, March 5, 2011

            Fat Grafting for Breast Enlargement/Augmentation

            The Use of Fat Graft for Breast Augmentation

            Fat grafting for breast enhancement has been thought to be a recent advancement for breast plastic surgery.  However, the concept of fat grafting was already pioneered in the late nineteenth century by Franz Neuber from Germany.  The idea of harvesting fat from areas where there's excess of fat (such as in the lower abdomen, hips or thighs), and using this fat for breast augmentation seems like a great idea.  Before one contemplates about fat grafting for breast enlargement, one should be fully informed about this procedure.

            Fast Facts about Fat Grafting for Breast Augmentation
            • Patients may need to use a device called the Brava device.
            • Patients typically use a Brava device 10 hours per day, generally overnight for several weeks before fat injection, and may need to use it for another 1-3 weeks or more. 
            • The Brava device is a plastic egg-shaped dome used to fit the patient’s breasts.  This is used to “create a gentle suction that stimulates tissue growth” per Dr. Khouri, inventor of the Brava device. 
            • The Brava device costs at least $800.
            • Multiple fat grafting may be required to cause a significant increase in breast size.
            • The fat graft volume retained one year after surgery ranged from 40 to 70% (average, 55%).

              Brava Device

              Advantages of Fat Grafting for Breast Enlargement
              • The main advantage of fat grafting into the breast is the avoidance of any complications associated with saline or silicone gel breast implants.
              • The augmented breasts may feel more soft and natural.
               Disadvantages of Fat Grafting for Breast Augmentation  
                • Only a moderate degree of augmentation is possible (possibly 1 cup size).
                • There is less projection of the breast with fat grafting when compared with a breast implant, but a more natural contour may be obtained with a fat graft.
                • The size of the fat grafted breast will likely decrease in size after 1 year.
                • The use of the Brava system for several hours per day before and after fat grafting of the breast may be too cumbersome for some patients.
                • The long term effects of injected fat into the breasts are still unknown and currently being studied.  
                • The injected fat could interfere with  mammogram readings, and thus may mask the ability to detect breast cancer.  However, a recent French study had shown no statistical difference in terms of breast density findings before and after fat injection. 
                Detection of Breast Cancer in a Fat Graft Augmented Breasts
                • The development of fat necrosis after fat transfer into the breasts may lead to formation of  liponecrotic cysts and microcalcifications..  
                • This may interfere with breast cancer screening.
                • Incidence of microcalcifications detected on mammograms ranged from 3.9 to 10%.
                • Incidence of fat necrosis ranged from 1.2 to 3%.
                • Incidence of liponecrotic cysts was 16.7% in one study.
                • A recent study showed that clustered microcalcifications, which are typically seen in a certain type of breast cancer (DCIS), was found in 16.7% of patients after fat injection for breast augmentation.  This clustered microcalcfication could not be distinguished from the mammographic findings typically seen in breast cancer.
                Who are the Best Candidates for Fat Grafting to Enlarge the Breast
                  • Women who are breast reconstruction candidates including those who have been treated with radiation. 
                  • Women who previously had breast reconstruction and would need revision breast surgery.
                  • Women with mild breast asymmetry.
                  • Women who are prepared to comply with strict peri-operative care and guidelines.

                  As of January 2011, the "American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgeons, in the interest of patient safety, do not recommend fat grafting for breast enhancement at this time."  Currently, it has yet to be determined whether fat grafting has any potentiating effects on breast cancer.  The mammographic confusion differentiating between a benign and a malignant calcification still remains a problem after fat grafting for breast augmentation.  I recommend asking one of your plastic surgeons regarding fat graft injections for breast enlargement. 

                  ASAPS Press Release: Fat Grafting for Breast Augmentation--What Women Should Know
                  Illouz YG, Sterodimas A. Autologous fat transplantation 
                  to the breast: a personal technique with 25 years of experience. Aesthetic Plast Surg 2009;33:706-715.
                  Parrish et al. Autogenous fat grafting and breast augmentation: a review of the literature. Aesthet Surg J. 2010 Jul-Aug;30(4):549-56.
                  Veber, et al.  Radiographic findings after breast augmentation by autologous fat transfer. Plast Reconstr Surg. 2011 Mar;127(3):1289-99.
                  Yoshimura K, Sato K, Aoi N, et al. Cell assisted lipotransfer for cosmetic breast augmentation: supportive use of  adipose derived stem/stromal cells. Aesthetic Plast Surgery. 2008;32:48-55
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                  Date Updated: May 28, 2011

                  Silicone Gel Breast Implant or Saline Breast Implant?