Between working on the book and doing my day job as a plastic surgeon, I’ve had to take a vacation from blogging for the last couple of weeks…But I was so inspired by this article in the May issue of Plastic and Reconstructive Surgery (Our plastic surgery Bible) that I had to make time to share it with everyone. In layman’s terms 
Most of you who know me are aware that I have been performing autologous fat transfer for breast augmentation (liposuctioning your fat from wherever you want to get rid of it and putting it in your breasts instead of an implant—yes, it’s a dream come true) for over two years and that I think it is an amazing procedure. (See my previous blog, “When fat is your friend.”) My patients have been thrilled with their results and I have had tremendous support from Doctors Lebovic, Schwimer and Goldberg–a very prestigious group of radiologists in town who specialize in breast imaging. So far the fat injections have not interfered with any of my patients’ mammograms.
If you have been seriously researching this procedure for yourself, you have most likely heard of the BRAVA. Developed by Dr. Roger Khouri in Miami, it is an external soft tissue expansion device that looks like a “Madonna Bra.” When you’re wearing it, it literally suctions your breasts out like a giant suction cup would, temporarily enlarging them. The theory is that wearing it before and after the procedure will increase the percentage of fat that “takes.”
Breast augmentation with fat grafting is probably the hottest new topic in plastic surgery, but the multiple variables involved with the technique still leave a lot of unanswered questions:
1) Does it matter where we take the fat from (ie, is back fat better than thigh fat)?
2) Does centrifuging it (spinning it down before injection to separate out the blood and fluid) really select out precious fat cells or just destroy them? There are two opposed camps on this topic.
3) What type of system should we be using to harvest the fat? Hand-held syringes or suction machines with the pressure turned down? Two opposed camps here as well.
4) What type of system should we be using to inject the fat?
5) Does Dr. Khouri’s BRAVA thing really work or is it another marketing gimmick?
6) Is selecting out stem cells with an expensive machine and calling the procedure a “stem cell breast augmentation” necessary for the fat to take? (The plastic surgeons who own the stem cell machines will say it is, but see my blog “What is a ‘stem cell breast augmentation’ or a “stem cell facelift” and is it worth the extra money?)
There have been multiple conflicting reports on this topic without real scientific data. Most of the plastic surgery journal articles are like second grade classroom show-and-tells: “This is what I did, and this is how it looks, Ta Daa!!!” As of yet the only thing that everyone agrees on is that there is no standard way of doing this procedure to give the optimum results.
But at least now we have an answer to question #5:
According to this new study, yes, wearing the BRAVA seems to increase the fat volume “take” from about 50 to 80 percent.
There is a strong possibility that this is accurate information. Last summer I was able to compare notes with Dr. Scott Spear on this topic. Since Dr. Spear is the chairman of plastic surgery at Georgetown University and one of the renowned breast surgery experts in the world, I felt validated to learn that my experience and results have been identical to his. We agreed that the most important determinant of success with fat grafting to the breast is the “skin envelope.” So, whether it’s from breastfeeding or age, in this situation, “sagginess” of the breast skin is good news. It gives the transplanted fat more room to live comfortably and survive better. I like the analogy in Dr. Khouri’s paper: when planting crops, the most important thing to a farmer is not the seeds, but what kind of soil he is planting the seeds into. If it’s crappy soil, the seeds won’t do well, no matter what kind of magic potion (ie, stem cells) they are mixed with.
This is why the BRAVA makes sense. It stretches the skin and tissues—and by doing so may also increase blood supply to the area–to allow for a more accommodating “home” for the fat grafts.
Other “pearls” that can be taken away from the results of the article are that:
1) when done correctly, the fat injections really do not interfere with the reading of mammograms as much as we first thought they would
2) spinning it down fast in a centrifuge is probably a bad idea.
So what does this mean?
In the past, when my patients have asked me about whether or not the BRAVA was worth the extra money (It’s about $800 at cost) I told them that it probably helps, it couldn’t hurt, and that the patients who used it seemed to have more of the fat volume survive, though I couldn’t guarantee it. I do not like “selling” things to people if I can’t justify it. I still can’t guarantee anything, but now at least I can quote this paper, that the patients who wore the BRAVA had about 80% retention of volume as opposed to about 50%.
However…
The results of this study may make more patients more motivated to wear the BRAVA, but most still won’t be able to do it. Logistically, it is quite difficult.
For one thing it looks like this:
Okay, sorry–I had a picture of someone wearing it here but I guess it got remove by the people that own this blog server for “porn” so I am working on a censored version of it with my IT guy–hopefully it will be up later today. How annoying is that? I mean, really. So you can see the shadow of a woman’s breast underneath it–so what? For now, just imagine big plastic domes that project about ten inches in front of your chest.
So, unless you’re okay with people staring at you for reasons other than being famous or impossibly gorgeous, you can’t wear it in public. Your regular clothes won’t fit over it. And the protocol calls for wearing it ten hours a day for a month before the procedure (with 24 hours a day for the last few days) so unless you work from home, you have to learn to sleep in it. The logistics are even challenging for “stay-at-home” moms, because most of them don’t really “stay-at-home.” You can’t show up to school drop-off wearing a BRAVA unless you have tinted windows, and forget about making the rounds at Whole Foods/Costco/the drycleaners unless you’re okay wearing a tent.
But at least I can assure my patients who are dutifully wearing it in preparation for their surgeries that yes, it does work.
Again, for all of you BRAVA-wearers out there, here are some inspiring before and afters:
Before, an A cup
One year after BRAVA and fat-grafting, a C cup
Here is the link if you would like to read the full article:
One more thing I would like to add:
In his video discussion of the article, Dr. Spear mentions that we must “respect the donor sites” (the places where the fat is being taken from) and that is EXACTLY what I tell my patients. I often see patients who have been told by someone else that they are candidates for the procedure. But as a surgeon who has performed thousands of liposuctions for over ten years—and someone who understands how a woman wants her body to look—I have turned some of them away because I felt that I could only get the fat out at the expense of causing deformities at the donor sites. MAKE SURE that your plastic surgeon understands that you CARE what your legs/arms/abdomen/back are going to look like after the fat’s been removed (unless, of course you don’t.) And make sure that your doctor is GOOD AT LIPOSUCTION, which is not as easy as it sounds, especially when the patient is thin to begin with.
For example, if someone looks like this to start with:
…she should look like this when you finish:
XO
LQ
