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Can I get my breast implants out and replace them with fat?

October 29, 2012
Lipo Queen
8 Comments

Most likely, YES. I’ve been doing this fat-transfer-to-the-breasts thing for over three years now and it really is the closest thing to a miracle that exists in plastic surgery. I’ve said it to all of my patients and I’ll say it again: If I hadn’t already had all my fat sucked out ten years ago I would totally have it done in a second. I know I’ve already blogged multiple times about it, but now I would like to address this specific question that everyone who wants to get rid of their breast implants asks me.

Let me start out by saying that I am absolutely all for breast implants. I still put a lot of them in and they’re great. They are. Most of the time. When everything’s good, they usually look better than real breasts of comparable size, because they give you that upper breast fullness that we start losing in our mid-twenties. You can get them done in a way that nobody will know, or in a way that everyone will know and show them off. You can go without wearing a bra. Men like them (see previous post, Do Men Like Breast Implants?) And they don’t sag like natural breast tissue does.  Women who come to see me for breast reductions can never understand why anyone would want to make their breasts bigger. It’s simple–DD breast implants defy gravity much better than real DD breasts that hang and pull, causing back and neck pain and bra-strap grooving and rashes.

But, as many of you out there know–and you’re probably the only ones still reading this blog–with breast implants, you’re never out of the woods. They move, they ripple, they (RARELY) rupture (rupture rate of the new Sientra implants recently reported at less than two percent, so that’s good.) They can be great for five years and then, for no reason you develop a capsular contracture (rates reported at anywhere from eight to thirteen percent for all gel implants). Or even worse, you could be one of the unlucky ones who gets a contracture from the beginning, and winds up getting one side removed and replaced three times in less than two years. Dr. Roger Khouri, one of the “fathers” of fat grafting to the breast calls those patients “Implant Cripples.” Sounds harsh, but he makes a point. For some women, they just never work.

So far, my patients and I have been extremely happy with the results with this procedure–removing breast implants from someone who’s “done” with them and re-augmenting with their own fat.

My goal with this particular blog is to help those of you who are genuinely investigating this procedure to understand how it’s being done. When patients ask me about it, they seem to have an image of me just taking out the implants and putting a big glob of fat in the space that’s left behind.

That’s not how it works.

I think that as surgeons, we make the mistake of assuming that our patients have a clear mental picture  of the anatomy of their surgery without explaining it to them, and then we’re confused when they don’t understand the limitations and mechanics of a certain procedure.

Just warning you, this is about to get somewhat dry and technical, but is extremely useful information for those of you who really need to know:

Whenever I am discussing a breast procedure with a new patient, I usually draw pictures like the ones below, which are diagrams of where  “under the muscle” (left)  and “over the muscle” (right) breast implants sit.

The white line around the implant is the “capsule.” This is your own normal scar tissue that has formed around the implant. If this scar tissue becomes thick, it squeezes on the implant, making it feel hard, and that’s a capsular contracture. 

When I am switching someone’s implants out for their own fat, after the lipo, I remove the implant through an inframammary (in the crease under your breast) incision. The fat is then placed not in the space where the implant was, but in tiny micro-tunnels in the layers of tissue between the capsule and the skin. This is one of the cases where we say that the “capsule is your friend” because it is keeping the fat from getting into the space where the implant used to be. And it’s okay to leave the capsule there. If we’re not putting a new implant in, and there’s not ruptured silicone all over the place, it doesn’t have to come out. It’s your own tissue and it will eventually reabsorb. A drain is placed in that space (those of you who’ve had multiple breast aug revisions are probably familiar with those) and the space closes down on its own.

How much fat can you get in there?

Depends on how much you have, and how thick the layer of tissue is that I’m putting it in. As you can imagine, it’s better for everyone if your implants are sub-muscular, because then there’s the added layer of muscle to put the fat into. Most of the time I can get enough fat in so that when I’m done, the breasts look almost as big as they did with the implants. In fact, most of my patients who have undergone this procedure laugh about how their friends say, “Are you sure she took them out?” (Obviously they haven’t explained the lipo part of it. :) )

But won’t my breasts be saggy afterward?

They might. And you may elect to do a mastopexy (lift.) I personally prefer to wait to do the lift as a second surgery because the breasts get swollen when the fat is placed, and you can get a better lift if you wait till the swelling goes down.

So, for those of you who are considering this procedure, I hope that this blog helped you understand exactly what it’s all about.

Before I leave you–here’s an update on the “Paris Girl” that everyone always asks me about, two years out from her fat transfer to the breast, still wearing a C cup.

She has no scars, and her breasts look and feel so natural in fact, that when she had a little tryst with a member of a royal family over there in Europe…well, I guess you could call it, “The Prince and the Pea.” :)

XO

LQ

Do I have to get my breast implants replaced every ten years?

March 21, 2012
Breast Augmentation, Lipo Queen
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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?

My theory:

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: 

https://www.loveyourlook.com/breast/implants/warranties/overview.aspx (for Mentor)

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.

XO

LQ

Do men like breast implants?

March 18, 2012
Breast Augmentation, Lipo Queen
5 Comments

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!

XO

LQ

First New Brand of Breast Implants In Over Ten Years FDA-approved and why this is such a big deal

March 10, 2012
Breast Augmentation, Lipo Queen
5 Comments

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!

XO

LQ

P.S. Here’s a link to one of the newsflashes if anyone is interested:

FDA clears 3rd silicone-gel breast implant for US

Can you always tell if someone’s breasts are fake?

February 22, 2012
Breast Augmentation
5 Comments

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?”

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How can I get a breast augmentation without implants? Or “When fat is your friend.”

February 6, 2012
Breast Augmentation
14 Comments

Fat Transfer from Butt to Breasts

I used to get asked this question all the time–meant as a joke. But the truth is, making your breasts bigger with your own fat can be a reality.

Fat injection is not a “new” procedure, and breast enlargement with autologous (your own, and no, you can’t use someone else’s) fat has been around for decades with good results, especially in Europe and Asia. I first heard about it a couple of years ago, at the Atlanta Breast Surgery Symposium. A plastic surgeon performed the procedure at a nearby hospital with satellite surveillance for the meeting attendees. It was the first time all day that I actually started paying close attention, as it was the first “new” thing in breast surgery that I’d heard anyone talk about yet. I was blown away—basically, the patient was getting the fat sucked out of her “problem areas” and injected back into her breasts! A dream come true!

The procedure just seemed like a natural addition to my liposuction practice. I researched it as much as possible—even spent two days in the operating room with Dr. Roger Khouri (one of the pioneers of the procedure in this country, as well as the creator of the BRAVA™ device) of Miami.

The first few I did on my friends, because what are friends for, right…? :)

Honestly, so far everyone has been thrilled. It’s truly an amazing procedure. I wish I could show before and after pics, but this is a G-rated blog.

So…What are the advantages over traditional breast implants?

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