Features
Alternative breast augmentation
PART 2
Lipofilling
In 1987, Bircolli reported the first case of breast augmentation using fat injection. Fat cells are harvested from areas of excess, such as the thigh or abdomen, and re-injected into the breast to permanently increase breast volume. The injected fat feels natural and increases or decreases in volume with weight fluctuations.
Despite initial success, concerns about complications such as fat necrosis, oil cysts and calcifications—which can be mistaken for cancer on standard breast screening—ensured the technique was surrounded by controversy. On the advice of the ASPS, most clinicians avoided the procedure, leaving few pioneers to further knowledge and experience in this area.
More recently, there have been procedural modifications in structural fat grafting which have been replicated by other surgeons to give encouraging results.
Innovations have been reported in an effort to overcome problems including unpredictable results and a low rate of graft survival resulting from partial necrosis. Based on these reports, it is tentatively concluded that fat is best harvested with a 2.5mm cannula or 18-gauge needle at less than 700 mmHg vacuum and re-injected with an 18-gauge needle without significant adipocyte damage.
Controversy remains about whether to pre-inject the donor site with local anaesthetic and adrenaline, which local anaesthetic agents to use, and for how long the fat should be centrifuged to give optimum fat survival. Coleman advocates centrifuging the fat at 3400rpm for three minutes, but others have found that non-centrifuged fat has a higher number of pre-adipocytes and more distinctly expressed cell proliferation.
Most authors employ some degree of centrifugation or filtration to remove the infiltrate, blood and liquefied fat. A closed system which limits exposure to the air is preferable. Reinjection is through a blunt cannula dispersing small aliquots of fat in multiple planes to create a 3D matrix. This prevents fat accumulating in lakes, which would reduce fat take and increase the risk of fat necrosis. Injection has been proposed in any anatomical plane, as long as the parenchyma itself is avoided.
The rate of fat take is variable and both technique and operator dependent, making comparisons between institutions and surgeons difficult. There is still much controversy surrounding the long term safety of these techniques. There are theoretical risks of cancer induction and propagation, interference with breast imaging and clinical examination. To date these concerns have been unsubstantiated in humans, but many surgeons desire the benefits of longer follow up before undertaking such techniques.
As a limited volume of fat can be injected at one time to ensure that the fat obtains a blood supply and remains viable, significant breast volume often requires repeated operations and considerable patient commitment.
Adult stem cells
Adult stem cells are undifferentiated cells, found throughout the body after embryonic development. They multiply by cell division to replenish dying cells and regenerate damaged tissues. Scientific interest in adult stem cells has centred on their ability to divide or self-renew indefinitely, and generate all the cell types of the organ from which they originate, potentially regenerating the entire organ from a few cells.
Large numbers of these cells reside in adipose tissue, making them amenable to harvesting. However, aspirated fat has around half the number of adult stem cells than excised whole fat because a large number of the stem cells are located around large vessels and left in the donor site after liposuction, and some are released into the fluid portion of liposuction aspirates. This relative deficiency of stem cells may induce postoperative long-term atrophy of injected fat, as was partially confirmed in animal studies.
Cytori's Celution system harvests and processes a small amount of patient-derived fat tissue and produces concentrated adipose-derived stem cells. The yield of 5% stem cells releases growth factors, prevents cell death and stimulates formation of new blood vessels. These cells can be mixed with unprocessed adipose tissue to give fat with a higher concentration of stem cells. This is then reinjected into the patient, to give a higher rate of fat take than standard lipofilling and improvement in the quality of the overlying skin.
Brava
An external breast tissue expander has been developed as a non surgical alternative to breast augmentation. The Brava device consists of two semi-rigid polyurethane domes that are placed around the breast and attached to the skin through silicone gel bladders. The pressure within the domes is maintained with a small battery-operated pump with a microchip processor.
The Brava can provide a non-operative alternative to breast augmentation for patients who wish to avoid breast implants or surgery, but it only provides a modest increase in breast volume for patients who are willing to put up with the wear schedule. Women must wear the device for a minimum of 10 hours per day for 10 weeks to achieve the desired results.
Some do not find this a problem and are either able to sleep with the Brava on or are able to wear it during the day. Sleeping with the system is often uncomfortable during the first week but once the wearer becomes accustomed to it they can adapt their sleeping habits.
The sustained tissue expansion of the breast results in swollen and oedematous breasts, which gradually recedes during the non-wear period. The increase in breast size immediately following device removal is significant but even after 10 weeks, 50% of breast volume increase is because of swelling. In contrast, tissue growth takes place relatively slowly at approximately 1-1.5ml per day.
It is difficult to maintain motivation when patients compare their deflated breasts with the ones immediately following device removal. It also becomes difficult to remain satisfied with 160ml of breast growth when patients have experienced a 310ml increase because of swelling.
Side effects such as sweating, itching and skin irritation can occur with the Brava but good skin care and effective cleaning of the domes can prevent most of these problems. The Brava can provide a minimal to moderate amount of permanent tissue growth and papers have shown that 75% of users are satisfied with the result. But the majority of women want more volume, particularly once they have seen what their breasts can look like.
The Brava can also be used in conjunction with fat grafting or lipofilling. Combining the two procedures allows introduction of large volumes of fat to give a permanent increase in breast size. The Brava is used to prepare the breast prior to fat grafting, expanding the breast to give a stretched tissue matrix with improved blood supply. Stretching the block of tissue permits large volume grafting in a breast that would previously only take a small volume graft.
The increased blood supply means that the graft is more likely to survive. The expansion schedule consists of two to four weeks' Brava wear, 10-12 hours per day. At weekends and four days prior to surgery, the Brava is worn for 24 hours per day. This will give a breast volume around three times greater than the starting volume. The reduction of Brava wear from 10 weeks, to as little as 2 weeks, ensures that there are few problems with patient compliance.
The fat is harvested by modified liposuction, performed with low pressure and minimal exposure to the air, from areas that have excess fat. The fat is then processed and reinjected into the breast. Injecting small volumes of fat with many passes avoids accumulation of large lakes of fat in any one area, which can cause cysts or necrosis of the fat. The Brava can be worn for one week after grafting to encourage take of the fat cells and immobilisation. For maximum effect Brava use should continue for 10 weeks postoperatively with a tapering regimen.
Implant breast augmentation is the most commonly used method for moderate to large volume augmentations. It has long term follow up and is of reasonable cost with acceptable side effect profiles. But in the current climate, many patients are searching for minimally invasive options to improve the size and shape of their breasts.
An array of alternative options exist, and the consumer is often faced with a bewildering choice. There is no substantiated evidence to suggest that homeopathic or herbal treatment potentiate breast growth in any form and there are often serious and unknown side effects from use of these modalities.
Other techniques all offer some degree of breast enlargement. Macrolane provides temporary small to moderate volume enlargements, but at considerable long term cost. Tissue expanders, such as the Brava device, also offer small enlargements but this requires considerable patient commitment and motivation, often with slightly disappointing results.
Combination of Brava with lipofilling is relatively more invasive but provides permanent large volume augmentations without implants and in a properly selected patient remains a viable solution.
Perhaps the most promising field lies in fat grafting, with or without concentrated stem cells. These techniques are evolving and remain, to some extent, experimental and many clinicians would rather longer term studies were available before committing to patient procedures.
Mr Vik Vijh FRCS(Plast), BAAPS, BAPRAS, ISAPS is an NHS consultant plastic and reconstructive surgeon at University Hospital Birmingham. He performs aesthetic procedures at Priory Hospital in Birmingham, Clementine Churchill hospital in London and Nuffield Hospital in Hereford. Mr Vijh would like to acknowledge the contribution of fellow Ann Dancey to this article.
