Explore Plastic Surgery - Dr. Barry Eppley

Fat injections continue to grow in popularity for numerous applications. While the procedure has good acceptance in the face, its use in the breast for correction of contour deformities is still in its infancy. Its use in breast reconstruction provides another potential tool for breast shaping due to its ease of use, lack of any significant complications, and its reported longevity.

Few plastic surgeons have significant experience to date with fat grafting to the reconstructed breast. In an August 2009 issue of Plastic and Reconstructive Surgery, Drs. Kanchwala and his associates report on their experience with managing secondary breast contour problems with fat grafting. They classify reconstructive breast deformities into three types. Type 1 are step-off deformities between the chest wall and the reconstructed breast interface. Type 2 deformities are deficiencies within a flap reconstruction, usually from fat necrosis. Type 3 deformities were the result of postoperative irradiation.

The authors reviewed 110 patients who underwent fat grafting, on average, more than 6 months after reconstruction. Grafting was usually done with other ancillary reconstructive procedures. More than half of the patients (61/110) required multiple fat grafting sessions with some (8) having as many as four injection treatments. The mean volume of transplanted fat was around 30ccs. They suffered no significant complications other than a few persistent contour irregularities. Their assessment was that satisfactory contour restoration was achieved in 85% of the patients. If good contour was maintained at three months after injection, they felt the results persisted.

Two interesting areas of injection fat grafting reported was for breast implant rippling and in the breast which is to undergo radiation therapy. Thickening the subcutaneous tissue between the implant capsule and the skin in problematic rippling seems like a good idea, provided one can avoid accidental penetration of the implant. The use of fat grafting into irradiated tissue beds may not be as successful as pre-grafting before irradiation, but this report confirms what others have indicated in which the quality of the tissue bed is improved by the graft.

The success of fat grafting in reconstructed breast contour defects is illustrated in this recent report. The key is that large amounts of injected fat grafts will not work. Notice that the injected volumes were small and optimal correction was obtained when necessary by multiple injection sessions. In my Indianapolis plastic surgery practice, I tend to use more than 30ccs, often up to 75 to 100ccs. As the authors have stated, there is clearly a volume point beyond which it is detrimental to graft survival, particularly when the injections are not put into muscle. To give an edge to injected fat survival, I mix it with PRP (platelet-rich plasma) given the larger amount of fat graft volume. Also, I prefer to inject more volume for the practical reason of health insurance coverage. Fat grafting into the reconstructed breast is viewed by some insurance carriers as ‘experimental’ and not a standard treatment as of yet. Repetitive fat grafting sessions can result in insurance reviews and denial of coverage.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

The condition known as “tuberous breast deformity” is a developmental disorder of breast shape and growth wherein the breast assumes a constricted shape. While it is not common, it is not rare either as it affects about 1 in every 200 women to some degree. Women who have developed in this way are usually very self-conscious about their condition and are very apprehensive about having their breasts seen by anyone.

Tubular breasts have a very narrow base and usually a long skin envelope. Sometimes people refer to tubular breast shape as similar to “snoopy’s nose” or a ‘rock in the sock’ look. By definition, tubular breast deformity is associated with herniation of breast tissue into the nipple areolar complex, constriction along the lower pole of the breast causing a poorly defined inframammary fold. Often the nipple areolar complexes are also lowered causing some degree of sagginess or ptosis. In some cases, the opposite breast is normal. But, more commonly, both breasts are affected and almost never the same. One breast will usually have much more skin and sag  than the other. Tuberous breasts come in all variations from a relatively minor areolar tissue herniation with small breasts to significant asymmetry and severely deformed breasts.

Tubular breasts are one of the most challenging problems in all of breast surgery that I see in my Indianapolis plastic surgery practice in which to get a good result. While improvement and better symmetry can be obtained, it usually takes more than one operation to do so. This is an important point for patients to understand. The abnormalities of the breast tissue and the asymmetry between the breasts pose surgical difficulties. Reconstruction of tuberous breasts are a combination of an augmentation, lift, and a reduction all rolled into one operation. Such a combination of dimensional changes, particularly in the face of asymmetry, do not usually allow for an ideal immediate result. Optimal results almost always come from secondary revisions.

The fundamental steps in tuberous breast surgery are implant augmentation (with inframammary fold lowering), areolar reduction with a lift, and release of the constricted breast base. Because an areolar reduction and breast tissue release is needed, a circumferential areolar incision is is needed. Through this approach a breast implant can be placed and the lower breast fold lowered and the lower pole of breast tissue released. This can also be done through a lower breast crease incision but this will result in two scars as opposed to one. Because the two breasts are usually different, two different size implants are needed. Either saline or silicone gel implants can be used. Saline implants are easier to get in through the areola, while silicone may be better off placed through a lower breast fold incision. Perfect symmetry between the implants is difficult as the amount of overlying skin is usually different between the two breasts.

The areolar reduction with a lift is also a key step. The periareolar reduction is done to keep scars off of the breast skin. But there is a limit as to how much lift can be obtained this way and these scars almost always widen, particularly if the donut of skin that is removed is significant.  It is the outward appearance of the areola and scars that ultimately almost always requires a revision to maximally lift the lower breast and to try and narrow the scars as much as possible.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis 

Of the many body deformities that result from excess skin after massive weight loss in the bariatric surgery patient, the most difficult in my experience is that of the breast. Loss of breast volume, a low nipple position, and sagging skin from a ‘deflated balloon’ creates a breast problem that offers a lot of challenges. Lifting and reshaping a bariatric breast is a four-dimensional problem consisting of tightening and lifting the skin sleeve, elevating the nipple into a more central position on the breast mound, adding loss breast volume, and trying to minimize the amount of scars necessary to do accomplish all these tasks.

 
The real challenge in making a better breast in the bariatric surgery patient is that lifting and reshaping the breast and adding volume through an implant (which is almost always necessary) makes it very difficult to predict an exact final result. Then when you factor in the important task of keeping the nipple alive through these manuevers (removing excess skin and putting in an implant can inadvertently knock off the blood supply to the nipple), raises the risk of further complications.

 
Based on these concerns, I advise patients that I will do my best to get a good result in one operation, but my experience has shown that it usually takes two separate procedures to get the best outcome. In other words, the revision rate in these types of breasts is quite high. Whether more skin needs to be tightened, the implants need to be repositioned or adjusted in volume, or the nipple needs to be lifted even higher, it is very difficult to get two, fairly symmetric breasts that match. Inevitably, some aspect of one breast or the other is ‘off”. Therefore, I advise my patients to think of their breast procedure as a two-staged operation with the hope that we do good enough that some patients will get by needing only one procedure. None of this has factored in the issue of scars and how they look which poses another risk. Fortunately, most breast scars turn out fairly well although it takes a considerable amount of time until they blend in well.

 
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Silicone Gel Breast Implants in Breast Augmentation - Scientific Assessment of their Safety

Despite the release of silicone gel breast implants for widespread commerical use in late 2006 and being one of the most (if not the most) studied medical device in history, some patients do question their safety. Any patient over 30 years of age has some recollection of the publicity surrounding the moratorium of silicone gel breast implants back in the early 1990s.

Understanding the science of silicone goes along way in addressing the safety of silicone gel implants for patients when used for both breast augmentation and in breast reconstruction.

First and foremost, silicon as an element is a naturally occurring material (check the Periodic Table) found in sand, quartz and in many types of rocks. It is one of the most common elements that we as humans come into contact with. (oxygen is the most common) When combined with oxygen, carbon, and hydrogen (all naturally occurring elements) in a manufactured process, the polymer silicone is borne. Secondly, silicone has great diversity as a manufactured product and can be made from a liquid form to a solid. It is part of thousands of manufactured products, many of them topical in form for human use. Many of the products used in the beauty industry contain silicone. More relevantly, the use of silicone in medical products is extensive from intravenous catheters to the coatings of joint replacements. As humans, we all have had sufficient exposure to silicone products that most every human alive will test positive for silicone levels.

While silicon is a element and we all have had lots of exposure to it, what does that mean when it is implanted internally in a high volume in one spot? (or in this case, two spots)

The historic conern about the safety of silicone gel breast implants revolves around their potential association with autoimmune diseases. Does a sufficient quantity of silicone, or a long duration of exposure, make the body think it is an immunogen and induce the possibility of autoimmune disease creation?After over 15 years of exhaustive clinical studies, no definitive link between any autoimmune disease (e.g., arthritis, lupus, scleroderma) has yet to be found. The initial link between silicone breast implants and women seemed obvious but the association has turned out to be coincidental as autoimmune diseases have a natural high predilection for women between the ages of 20 and 50, who also are the main recipients of breast implants. The occurrence of autoimmune diseases in women with breast implants is no higher than in women who do not have breast implants. In short, there is no scientific evidence that a silicone gel breast implant increases the risk of autoimmune disease…..or increases the risk of developing breast cancer.

Lastly, it would be hard to imagine that the FDA would re-introduce silicone gel breast implants, and all of the attendant medical-legal risk and liabilities, unless there was absolutely no current evidence of potential harmful effects. As a precaution, the commerical release of silicone gel breast implants comes with a mandate from the FDA…every implanted patient must be enrolled in the Post-Approval Study where further long-term data will be collected over the next ten years. This obligates every implanting plastic surgeon to enroll their patients in this monitored long-term study. The final statement on the safety of silicone gel breast implants will be written in another decade based on hundreds of thousands of implanted women.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.eppleybreastaugmentation.com
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Resection of small cancers or potential areas of malignant change, through a
lumpectomy excision, has become commonplace over the past decade in lieu of a more extensive mastectomy procedure. This has created smaller breast contour defects which are not always amenable to standard breast reconstructive techniques which are often better suited to larger mastectomy defects.

 Fat injections, a commonly used technique in facial cosmetic surgery, may have applications in smaller breast contour defects. Fat injections require harvesting the patient’s own fat. It is then prepared by concentrating the number of fat cells to be injected into a syringe from which it is injected back into the body. Small tunnels are made with the needle to create linear tracks underneath the skin. Such ‘fat lines’ are more capable of surviving because they are thinner and can get a blood supply quicker. Such fat injection techniques have enjoyed great popularity over the past decade. While fat survival is not always guaranteed, the fat that does take is relatively permanent and is natural.

Such fat injections have more recently been applied to breast lumpectomy defects
with good success. Because fat cells carry stem cells as well, they may help repair
damage to surrounding breast tissue and skin often caused by the use of radiation in
the prior treatment of the breast cancer. While this fat injection application is still
considered investigational, it is a promising application of an aesthetic technique
applied to breast reconstruction. How well and how long these fat injections last in
the breast requires further study in larger numbers of patients. Also, calcifications
may occur from incomplete fat survival and whether this interferes with breast
cancer detection remains to be determined.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis