Breast augmentation is one of the top cosmetic plastic surgery procedures performed today. It has a relatively long history and its success is based on using either a saline or silicone gel breast implant to achieve its breast expansion effect. Like many medical devices, it is tremendously successful but not complication free. With breast implants there is a known overall risk, for a variety of reasons, for having a device-related complication necessitating a revisional surgery. That risk is not rare and the chance of complications vary but estimates are a 24% to 31% risk in the first five years after their initial placement. Because of this, there has been a renewed interest in “natural” forms of breast augmentation.
Besides unsubstantiated nutritional supplements are marketed for natural breast enlargement, the one natural method is that of the BRAVA system. This is an external tissue expander that became commercially available in 2001. These ‘suction cups’ applied to the breast use gentle negative pressure (15-30 mmHg) to place the breast mound under sustained tension. These traction forces cause the underlying tissue sto grow and the overall breast to expand. Clinical research has shown that women who were compliant with the system experienced a modest increase in size, on average about 100 ml (approximately 1/2 cup size). The protocol for the BRAVA device calls for 10 hours of continued wear, followed by 14 hrs off, repeating this cycle for at least 10 weeks in order to achieve a modest breast size size. With a limited effect, compared to breast implants, the BRAVA device is intended for those patients who are well informed, have reasonable expectations, are compliant with treatment, and above all, willing to be patient to see the results.
What is the mechanism by which the BRAVA system is able to grow breast issue? The BRAVA system uses the basic concept of tissue expansion which is based on the principle of mechanical stretch. Such stretching forces on the tissues causes a cascade of events which results in cellular growth and tissue regeneration. This is referred to as the stretch-induced signal transduction pathway. This pathway has been described in some detail. Growth factors, particularly epidermal growth factor and transforming growth factor, are triggered causing cell expansion and fibroblast growth and stimulation of the extracellular matrix. Mechanical deformation of the extracellular matrix sets off a signaling pathway which results in cell mitosis, or division. The mechanical stress also inhibits protease activity which allows further cell proliferation. In short, there is real science to the effects of how external suction causes tissue growth.
Another recent, but more widely adopted, method of autologous breast augmentation is through fat injections. This can be combined with the BRAVA system which not only prepares the recipient bed by preexpansion and increasing vascularity but also allows for larger volume grafting. Clinical studies have looked at the combination of the BRAVA system with autologous fat transfer for breast augmentation. In these studies, women underwent baseline breast MRIs to assess the amount of breast tissue. (both gland and fat) The women were then asked to wear the BRAVA system for 10 hours/day for four weeks in order to undergo preexpansion, which greatly increases the vascularity of the breast. For the last 36-48 hours, the women were asked to leave the device on continuously. The device was then taken off in the operating room just prior to fat grafting. Within 24 hours, the women were to remove their dressings, shower, and place the BRAVA device back on for the next 48-72 hours continuously in order to stent the grafts during the period of revascularization and early engraftment. On postoperative day 3, the women were to start only wearing the device at night for 4 more nights then start tapering it off over several more weeks. The women then received postoperative MRIs at 3, 6, and 12 months. What they found that the 3 and 6 months MRIs were unchanged, meaning at whatever graft survived to the 3 month mark was stable. The average volume of fat that was grafted was around 250ccs with a near 80% graft retention rate. Breast augmentation with fat grafting has the same caveats. Patients must be have a thorough understanding of the procedure especially that it may require multiple surgeries and that there may be asymmetry due to resorption of the grafts, they must have modest expectations, they must be compliant particularly if the BRAVA system is to be used preoperatively and they have to have enough donor tissue to perform the procedure.
Over the past few years modifications of BRAVA use in fat injection breast augmentation have been seen. Most plastic surgeons are no longer using it after surgery and its use is only in those women before surgery that have tight breast skin.
Dr. Barry Eppley
Dr. Jane Namkung
Indianapolis, Indiana