Fat transfer to breast is a good alternative to implants and may even serve as a viable option in breast reconstruction. This is now a well-established technique that allows the patients to improve their breast shape and size with the most natural material possible—their very own fat.
One of the early criticisms of fat transfer to breast or any part of the body was the low survival rate or temporary results. However, plastic surgeons have fine-tuned their techniques that nowadays most are able to achieve at least a 70 percent survival rate.
The photo shows the difference between the breast injected with fat and the other side that is yet to receive the procedure.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says any fat volume that remains after six months is expected to be near permanent, with the breast expanding and shrinking depending on the patient’s weight.
Recently, he performed fat transfer to a patient who asked her implants to be removed, which could leave her breasts deflated—particularly its upper pole and mid cleavage—if no volume restoration procedure was performed simultaneously.
After removing the implants from their pocket, Dr. Smiley injected discrete layers of fat above the area where the prostheses were previously positioned. His goal was to inoculate the fats into highly vascularized tissue (i.e., they have more blood vessels), allowing the grafts to persist long term.
Aside from women having implant extraction, Dr. Smiley says that fat transfer is also a viable option for first-time breast augmentation patients who want to avoid implants, which carry risk of leak and displacement.
Fat transfer can also complement the results of implants; this is particularly true for women with notably poor cleavage or very little soft tissue to begin with that makes them prone to implant rippling and palpability.
While fat transfer to breast can deliver near permanent results, the celebrity plastic surgeon says it also comes with certain limitations, particularly in terms size. In general, the technique cannot double the breast size as over-filling the tissue can lead to low survival rate and other complications.
In most cases, fat transfer to breast involves around 200 cc of fat injection per side, although a 2011 study has shown that up to 300 cc can be injected provided that the breast has been pre-expanded weeks leading up to the surgery.
To expand the breasts and create more room for the fat grafts, the researchers required 25 patients to use Brava, which is a bra-like device that releases negative pressure. The technique allowed them to inject up to 300 cc of fat on average.
Breast revision after capsular contracture requires multiple methods to prevent the problem from recurring. Using new implants, irrigating the implant pocket with strong antibiotic solution, and removing the entire scar capsule are the most commonly accepted approach.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video of a patient with capsular contracture that caused visible breast asymmetry, with the left implant riding higher than ideal due to the scar capsule pushing it too high on the chest wall.
Scar capsule naturally forms around breast implants or any type of artificial prosthesis; it only becomes a problem when it has thickened or calcified, leading to pain, hardness of the tissue, and deformity. Typically, the symptoms arise in the first few months of surgery, although some patients develop them after several years.
Dr. Smiley performed breast revision after capsular contracture with the creation of a small incision around the lower border of the areola, which was the previous incision site and thus additional scar has been avoided. Then, he removed both implants together with the calcified and thick scar capsule.
While some doctors do not remove the entire capsule when doing revision for capsular contracture, Dr. Smiley believes complete removal can significantly reduce its recurrence—just 4 percent versus 15 percent when the capsule remains inside.
Furthermore, removing the entire capsule allows the implants to settle to a more natural position, which of course results in a more natural breast shape and feel.
After removing the entire capsule, Dr. Smiley is seen irrigating the implant pocket with strong antibiotic solution. Studies have suggested that capsular contracture occurs when bacterial contamination around an implant causes the body to over-react and release copious amounts of collagen fiber.
To further reduce capsular contracture recurrence, Dr. Smiley used a pair of new implants, which he propelled into the pocket with the Keller Funnel, a device that closely resembles an icing bag.
The implant is poured from its sterile packaging into the Keller Funnel, which is then squeezed to propel the implant into its pocket. This implantation process is known to reduce the risk of implant contamination and ultimately lower the risk of capsular contracture.
Capsular contracture is also linked to blood (hematoma) that forms around an implant after surgery and so the celebrity plastic surgeon uses meticulous pocket dissection to control bleeding and minimize risk of complication.
Breast implant replacement surgery requires a highly customized approach to achieve the most natural-looking results possible and to deliver the patient’s cosmetic goals, which she must be able to explain in detail.
Leading Inland Empire plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on Snapchat to demonstrate a patient who had saline implant deflation and thus required replacement.
The before photo shows the right breast looking deflated due to saline implant rupture. The after photo, meanwhile, shows the results of new silicone implants combined with internal lift.
The patient’s right breast appeared smaller than the other side due to saline implant leak. Also, she had moderate breast ptosis (sag) that could benefit from internal lift and implant pocket repair.
To remove both saline implants, Dr. Smiley created a small incision right at the lower border of the areola, which was the location of her previous scars.
Dr. Smiley says a good number of his primary and secondary breast augmentations are performed through the peri-areolar incision technique because the scar blends well into the dark-light skin junction.
When the right breast’s saline implant was extracted from its pocket, it was completely deflated. Dr. Smiley says that full deflation takes about four days, causing the affected breast to look smaller than the other side; however, the leak does not cause any harm since the filler material is saline, i.e., salt and water, which is naturally found in the body.
“The saline is simply absorbed by the body and excreted by the kidney,” the celebrity plastic surgeon says in one of the videos.
Both saline implants were replaced by silicone implants, which are filled with a more cohesive filler material. To ensure that they settle “more naturally,” Dr. Smiley performed internal lift and pocket repair.
Pocket repair was mainly performed by tightening its lateral side, allowing the silicone implant to settle to a more natural position and therefore giving the right amount of fullness along her mid cleavage and upper breast pole; this ancillary technique also prevents excessive lateral bulge (i.e., implant displacement).
During the actual implantation, Dr. Smiley used the Keller Funnel technique in which a cone-shaped disposable device was used to propel the silicone implant into the pocket with just one “squeeze.”
Aside from reducing the operative time, the Keller Funnel device is also known to minimize trauma around the wound. To further promote favorable scar—i.e., it is barely visible at the areola’s border—Dr. Smiley closed the incision in several layers without picking up the outermost layer of the skin.
Only the dermis, which is the deeper layer of the skin, was sutured to ensure that the most superficial layer would receive no or very little tension, which is the key to the most favorable scar possible.
Breast augmentation through fat transfer offers unique benefits: Lack of any risks associated with artificial implants, more natural shape and feel, and more control over the final cleavage appearance (i.e., upper breast pole and mid cleavage).
And because the procedure entails liposuction, which is the process of harvesting fats from “troublesome” areas of the body, patients can also expect a more holistic improvement compared to the standard breast augmentation.
The deflated breast has its implant removed. The “perky” side, meanwhile, has already received fat transfer giving it ample volume and projection with the use of the most natural material possible–the patient’s own fat.
Renowned Inland Empire plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on Snapchat to demonstrate a female patient who has had breast implant removal immediately followed by fat transfer.
During surgery, Dr. Smiley removed the implant through an incision made precisely at the upper border of the areola (this was the same incision created during her previous breast augmentation).
Removing the implant could lead to deflated-looking breasts, particularly in the upper pole; hence, Dr. Smiley performed a simultaneous fat transfer.
To harvest sufficient fat volume, Dr. Smiley performed liposuction on different body areas including the abdomen, flanks, and lower back. The collected amount is then washed and sorted to remove dead cells and other “non-fat” biomaterials such as blood to ensure high survival rate.
The purified fat volume was then injected into the breast, specifically above the implant pocket. Dr. Smiley said microdroplet (less than 0.1 cc) of fat has been inoculated into the tissue and muscle to promote vascularization or blood supply ingrowth, which allows the fat cells to persist long term.
About 70-80 percent of the injected fat volume is expected to survive long term, while the remaining is resorbed within a few weeks of injection. Hence, it is a common practice to slightly overfill the breast to anticipate this “consequence.”
Final result from the surgery
Another issue with breast augmentation through fat transfer is the varying permissible amount of fat injection. It is important to note that overzealous augmentation may lead to low survival rate because of the excessive pressure experienced by the fatty cells; this is particularly true for patients with markedly tight skin.
In general, 200-300 cc of purified fat can be injected into each breast without worrying about low survival rate and other complications caused by excessive pressure.
In the video, Dr. Smiley said the main advantage of breast augmentation through fat is that it “provides more control over the final width of the breast,” making it easier to improve the mid cleavage and upper breast pole compared to implants.
Breast augmentation and cleavage enhancement. Can these two cosmetic goals be achieved, or should the patient accept some compromises and limitations?
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted photos on Snapchat demonstrating a patient with bony indentations and wider gap between her small breasts.
With the use of a slightly wider breast implant, Dr. Smiley is able to hide the bony indentations along the patient’s sternum.
To “hide the bony indentations and create a “very soft and natural cleavage,” Dr. Smiley said he used a slightly wider breast implant to “fill in the gap and visible dents.” Nonetheless, he made sure that the horizontal measurement of the implant would still “reflect” the patient’s pre-existing soft tissue coverage to prevent rippling and increased palpability.
“A lot of followers asked if I used fat grafting or injecting to hide the bony indentations. I did not. The right implant design is enough to deliver good results for this patient,” he said.
The patient shown in the picture also received a conservatively sized implant, 400 cc, further reducing the risk of rippling, scalloping, and palpability, problems that plagued overlarge breast implants.
The implants were propelled into their pocket through a peri-areolar incision, meaning a small U-shaped scar was positioned at the lower border of the areola. At three months, it is almost undetectable thanks to meticulous wound closure technique in which no tension was put on the skin.
“That’s why you should always respect the skin. The scar is just three months old and is already unnoticeable. It will continue improving up to 18 months,” Dr. Smiley said.
The patient has been deemed a good candidate for the said incision technique because of the stark color contrast between her areola and the surrounding “normal” skin, making it easier to hide the scar.
Dr. Smiley said he follows a “nine point system of breast perfection” to achieve natural and proportionate-looking breasts.
“The nipple should be right in the middle of the breast, at the most projected part, and should lie at least 2 cm above the inframammary crease. Most of the volume should go to the bottom or lower breast pole, while the upper pole should receive a moderate degree of fullness. The lateral bulge, meanwhile, should not account for more than 10 percent of the total volume,” he explained.
The inframammary fold breast augmentation technique places an incision within the “new” breast crease so the scar blends well into the background. About 50 percent of the breast implant surgeries is performed through this method due to its “simplicity” and direct access to soft tissue layers of the chest.
Hence, the risk of asymmetry is perceived to be lower when the inframammary fold breast augmentation is used compared with other techniques.
In spite of the many advantages of this technique it has one major caveat: the visibility of scar.
The use of Keller Funnel allows Dr. Smiley to shorten the incision, leading to more hidden scar within the breast crease.
Nonetheless, leading Beverly Hills plastic surgeon Dr. Tarick Smiley says certain steps can prevent or at least minimize risk of visible scar, with patient selection being the most important variable.
In Dr. Smiley’s recent videos on Snapchat, he demonstrated a patient he deemed to be a suitable candidate for the incision technique: She had mildly droopy breasts, which resulted in deep folds that could make it easier to hide the scar compared to someone without a prominent crease.
Dr. Smiley says breast implants can give the patient “more symmetry and fullness,” particularly when the implants would “reflect” her anatomy and cosmetic goals.
The patient received silicone breast implants known to provide softer results and more natural contour than saline implants.
Silicone implants are filled with silicone gel, while saline implants contain salt water solution and thus they have a strong predisposition to appear globular and firm once inside their pocket. This is particularly true for patients who are thin or small breasted, meaning they have little soft tissue coverage.
Proper marking prior to the placement of incision and pocket creation is the first step to ensure a well-hidden scar. Dr. Smiley marked the pre-existing inframammary fold and placed a short incision (not longer than 3 cm) slightly above the line.
The incision and its resulting scar are expected to remain on the underside bulge of the breast. (Note: In the first two months of recovery, the implants typically ride higher leading to excessive upper pole fullness; however, this rather unnatural appearance almost always corrects itself as the prostheses settle to their more natural location.)
Aside from proper patient selection, the risk of visible scar was further reduced with the use of Keller Funnel, a device that resembles an icing bag that propels the implant into its pocket with just a few successive squeezes. Not only it reduces the scar length, the amount of trauma around the wound edges is minimized as well, further promoting the best scar possible.
Because the patient’s pre-existing right breast was smaller than the other side, Dr. Smiley used a slightly bigger implant size to improve their symmetry.
And lastly, he closed the incisions in several rows, ensuring that the deeper layers received most of the tension while the skin was spared from “excessive pull,” thus further promoting the most hidden scar.