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One of the most talked about topics at the most recent Plastic Surgery Society National Meeting was fat grafting to the breast.  Historically, this was not done secondary to breast cancer concerns.  What if the additional fat increased risk for breast cancer?  What if some of the fat became hard and was difficult to discern from a cancerous mass?

Pioneers in this and other countries performed studies, and there appears, to my knowledge,  to be no cancer risk associated with fat grafting.  As for the masses, it turns out that most look very different on radiologic studies than cancer and are therefore not now considered as concerning.

Many surgeons use fat grafting as an adjunct to breast reconstruction.  This is most frequently done to feather the hard edges of an implant or tissue flap. See the case of the month below.  It takes several sessions to get the desired effect, but many of my patients and I have been happy with the results.  It is not a procedure for everyone and results do vary.  One new concept is to place a relatively small back or abdominal piece of tissue in the breast mound position with the intent to go back later and inject fat into the improved tissue bed.  Another is to use the fat to improve the condition of radiated tissue.

Other surgeons are starting to use fat grafting for breast augmentation instead of implants.  There are many problems with this approach, but I have seem some nice results presented.  One problem is that many woman who are small enough to need implants do not have enough extra fat for grafting.  Some may have enough fat for only a small size increase compared to an implant.  Another problem is that larger amounts of fat may have more difficulty surviving and may be associated with more complications.  Finally, the procedure takes a long time and may be cost prohibitive.  These techniques are still new, so implants are  how I plan to do breast augmentation.  I will keep learning the new techniques and only offer them to my patients when they present a good risk benefit balance.

Curb Cup Contestant

Post op initial reconstruction

Post initial reconstruction oblique

Post fat grafting oblique

The patient presented post mastectomies with thin coverage and a peak shaped chest.  We discussed using latissimus flaps for improved coverage, but she wanted to avoid a more involved operation.  We used acellular dermis with the initial expander and implant reconstruction to improve the tissue thickness inferiorly and to keep the implants from sliding off the chest and into the axillae (arm pits).

She then had visible rippling secondary to the thin coverage.  This was improved with four sessions of fat grafting.  Note the decreased rippling, improved superior and medial transition from breast mound to chest.

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From our Esthetician, Lindsey…

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*Treatment of the Month*

Oxygenating Peel

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Tip of the month:

The daily use of broad-spectrum sun protection is proven to reduce the incidence of skin cancers and premature skin aging. Sun damage contributes to an estimated 85% of skin damage and aging. Are you covered? Even during the winter months, sunscreen is an imperative step for your beauty regimen. I suggest PCA’s Perfecting Protection spf30. Its light-weight formula combines superior UV protective benefits with five melanogenesis inhibitors to reduce current and prevent future skin discolorations. This revolutionary product is suitable for all skin types.

? Curb Cup Contestant ?

Toronto CN Tower Reflection

Over the next few months, I will review topics from the most recent American Society of Plastic Surgeons’ Meeting in Toronto.  A three hour block of time was devoted to a particularly important patient safety issue, Venous Thrombo Embolism (VTE).  VTE is a catch all term to describe problems associated with blood clots after surgery.

The most common is deep venous thrombosis (DVT), a clot in the deep leg veins.  Signs of DVT include calf pain and swelling.  DVT is confirmed with an ultrasound of the legs called a duplex and it is treated with blood thinners.  Although a local problem, DVT clots may break off and become a Pulmonary Embolism (PE). Long term, DVT may cause chronic leg pain, swelling, and even wound healing problems.

PE is one of the most feared adverse outcomes in surgery, especially in otherwise healthy Plastic Surgery patients.  Blood clots in the lungs may cause serious breathing problems and may even lead to death.  PE is notoriously difficult to diagnose as the symptoms may be vague and may be mistaken for less threatening post operative problems.  The gold standard test is a CT angiogram which looks for clots in the lungs.  A negative expensive test is much preferable to missing a PE.

VTE are treated with several months of anticoagulation (blood thinning).  Patients are usually started on IV heparin or injected low molecular weight heparin (Lovenox most commonly) and then transitioned to oral coumadin.  The blood test PT/INR is then followed frequently to make sure that the blood thinning is not too little (risking another clot) or too much (risking a bleeding episode).

The best approach, however, is to avoid the problem altogether.  All patients under general anesthesia have sequential compression devices (SCD’s) and compressions stockings.  This helps prevent blood from stagnating in the legs and forming blood clots while the patient is asleep.  Some patients may be more prone to blood clots (hypercoagulable) and should be treated with Lovenox for a period of time around their surgery.  Blood thinners are expensive and do risk unintentional bleeding after a surgery which may harm the result and even require a return to the operating room to treat the problem.

The big question we are all trying to answer is, “who should be treated with Lovenox, when, and how long?” The problem is that no one really knows.  VTE is a rare enough event that studies with very large numbers of patients must be performed to get statistically meaningful information.  That task is even harder in a specialized subset of plastic surgery patients.  We do know that certain patients have greater risk than others for VTE.  In the Plastic Surgery population, the most important ones are age, weight, history of cancer, family history of clotting, and length of surgery.

The Plastic Surgery leadership has proposed that we evaluate our patients with the Caprini risk assessment system and give them a score.  Based on the score, we will then have guidelines on who to treat and for how long.  The scoring system is well established, but the treatment guidelines are still being developed.  Again, it is up to individual surgeon judgement.

What do I do?  I score each patient in our electronic medical record (EMR) at the pre operative visit.  Patients with higher scores and / or other contributing factors are started on Lovenox the day after surgery and usually continued for 10 days.  Selected patients have specialized blood testing and even consultation with a hematologist (blood and cancer specialist).  I counsel patients that there is a trade off between the risk of VTE and the cost, inconvenience, and bleeding risk associated with Lovenox use.  Unfortunately, there are no standard of care guidelines, so I usually lean towards treatment.  After all, it is easier to treat bleeding than it is a VTE.

Mark D. Wigod, MD, FACS - Cosmetic and Reconstructive Plastic Surgery

Serving  Boise and Meridian as well as the Greater Treasure Valley and Southeast Idaho Region

Pre op AP

Post op AP

The patient is a woman in her 50’s who had a large surgical weight loss.  She was dissatisfied with her breast size and shape and underwent a mastopexy.  The breast tissue (parenchyma) was reshaped and sutured higher on the chest was to give as much fullness as possible.

Pre op oblique

Post op oblique