Breast Augmentation, No Implants Needed?

Feb. 19, 2010— -- Staria Peterson loves her breasts.

"My breasts are beautiful," said Peterson, 75, of Miami, Fla. "They are not great, big breasts, but to me they seem huge."

Peterson's enthusiasm over her bust may seem unusual to those unfamiliar with her story. But for women like her who have undergone double mastectomy -- the removal of both breasts – after breast cancer, her reaction is completely natural.

Her breasts, too, are completely natural. Peterson refused artificial breast implants after her surgeries, fearing they would obscure evidence of her cancer if it recurred. That was 35 years ago. For more than three decades, Peterson lived without breasts.

"I went 30 years with nothing," she said. "I was flat-chested, with scars on my chest. It was not pleasant."

That was until 2007, when Peterson opted to undergo a novel procedure that injected her own fat, harvested from her waist and buttocks, into her chest. It is an approach that has been attempted for decades, but with limited success. Now, a doctor behind a new technique to inject fat into the breasts says that this time it is different.

"Fat tissue grafting to the breast has been frowned upon for a very long time," said plastic and reconstructive surgeon Dr. Roger Khouri of the Miami Breast Center in Miami, Fla. However, he said his new approach, which incorporates a vacuum pressure device to expand the breasts before and after injection, leads to better results than in the past.

"It is feasible, and the results are very good," he said. "We've refined the technique to really make it work."

One of the technique's supporters is plastic and reconstructive surgeon Dr. Thomas Biggs. "We've been injecting fat for a long time, but never as successfully as we have recently," said Biggs, who is also the protégé of Dr. Thomas Cronin, one of the inventors of the first artificial breast implant.

Other plastic surgeons agreed the technique is an intriguing one with great potential, particularly for mastectomy patients. However, some plastic surgery experts said that it would be a while yet before this technique would enter the mainstream of the lucrative cosmetic surgery market. One of these experts is president of the American Society of Plastic Surgeons (ASPS), Dr. Michael McGuire.

"Ideally this is a great solution," McGuire said. "I can't tell you how many patients have told me, 'I have too much fat here, and my breasts are too small – can you take this out and put it there?'

"Unfortunately, there are still a large number of issues that remain."

Fat Transfer and Safety Concerns

The most prominent of these issues has been that historically, not all of the fat transferred into a breast will survive. The first surgeons who attempted to move fat from other parts of the body learned that the fat that died off led to loss of volume and, in some cases, a lumpy appearance. Worse, this dying fat formed calcifications in the breast, which could obscure the presence of breast cancer during subsequent mammograms.

Dr. Julius Few, director of the Few Institute for Aesthetic Plastic Surgery in Chicago, said that these concerns may still linger. "If someone is considered at higher risk for breast cancer, due to family history or other factors, it is vital they discuss this with their primary doctor," he said.

However, professional plastic surgery societies have gradually changed their stance on fat transfers into breasts as the technique has evolved. In the late 1990s, ASPS issued a very strong statement against the practice. This ambivalence toward the technique lingered; in 2007, the ASPS issued a press release titled "Plastic Surgery Societies Issue Caution on Fat Grafting for Breast Augmentation," in which it, along with the American Society for Aesthetic Plastic Surgery (ASAPS), announced that "fat grafting for breast augmentation is not recommended at this time based on the lack of safety and efficacy data."

In January of 2009, however, the ASPS issued guidance on the procedures that took a softer approach, stating that, "Based on available literature, complication rates associated with fat grafting are not, overall, unduly high," and that "Concern regarding the interference of autologous fat grafts with breast cancer detection is not validated by the limited number of studies available on the topic."

Fat Grafting for Breast Augmentation May Still Far from Mainstream

Khouri hopes his technique will foster further acceptance of the procedures. On Sunday, Khouri hosted around 200 plastic surgeons from around the world to a seminar to demonstrate his new approach. Using the BRAVA system -- a vacuum suction device that a woman wear to expand the tissue of the breast -- Khouri said he can prepare the breast to receive the fat that has been harvested from another part of the body. Rather than depositing all of this fat in one place in the breast, Khouri's approach involves about a dozen injections per side to ensure that the fat has enough room to take hold and survive.

"We're not trying to stuff or force a lot of stuff into a tight space; it's like putting seeds in a field," he said. "You can stuff a lot into a small pot, and they're not going to grow. But if you take the seeds in that pot and stretch it into a large field, you're going to get growth."

Khouri has research to back up the technique; at the European Society of Plastic and Reconstructive Surgery (ESPRAS) meeting in September, he presented a study which looked at the technique in 50 women. On average, 85 percent of the fat transplanted into the women's breasts survived. And on average, these women experienced 210 ml of augmentation per breast from the technique six months to a year out.

As for when the technique could become more widely used, the picture is unclear.

"Basic research is costly; it requires financing," Biggs said. "The interest is there, but two or three voices can only do so much.

"I can't give you an answer in terms of number of years. All we know is that we're going full speed ahead."

If and when the procedure does become a mainstream treatment, Biggs said it was unlikely that the procedure would supplant artificial implants -- at least not yet.

"For augmentation, breast implants themselves have been improved so significantly, a person may prefer to have an implant rather than enduring the longer time it takes for grafting," Biggs said.

Other plastic surgeons agreed. "To think that you can actually take a woman from an A cup to a C cup with fat transplants is unrealistic," McGuire said. "The best use is really in a post-mastectomy breast reconstruction patients who...[have] residual post-reconstruction defects after their operation."

No Competition for Breast Implants -- Yet

"It's on its way, but I don't think it will totally replace the implant as it takes several sittings over several months, depending on the enlargement required," said Dr. Garry Brody, professor of plastic surgery at the University of Southern California. Brody also said women may not have patience with the vacuum expansion process, which he said could be "annoying."

Additionally, Denver, Colo.-based plastic surgeon Dr. John Grossman said that a big question that remains to be answered is how long the results of the procedure will actually last.

"If the fat used in a breast enlargement is only going to last for a year or less, it will never supplant silicone implants," Grossman said. "However, if we're talking about years of duration, then it's going to be a viable option... I think that in the next couple of years, we'll know whether fat will be one of the breast enhancers considered mainstream."

But mainstream or not, some patients -- including Peterson -- said they are happy with the new breasts they received through the procedure.

"It was exactly what I wanted," Peterson said. "I got my life back."