A ^Retired Plastic Surgeon's Notebook

I’ve now been doing fat transfer to the breast for over seven years.  I remain enthusiastic about this procedure in patients with favorable anatomy and realistic expectations.  One FAQ relates to changes in the breast with weight changes.  So here is what I have observed so far in my practice:

Yo-yo is a no-no for fat transfer!

If patients lose weight, the transferred fat shrinks and the patient loses volume in her her breasts.  This also goes for patients who lose fat but maintain their weight.  I have seen this in a couple of patients who did not have a major weight loss but who really leaned out with vigorous exercise.  They both became Crossfitters and both lost a lot of the volume they gained after fat transfer.  One went on to have implants.  The other did not.  I am thinking about adding “do not join Crossfit” to my post-op instructions!

Conversely, if a patient gains weight, the fat that was transferred to the breasts will expand and the breasts will get larger.  I have seen this in a couple of cases.  One case was a middle aged flight attendant who gained about 7 lbs on a cruise (this is why I do not go on cruises!) and became alarmed at how large her breasts became.  I assured her that her breasts would go back to their pre-cruise size when she lost that extra weight and indeed they did.  In another case, a patient gained just a few pounds and rather than going to her saddle bags as it usually did prior to fat transfer, she was delighted to see that it mostly went to her chest!

So whenever we are moving fat around, it’s best to have surgery when you are at a healthy and sustainable weight.  I do not recommend fat transfer in patients who yo-yo.  Significant weight fluctuations make for fluctuating results.

Thanks for reading and did you notice I did not say “ideal” weight?  Sustainable and healthy weight is more important and more obtainable than ideal for most of us who are over 25 years old!

Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Seattle Plastic Surgeon blogs about fillers she does not like and does not use.  

I’ve written many blogs on the miracles of fillers for facial aging.  I think they are the best thing for facial maintenance since sunscreen.

Facial silicone gone bad. Really, really bad.

The fillers I really like and use a lot are Voluma, Juvederm, Restylane, and Perlane which are all hyaluronic acid (HA) fillers.   The thing I love about HA fillers is their ease of use, safety, and their reversibility when a rare patient (1 every five years or so) does not like the result.  The HA fillers can be reversed by injecting an enzyme which dissolves the filler within 24 hours.

I also use fat as a facial filler in some cases. The thing I like about fat is that there is usually an abundant supply and it is often very, very long lasting and sometimes permanent.

There are other fillers out there.  Here’s my list of fillers that I just don’t like or use.  Full disclosure here:  this is based solely on my (sometimes very limited) experience, hearsay, prejudice and my risk adverse nature.  Some of my colleagues use these regularly and successfully but these fillers just give me the creeps.

• Collagen:  It is sooooo yesteryear.  Even when it was the only legit filler out there, I didn’t like it.  Patients needed a skin test 30 days prior to using Collagen.  The results were fleeting and even a detail freak like me had trouble getting a nice smooth result.  Oh, it also had to be refrigerated and shelf life was very limited.  Oh, one more thing, it comes from cows.
• Radiesse:  This is used quite a bit in the Seattle area but it gives me the creeps.  It’s made of teeny, tiny spheres of calcium hydroxylapatite and provides a scaffold for connective tissue growth.   It is quite thick and can fill in deep creases nicely but can also result in nodule formation.  Radiesse lasts 1 -2 years which is great (unless you are one of the unlucky ones who develops nodules).   I used it a few times years ago in a a few  employees who volunteered (really, they did) to be my training subjects.  All three of them bruised really, really badly and I felt like a worm until their bruising resolved.   I don’t have a cajones to try it again.
• ArteFill:  Yikes.  This is a scary one.  This is a permanent filler which is made up of teeny, tiny spheres of polymethylmethacrylate.  They elicit a “foreign body response” which walls off the little spheres with collagen.   It also requires a skin test 30 days before injection because the sphere are carried in liquid collagen.  My training subjects this time were two pals of mine.  Both had negative skin tests.  My first patient did fine and is still my pal.  The second patient, who was from out of state,  had to delay her injection because a family illness prevented her from traveling.  Four months later, she had a rip-roaring inflammatory reaction to the little spot on her forearm where I had injected the test dose.  It was by the grace of a good and loving God I had not injected her face.  She is still one of my very best pals.  I have also seen many case reports and a couple of patients with poor results from ArteFill.  The only way to get rid of it is to surgically remove it.
• Sculptra:  Sculptra stimulates dermal fibrosis and thickens the skin.   This is filler was first introduced about 10 years ago for use in patients with HIV.  The medications that many HIV patients rely upon to stay healthy have the side effect of facial wasting.  This filler is made of poly-L-lactic acid, the same chemical that a common suture, Vicryl, is made of.  I use Vicryl a lot.  It is easy to sew with.  It provides strength and support for a couple of months while an incision heals and then the body absorbs sit.  But once in awhile, a patient has an inflammatory reaction to the suture.  I have had maybe a dozen patients over 20 + years of practice who have “spit” every single stitch.  There are many case reports of disfiguring inflammatory reactions to Sculptra and all I have to do is think of one of my Vicryl “allergic” patients and I break out into a cold sweat.  Am I a wimp or what?
• Silicone:  This is the Queen Mother of Bad Fillers (in my humble opinion).  It has been used for decades and is responsible for the permanent disfiguration of many, many patients.  I will never forget a lecture I attended when I was a surgery resident on the treatment of a bizarre condition called Romberg’s disease.  This disease causes profound atrophy of facial fat.  Way back when, these patients were injected with medical grade silicone and initially it was beneficial.  But fast forward 10, 20 even 30 years and many of these patients went on to develop severe inflammatory reactions that were more disfiguring than the original disease.  I know of a plastic surgeon in Hawaii who used this stuff on his wife’s lips.  Yikes.

So there is my personal rogue gallery of “no thanks” fillers.  All of these (I think) are still in the good graces of the F.D.A. but you won’t find them on my shelf.

Hey, thanks for reading.  That was a slog, wasn’t it?  Dr. Lisa Lynn Sowder

Fat transfer to the breast by Seattle Plastic Surgeon takes time and patience.

Fat transfer to the breast doesn’t seem like it would be a time consuming procedure but it is if done properly.    Here is what’s important and why fat transfer takes time and patience:

Patience – one of my few virtues.

•  The fat must be harvested very gently at a low vacuum.  This is a much slower process than regular liposuction.
• The fat is often harvested from the posterior hip and buttock and lateral thigh area with the patient prone.  This means that a position change is necessary and that also takes time.
• The fat must be handled with great care when it is transferred into injection syringes.  It’s important to have a patient and detail oriented assistant.
• The fat must be injected in small aliquots into the breast, making sure to inject into several different layers.   This tedious technique pays off in the long run because it gives the fat a much better chance of survival compared to injecting big blobs of fat that probably won’t survive.  It has to do with blood supply.  That’s another blog topic.
• The areas of injection vary with the shape of the breast.  When doing an augmentation with an implant, there is very little control of the breast shape but with fat transfer, the shape of the breast can be altered.  This also takes time and multiple visual assessments with the patient sitting up.

Some surgeons do not have the temperament to do procedures as tedious as fat transfer to the breast.  But I do!

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon discusses the promotion of stem cell face lifts by ethically challenged physicians.

Pssstttt …. I’ve got a Stem Cell Face Lift for sale.

Recently I have had several inquiries about “stem cell face lifts” and whether or not I perform them.  There must be someone out there promoting this as the latest and greatest fountain of youth.   That someone  is probably deceptively promoting him or herself as a plastic surgeon with a magic wand.

A little background on stem cells:  These are little baby cells that can differentiate into almost any adult tissue.  Research on stem cells is one of the hottest areas of biology and with good reason.  Figuring out how to turn on the right genes in a population of stem cells could lead to tissue and organ engineering and amazing advances in the treatment of human disease and injury.

Adult fat tissue has a lot of stem cells.  Cool, huh?  Who would have thought that Mother Nature would pack away these tiny powerhouses of potential in our blubber?  Stem cells can be isolated from fat tissue in the laboratory using very sophisticated equipment .  This equipment  is not something available to physicians working in a clinical setting.   Stem cells are not being isolated from fat and injected into human faces.

So what’s the deal? Fat transfer for facial rejuvenation has been around for 20 + years and is becoming more and more popular as we understand the aging process better and also get better with the very fussy techniques required for successful fat transfer.  I’ve been doing fat transfer for facial rejuvenation for 15 years.  Fat transfer does something that is very obvious:  it plumps up a deflated face and makes it more youthful appearing.  It also does something else that has been observed by those of us who do fat transfer:  it improves the quality of the overlying skin.  And this qualitative improvement is likely the effect of stem cells that come along for the ride with the fat.  So the “stem cell face lift” practitioners are doing fat transfer but are promoting it as something new and unique.   It’s a little like calling a jelly donut a new type of fruit serving.

Check out this article in the New York Times. 

Thanks for reading and if you find a jelly donut that really is a fruit serving, please let me know.  Dr. Lisa Lynn Sowder

Fat transfer to the breast is looking like a great operation to this Seattle Pastic Surgeon.

Before (left) and after (right) fat transfer to the breast in a 60 year old jazz vocalist.

Here is yet another satisfied fat transfer to the breast patient.  I slimmed down her muffin top and added some fat to her breasts.  She went up one cup size and also got a bit of a lift, not only in her bustline but also in her spirit!

Her recovery was quick.  She was back to all her normal activities in about 3 weeks.

It has been sooooo rewarding doing this new procedure for the past year and a half and seeing what a difference it can make in selected patients.

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon is seeing some very nice results from fat transfer to the breast.

Left side : before fat transfer. Right side : 3 months after fat transfer. She has gone from a B to a C cup.

It takes quite a bit to get me enthusiatic about “new stuff” because “new stuff” pops up every day and more often than not, the reality does not begin to live up to the hype.  This tends to make one (me, for instance) a bit skeptical.

As discussed on my website and previous blogs, fat transfer to the breast is a new procedure that I am now offering to very carefully selected patients.   And now I am starting to get some sort of longish term follow-up and I am starting to get, well, a little bit excited.

This lovely mother of two darling boys had her fat transfer last fall and her size is holding steady.  She was a B cup before transfer and a C cup three weeks after transfer and today is a C cup three months after transfer.  She is thrilled and so am I.

She not only has no implant to maintain, she has virtually no scars on her chest and she has a subtle improvement in her breast shape.  No, she’s not going to stop traffic with this chest but that was never her intent.

And another cool thing about fat transfer – it’s really a twofer.  In this patient’s case, I took the fat off of her posterior hips and she is much slimmer in that area and with the increase in her breast volume, is much better balanced between her upper and lower body.  SWEET!

Thanks for reading!  Dr. Lisa Lynn Sowder

Before and after fat transfer from the abdomen and hips to the breasts. Note the increased fullness of the upper pole of the breast and the uplifting effect.

Seattle Plastic Surgeon blogs about her early results of fat transfer to the breast. 

Lately I am getting a lot of inquires about fat transfer to the breasts.  There must be a “BUZZ” out there.  And I am soooo glad that I have started doing this procedure.  I was skeptical (it’s my Germanic nature) until I attended the annual meeting of the American Society for Aesthetic Plastic Surgery (ASAPS) last May in Boston.

I attended every presentation on fat transfer to the breast and became convinced that, in the right patient, this was a procedure I wanted to add to my practice.

I am now starting to see some of my early postoperative results and I am even more convinced that this procedure has a place among the many breast operations I do.

This lady on the left has given me permission to use her photos.  The after photos were taken 3 months after her surgery.  Her breasts are completely soft and natural feeling and looking.  I do not think she had any significant residual swelling.  I will be following her and all of my fat transfer patients closely for several years to observe the long term size and shape of the breasts.

I am eternally grateful to this lovely young mom who agreed to be one of my first patients.  I do not take the trust she showed in me lightly.

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast enhancement with your own fat? Well, maybe.

Fat transfer to the breast:  Seattle Plastic Surgeon adds her two cents worth.

One of the hot topics at the annual meeting of the American Society for Aesthetic Plastic Surgery(ASAPS) in Boston which I attended last week was fat grafting to the breast. This procedure has a very interesting history.  Back when the earth was cooling and I was training to become a plastic surgeon (1983-1991), fat injections were considered fringe surgery and fat injections to the breast were for all practical purposes panned by the American Society of Plastic Surgeons (ASPS) and ASAPS.  Fat  injections to the breast were considered ineffective and dangerous. Well, that was then and this is now.

Fat grafting is now a well established procedure that has been used for facial rejuvenation, hand rejuvenation, the treatment of liposuction divots, buttock enlargement and a few other indications. Much of the early work done with fat grafting was performed by Dr. Richard Ellenbogen in L.A. and Dr. Sydney Coleman in New York and these two doctors were subject to ridicule and disbelief for several years. I remember in 1993, when I took my plastic surgery board exams, the correct answer to any question about fat grafting was that it didn’t work.   That is not the correct answer any more.

Fat grafting to the breast started with surgeons, myself included, using fat around the periphery of a reconstructed breast. For example, if there were contour defects at the edges of a breast reconstructed with an implant, some fat would be used to smooth that area out. Then we started using it for patients who had thin areas anound the breast following cosmetic breast augmentation.

Now we are using fat injected into the breast itself for breast enhancement. After taking several instructional classes on this topic in Boston, I am convinced that this is an appropriate and safe procedure for a very select group of  patients.

Fat injection, at least currently, will not acheive the same volume of enlargement that implants can.  Most fat injected breasts go up only one cup size. That eliminates a lot of ladies wanting to go a lot larger.  One of the doctors who spoke in Boston (and who has the most experience with cosmetic fat transfer to the breast) still uses implants in 90% of the patients who present to him for breast enhancement and uses fat in only 10%.

For the best results in patients with very tight breasts and chest tissue,  it is necessary for the patient to undergo breast expansion to stretch the breast and skin and to increase the breast vascularity prior to the fat transfer. This is done using a gigantic breast pump called the Brava System.

They should have called it the Brave System because it takes a brave lady to strap one of these babies on and then go out grocery shopping. The plastic surgeons who have the best results in thin, tight patients with fat grafting have their patients wear the Brava 10 hours a day for about 4 weeks. This is no small task. This Brava requirement also eliminates some patients wanting fat grafting. The experts (and who am I to question them?) tell these patients who want fat grafting “no Brava, no breasts”.

For patients who have experienced breast atrophy following breast feeding or weight loss, the tissues are loose and this preoperative stretching is not as important.  These patients will likely do okay without the Brava.

My week in Boston at the ASAPS meeting really opened my mind to this new way to enhance the breast and I am looking forward to offering this procedure to selected patients. But remember,  if you are “tight” – “no Brava, no breasts”.

Thanks for reading!  Dr. Lisa Lynn Sowder