Joseph L. Grzeskiewicz, MD, FACS

It is definitely frustrating to experience anything recurrent after undergoing a procedure to correct a problem, such as you have done for rippling of your implants. It is doubly frustrating to find that what is probably the simplest option to address rippling, fat transfer, is not a great option for you due to the lack of suitable fat deposits to serve as a donor site. The one obvious possible factor that hasn't been mentioned thus far in this thread is the placement of your implants and the location of your rippling. If your implants are subglandular, i.e., above your pectoralis muscle, this could be a huge factor in the rippling, especially in a thin person and especially with rippling in the upper or inner part of the breast. Thus, a simple switch to a submuscular pocket location may be enough to take care of the problem, and you would need neither new implants nor Strattice/ADM. Aside from this, we are left with trying to find options to improve the situation using either the breast implants themselves or something to "line" or "thicken" the pocket. It appears that you have selected the most cohesive (solid) type of gel implant, the Allergan Natrelle 410, so unless, as some of the other doctors have already suggested here, your implant dimensions exceed those of your chest wall or pocket thereby creating standing folds in the implant shell, there probably isn't another implant option, at least in the US, that will be significantly less prone to rippling just based on mechanical folding of the gel. The only thing that may make me consider a different implant altogether is that the 410 is a Biocell, or macrotextured, implant, and sometimes the macrotexture adheres very tightly to the tissues, and this can create some folds or ripples by preventing the implant shell from gliding in the pocket and staying more smooth. It's also interesting that your post is dated June 26, 2019, and you state that you were four weeks postop at that point, meaning that you had your surgery a mere month before the FDA requested that Allergan voluntarily suspend sales globally of all of its Biocell textured implants due to concerns about ALCL (anaplastic large cell lymphoma) related to textured breast implants, especially macrotextured implants like Allergan 410's. At this point nobody, including the FDA, is recommending that people get their Biocell textured implants removed strictly because of this, but some people are still concerned enough about it that they may wish to, given this information. Thus, if the implant size and dimensions are appropriate for your chest, and the texture does not seem to be a problem with regard to creating ripples (an MRI could possibly shed light on this) or with regard to ALCL risk for you personally, then there would be little else to motivate me to suggest considering different implants at this point. This leaves us with finding "something" to line the pocket with in an attempt to create some thickness of the tissue to camouflage any folding or rippling of the implant shell. Most implants will fold or ripple slightly depending upon position, it's just that when this shows through thin tissues we dislike the look and feel of it. Just recognize that this doesn't necessarily mean something is "wrong" or "broken" with the implants or your body, it's just a natural occurrence, and we don't like it. The usual options for lining pockets are the so-called "ADM's," or Acellular Dermal Matrices (or Matrix, singular). These are basically pieces of dermis, or deep layer of skin, harvested from either humans or other animals, like pigs in the case of Strattice. They are all sterilized and prepared to prevent infections or cell reactions from the donor skin, and they basically provide structure to the system. The main reasons for using one versus another boil down to cost, dimensions (including thickness, not just length and width), and availability. In the case of cosmetic versus reconstructive breast uses, some of the human options, notably Flex HD, are not available due to constraints placed by the company in agreement with the donor families; they just choose to provide ADM only for reconstructive cases, not cosmetic. The human-source ADM's are generally much more expensive than the others, and this is often a limitation in their use for cosmetic cases, which are usually paid out of pocket. The Strattice options available in sizes suitable for breasts are generally one thickness, however, in contrast Alloderm can be obtained in different thickness, e.g. medium or extra thick, and this may be an advantage for someone who is really looking for as much thickness to camouflage an implant as possible. Be aware that the cost for this may be double what you would pay for Strattice, but then again, it may lessen the chance of recurrent rippling by its greater thickness, too. One last consideration that you may hear about is prosthetic meshes, like Galaflex or Durasorb, for example. These are meshes made out of absorbable materials similar to absorbable sutures, and they are probably more often used for structure or strength than simply for adding thickness. However, they will still provide some coverage and thickness over an implant, with the advantage that they are usually considerably less expensive than the biologicals, even Strattice. That's a quick rundown of some of the other options available to us in a little more detail than just considering Strattice alone as a knee jerk reflex, and the rationale for why a surgeon might make one or another recommendation. In doing as much revision surgery as I do now, one of the things I have learned is that it is always better to have several options to address something, as every case is different and every patient is different, with different problems, goals, needs and priorities, and one size doesn't always fit all. Make sure you consult with a surgeon who is not only experienced in primary breast surgery, but also revision breast surgery too, as that will be the best way to ensure that you will learn about all of your options and get the best outcome possible. Revision surgery is something you want to get right the first time, if at all possible, and not have to keep doing it again. Best of luck!

I do a LOT of fat transfer breast augmentation in my office fully awake, in fact I would also consider myself an expert in the field as I am a consultant for 2 different companies in the fat transfer space, and I had never heard of the "SVELT" procedure before this.  A quick Google search, however, turned up a description on it attributed to Dr. Daryl Hoffman in the Palo Alto, CA area, who supposedly developed the technique with a dermatologist in Canada.  While I commend them on their creativity in coming up with the cute term and the marketing efforts, in all honesty, the procedure is nothing more than a breast augmentation using only fat.  In fact, the way he has described it, I can make an argument that while it may ultimately work just fine to achieve the goal, it puts an unnecessary strain on patients by planning up front to make them return for multiple visits to have fat placed into their breasts to achieve only 1 cup size increase, while in my experience, and I think that of most surgeons doing this procedure too, one, and at most two treatments usually suffices to produce that one, if not two or more cup sizes in increase.  Fat transfer to the breast really should not be thought of as a "hard core" size augmentation procedure anyhow, as implants are always best if that is your main goal.  A fat transfer only enhancement of the breasts is really a shaping, balancing, contouring, and "filling out" procedure that has its strength in accomplishing those goals without subjecting ladies to the need to have implants placed.  We can even use fat transfer in conjunction with implants if we need to balance a contour or even out symmetry.  

This "SVELT" procedure is the kind of approach to most procedures that use fat or lipocontouring usually taken by office based dermatologists, as they are most accustomed to performing office based procedures with local anesthesia and using smaller devices and smaller volumes than surgeons typically would. The term "SVELT" is supposed to stand for "(Serial) Small Volume Elective Lipo Transfer," and the key is "small volume."  That's why you have to return for "several appointments" as Dr. Hoffman himself states on his website in the description of the procedure.  Again, most of us can achieve the desired results with one, or maybe two sessions at most, and we also can do it awake, in an office procedure room, with no general anesthesia, and no operating room fees just like he describes.  He accurately states that the results are usually not as significant as can be achieved with implants, and that sometimes volume can be lost, especially if you lose weight after the procedure, and this is why sometimes we might want to do a second session, but I rarely plan up front to do a second session, because more often than not, if the first is performed properly, it is not needed.  I'm not saying there isn't a limit to how much fat that can be transferred into a breast at one time; there is.  But generally, that is sufficient to achieve the results that most ladies choosing this option for their breast enhancement are happy with.  And again, if they aren't after enough time has gone by for settling, we can always do a second session provided that we have enough fat in another part of the body to donate.  In general, I can't criticize any of the information provided in his description of the procedure on his website, as I think it is all accurate and pretty standard.  I just take exception to the notion that the technique is somehow a novel approach to breast enhancement without implants, that it is "his" ( or Dr. Lycka, the dermatologist's) concept, and that it must be done with small volumes in several appointments stretched over several months.  Those things are more marketing, or just plain old not-best practices, in my opinion.  I also agree with him about seeing only an experienced surgeon to perform this procedure, and I would add that they should also be a board certified plastic surgeon for your breast surgery too, as they are really the only surgeons certified by the American Board of Plastic Surgery, a member of the American Board of Medical Specialties, to do aesthetic surgery on the breast, and they are going to be the ones who will have the most expertise and experience in this field and be most reliably prepared to offer you all of your options.  Good luck to you!

While there are other aspirators out there now, the Wells Johnson systems are the first real dedicated liposuction aspirators and generally recognized as the best.  They are probably the most widely used too.  All aspirators do is create a negative pressure, or suction, and with regard the cells, it's not the fat cells we necessarily need to preserve, but all the others that create most of the results we see.  The highest (or lowest really) negative pressure that any standard aspirator (one without special amplifying components) can create is one atmosphere, or about - 29 inches of mercury.  At this level of suction, the outside pressure of the air equalizes and prevents the vacuum from "sucking" any harder.  Thus, aspirators are limited, and most hope to hit this high of a level; suboptimal ones don't.  The higher the suction force, the more efficient the fat removal will be.  One of the major factors in damage to tissues during lipoharvest is actually the design of the cannula, not the suction power.  I usually want the most suction power I can achieve, but I want my cannula design - size, number, configuration and design of holes, etc. to be correct.  Thus, the short answer to your question, is "yes," the Wells Johnson machine is excellent for lipoharvest, and if your surgeon is proposing to use that, it is good.  The main question to ask is what about all of the other devices and techniques will he use?

You may already be aware that there is a thing called the "Koebner Phenomenon," named after Heinrich Koebner, and basically what happens is that at sites of trauma to the skin, like an incision or some other form of injury, the skin can develop a plaque of psoriasis.  Doctors don't really understand exactly how this works, but it is well described.  I don't think the psoriatic plaque near your areola has anything specifically to do with the fat transfer per se, but it could very well be the result of fat transfer to the breasts, especially if that area is one were a small incision or access point was made to inject the fat.  The fat should have been injected well deep to the skin where the topical medication should not reach, and the psoriasis mainly involves the skin, so you should be safe applying your topical medication to the area.  Check with your surgeon first too, just to make sure there aren't any other considerations.  Best of luck to you.

You've asked an excellent question about a number of measures that can be taken to lessen risks and improve the overall patient experience with surgery.  For the longest time, and in some instances still to this day, surgeons have been "tunnel vision focused" on their surgical plan, and the overall management of patients was either overlooked or simply deferred to the anesthesiologists.  With the advent of a new mindset in surgery known as "ERAS," or Enhanced Recovery After Surgery, this is all changing.  In a nutshell, ERAS is a concept that originated first in Scandinavia with colorectal surgeons trying to decrease risks in surgical patients and expedite recovery and hosptial discharge, then made its way to the UK, and now has been increasingly used by surgeons in the US and Canada with great success in all different surgical specialties, including plastic surgery.  The general concept of ERAS is one of detailed analysis of all processes before, during, and after surgery which affect surgical outcome, risk, patient comfort, and the like, in an effort to develop a list of "best practices," or those things which should be done routinely to optimize the overall experience for our patients.  Things like urinary catheters and preoperative beverages fall into this category.  For nearly the past 10 years, I have been fortunate to work with an anesthesiogist who has been at the leading edge of the ERAS movement internationally, and in fact she patented and manufactures the first specially formulated preoperative beverage in the world, which I'll mention momentarily.  I have learned so much from her, and I can proudly say that I have had an ERAS practice now for nearly a decade, and it really works - the things you are talking about in your question ARE important and they DO affect outcomes.

As far as urinary catheters go, much of the decision around that specific measure will depend upon the type and duration of the surgery and the amount of intravenous fluid the anesthesiolgist anticipates giving during surgery.  Usually from the standpoint of an ERAS practice, the anesthesiolgists will "run patients on the dry side," meaning they will give minimal amounts of fluid during surgery, and this will keep urine output on the lower side, which in turn will keep the bladder from distending, and this will help with things like postoperative pain and nausea.  In shorter cases, we wouldn't use a catheter because we wouldn't really need it to protect the bladder and then the risk of possible urinary infection or urethral or bladder irritation are eliminated.  In my practice if we anticipate a case to extend beyond about 4 hours, or involve abdominal wall surgery, like a tummy tuck, we will most certainly use a catheter.  We put the catheter in once our patient is asleep in the OR and usually take it out before they wake up, especially for breast-only surgery.  In the case of a body procedure, like tummy tuck or body lift, we might send our patients home with their catheter and remove it the next day.

With regard to your question about drinking water preoperatively, since studies show that the stomach is emptied of clear liquids after about 2 hours, we now believe it is safe to drink clear liquids, including water, up to 2 hours before the time of surgery.  The main risk of drinking anything other than clear liquids, or eating anything solid, is that the stomach may not be empty when going to sleep under anesthesia, and the patient can vomit and aspirate stomach contents into their lungs.  While water may be OK, it's not really the best beverage though.  Many studies have also shown that a special type of carbohydrate additive in a clear beverage, in addition to some electrolytes and certain minerals and other components, is superior to water alone.  This will provide not only hydration for the body and keep you from being thirsty, but the carbohydrate also provides energy for the brain and heart, and this decreases things like anxiety, pain, and glucose intolerance.  The beverage like this that I mentioned before is ClearFast®, and I have been using that one for my patients for almost 10 years.  It's amazing how much a simple little intervention like this improves so many aspects of risk and overall patient experience.  There are many, many other measures that a true ERAS approach will also include for each kind of surgery, and if you are interested in finding out if your surgeon uses an ERAS approach, you should ask them about it and discuss what measures their approach includes.  

Always choose a board certified plastic surgeon for your surgery, as this is one of the best ways to assure that your surgeon will have the best training and experience to provide the safest care and achieve the best overall outcome.  In addition to being certified by the American Board of Plastic Surgery, the only generally recognized organization which certifies true plastic surgeons and has the term “Plastic Surgery” in its title, your surgeon should also participate in the Maintenance of Certification (MOC) program administered by that board. This program requires that surgeons who participate continue to update their credentials and professional standing regularly, as opposed to practicing on a single lifetime certificate like those plastic surgeons who received their certificates prior to 1995 and voluntarily elect not to participate. To find further information about this program and any surgeons you might consider for your surgery, I suggest visiting these sites: abplsurg.org and abms.org. Good luck.