Joseph L. Grzeskiewicz, MD, FACS

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.

I definitely understand your fear about anesthesia, and believe it or not, you are just like almost every patient I talk to about surgery - you are more afraid of the risks of the anesthesia than you are of the actual surgery!  When you stop and think about it, this is only natural, because "going to sleep" with a general anesthetic represents one of the scariest things most of us can think of.  It represents a total loss of control over one's fate, and putting that control in the hands of people you HAVE to trust if you are going to have surgery:  the anesthesiologists and the surgical team.  I would be at least a little afraid of that myself, especially if I didn't know much or anything about medicine, surgery, or anesthesia.  I think everything you are hearing about this from medical professionals is accurate and well-meaning, but I can also see how that still might not be very reassuring.  Everyone says "oh, don't worry about that, you won't die," or "you have a greater risk of getting struck by lightening than dying from a breast augmentation," or "as long as you are healthy the anesthesia is very safe."  All of those things are pretty much true, but I can see how they can either minimize your concerns or at the very least not provide a sufficient answer for you and be unsatisfying.  So, at the risk of saying too much here in a long-winded response, I'm going to give you a very thorough response to your question, and I hope that it helps allay your fears.

You have really asked 2 things here in your post:  1) you've essentially asked about some idea of the level of risk of general anesthesia for breast augmentation, and then 2) you've asked what you and your doctor can do to lower those risks in your case.  So let's look at the first part first.

From the standpoint of risk with general anesthesia, something many people may not realize is that there is actually a very well defined, well-tested, tried and true process on the part of both anesthesiologists and surgeons to assess and manage this risk.  While we may not go through and discuss each assessment and analysis we make at the time with the patient, much like driving a car - we don't say "OK, I'm turning the key here, now I'm putting it in gear, now I'm stepping on the gas, etc., etc," we just do it, we just drive the car - so it is with our assessment of risk, especially in people who don't have a lot of factors to consider, like younger, generally healthy people, we do it as we're interviewing and examining you and reviewing your health history.  Specifically, the anesthesiologists have a reproducible, quantifiable method for assessing risk for general anesthesia that has been used for over 50 years, and each and every patient that undergoes a general anesthetic is classified according to this schema.  It is called the "ASA (American Society of Anesthesiologists) Classification, and it uses very specific criteria to classify each individual patient undergoing an anesthetic from Class 1 to Class 6.  In a nutshell this classification uses things like general health status (smoking, alcohol use, any diseases or medications, weight/obesity, illnesses, like diabetes, high blood pressure and severity of those, and other factors like that) together with nature of the surgery (elective, emergency, organ procurement for donation, etc) to make a determination of ASA class for the purposes of evaluating (and managing) risk.  Doctors also take into account a person's age, the specific nature of the surgery, duration of surgery, and factors like that to round out the mathematical and subjective assessment of risk.  In general most studies that have looked at this in terms of mortality (death rate or risk), the numbers have been very roughly around 0.03% (3 out of 10,000) chance of death for someone in ASA Class 1.  This is a somewhat rough number, as there is a lot of variability, and like I said, things like age and type and duration of surgery factor in as well, but at least this gives you some idea other than just "don't worry, the chance is low, you won't die."  I would venture to say that for most young healthy nonsmoking patients without any medical conditions like asthma, diabetes, etc. undergoing only elective breast augmentation, which is typically a brief 1 - 1/2 hour procedure that loses very little blood and requires generally light anesthesia, they would wind up easily in ASA Class 1 and have extremely low risk for death with anesthesia.  It would be even lower from a purely surgical standpoint.  Beyond this, you will have to review your own individual medical history and risk profile with your anesthesiologist and surgeon in order to get a more specific idea of your personal risk.

With regard to things that you and/or your surgeon can do to lower your risk, I think the above discussion gives a clue to at least some of those.  Clearly, healthy people who are not obese, who don't smoke or drink excessively or use drugs, who have good control over any diseases or medical conditions they might have, and who have straightforward surgical plans for breast augmentation will have the lowest risk.  Thus, things like stopping smoking if you smoke, avoiding excessive alcohol or drug use, maintaing a healthy weight and body fat percentage/BMI, following any doctors' orders to control medical conditions, and exercising to keep fit are all things you can do to lower your anesthetic risk, and in particular your (likely extremely low) risk of an anesthetic death.  Your surgeon may also include some other things in the mix to lower risks as well, like preoperative hydration with a specially formuated pre-op beverage (like ClearFast®, which I use for my patients) which lowers things like preop anxiety (thus the possible need for deeper anesthesia or greater doses of anesthesia), risk of intra- or postoperative nausea and vomiting, and hypo- or hyperglycemia, use of preoperative premedication with acetominophen (e.g., Tylenol) which can also decrease overall anesthetic requirement, and thus risk, or certain blood pressure medications or other drugs administered by the anesthesiolists at the start of the procedure which can also lessen risks.  Additionally, there are also some things the surgeon can do to lower other risks too, like risk of infection, but those aren't really involved with risk of anesthetic death per se, so we won't go into those here other than to just make you aware that risk avoidance is a very real thing that we surgeons think about (or shoud), and there are LOTS of things that we can do to lower overall risks for our patients and get reliably good results safely.

I know this is a long-winded response, but I hope it was interesting to you and helped make you feel better than just saying "oh, don't worry about it, the risk is very small."  Lastly, make sure you also go to a board certified plastic surgeon for your surgery (and board certified ANESTHESIOLOGIST as well), as this has actually been shown to give you a better statistical chance of a safer operation with a better outcome, not because we are all geniuses or the only ones who can do this surgery, but because we are a select group of surgeons who have demonstrated a commitment to things like safety and best practices, and with anyone else you don't get that reassurance, so you just don't know.  Best of luck to you! 

It is most likely that you had a little too much fat removed from that specific area during your procedure.  This is usually a technical issue and under the control of the surgeon.  It's not as simple as just saying "only 20 cc was removed," as although 20 cc sounds like a small amount, if it was all removed too superficially, that is, just beneath your skin, even a small volume deficit will look conspicuous.  Furthermore, it appears as though the surgeon maintained the cannula, or the metal tube used to suction out the fat, in predominantly the same direction, moving back and forth without "fanning" or changing angles, thereby making it likely that more fat was removed from the same "linear tunnel" than intended.  This happens most frequently when the surgeon fails to recognize that the cannula is twisting on the ligaments just beneath the skin, and he doesn't withdraw it sufficiently to free it up from those ligaments before advancing it again.  This means that essentially each time the cannula is advanced back and forth it cannot find a new "tunnel," thus it keeps removing more and more fat from the same exact path, and if it's too superficial as well, this kind of deformity results.  The darkness could be from either shadowing due to the contour difference or your skin pigmentation.  If it's the latter, that sometimes gets better with time; perhaps a few months or so.  If it's the former, or a combination of the two (most likely), then it will always be there until the contour is corrected.  I don't think PRP will be enough to do the trick, but it's certainly easy enough and it's reasonable to try that first.  It might be a better idea to combine PRP - or better yet PRFM (plately rich fibrin matrix) - with some fat and just graft that area to restore the volume beneath the skin.  The good news is that this can likely be corrected fairly simply.  I would wait another 3 months or so, though, just to let things fully heal and stabilize before I did anything.  Best of luck!

Your situation is a bit more complex than what can be completely discussed here on RealSelf, but I can tell you that it's a very common situation.  Variations of tuberous breast development are quite frequently seen by most breast surgeons, and along with that comes asymmetry.  I think the obvious "knee-jerk" response for both surgeons and patients is to try to correct asymmetry by using two different sized implants, or even implants of different profiles or dimensions for the two sides.  Sometimes this is necessary, but most times I think this just creates a new asymmetry that replaces the old one.  Implants, especially today's modern highly cohesive, form-stable "gummy bear" implants, should be thought of more as having "dimensions" as opposed to just "volume."  In other words, while we all like to think of implants in terms of say "300 cc" or "350 cc," we have to remember that there are different widths and heights of those implants too, not just their volume, and especially in the case of the form-stable implants, those dimensions significantly influence the shape and dimensions of the resultant breast.  Thus, many times if a surgeon attempts to correct a complex asymmetry of the breast using just different sized implants, while it is very basic and easy to do and for that reason appealing, it winds up leaving us with just another form of a visible asymmetry.  In my experience it has become much more reliable to use what I call "composite breast augmentation," or even breast augmentation with fat transfer alone, to correct this kind of asymmetry.  In the case of "composite augmentation," we use implants for the "foundation" of the breast mound augmentation, but then we also supplement that with a transfer of the patient's own fat to "refine" and correct specific areas of asymmetry or irregularity with the patient's own tissues.  In the case of fat only breast augmentation we obviously use only fat and no implants at all, and though we might be limited ultimately in the final size of the breasts we can produce this way, we are still able to make adjustments to size, dimension, and many ladies only need this or want this type of correction.  Thus, in both cases we are performing a much more "cause specific" correction of the asymmetry, because obviously your current asymmetry is caused by a TISSUE imbalance, not implants, and we are thus correcting the tissue imbalance with TISSUE, not implants.  Then, if we used implants at all, we use more or less identical implants and we wind up with less of a risk of creating other types of asymmetries.  With regard to your question about "pointiness" and other contour issues, I can tell you that by and large those can most times be adddressed with either fat transfer as well or other maneuvers that a skilled surgeon has at his disposal.  Beyond this it will be hard to answer you specifically here, and this is why I suggested above that we may not be able to provide a complete answer to your question in this forum.  For that you would need a personal evaluation and exam.

Make sure that you always visit a board certified surgeon who has experience with all methods of correcting breast problems, and that way you will have the best chance to learn about all of the available options for your specific case.  Make sure you understand any plan that is proposed to you, what the pros and cons are, as well as the limitations and what is proposed to deal with those.  Best of luck to you!

While this answer seems somewhat casual, the truth of the matter is that just about any area of the face where "fat" is needed is a good area to inject it.  The question is:  what does "needed" mean, and what do you actually mean by injecting "fat?"  We have learned so much about autologous fat transfer in just the last 5 years, and techniques and technology are dramatically different than they were even before then.  We now know that "fat" transfer isn't just about transferring "fat" - what most people consider to be the mature adipocytes, or fat cells, that are largely responsible for the volume and fullness that we typically associate with fat tissues.  So much of the results of fat transfer has to do with  the cellular biology and the involvement of other components of fat tissues, such as stem cells and progenitor (immature) fat cells, microscopic blood vessel components, and even the fibrous structures we find in the fat tissues.  We are now able to micronize, or break the fat down, into small enough particles such that it performs pretty much as a liquid and can even be injected through a tiny "Botox-sized" needle.  This is significant because in addition to the traditional ways we have used fat in grafting like adding volume to cheeks, lips, brows, and chins, we can now safely and reliably deliver the regenerative functionality of fat transfer to thin tissues like the lower eyelid skin, scar tissues like acne scars, dermal creases, and other thin areas without creating volume or mass-effect.  I can even "resurface" a thinned out, skeletonized nose with micro-fat!  And, this fat that is transferred does way more than just creating volume - it also has a regenerative/rejuvenative effect on the actual tissues, and this creates a lasting and real change in things like tissue blood flow, thickness and elasticity, and overall surface tone and texture. This is quite an innovation, and in my opinion, it has revolutionized the use of adipose tissues in facial aesthetic treatments. 

The one caveat I'll make here is that this type of fat transfer is highly technically dependent, and there are many important steps, including harvest of the fat, preparation of the fat for transfer, and the actual injection of the fat, where this can be done inexpertly and affect the results.  Be sure that you seek out consultation with only properly trained, experienced, and certified surgeon who is up to date with the latest techniques and technology using fat transfer, as this will be the best way to ensure that your results are the best that they can be.  Best of luck!

As long as you are fully recovered from your hip procedure, your blood counts are normal, and everything else is fine, meaning you have no medical conditions that would otherwise disqualify you from having the surgery, there should be no reason why you can't undergo VASER assisted liposuction.  VASER uses locally transmitted ultrasonic energy to "cavitate," or break up the fat tissues and make it easier to remove them, and this all occurs in the more superficial subcutaneous layers of the body.  There should be no interaction with your hip joint or implant if done properly.  Be sure that you seek out a properly qualified board certified plastic surgeon to perform your surgery, as unfortunately, VASER is one of those procedures that lends itself well to poorly trained and/or qualified individuals, and your risk of complications or poor outcome is always increased in cases performed by such people.  Best of luck!