Dr. G Plastic Surgery - San Diego

A: 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!

A: 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!

A: 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!