Microfat grafting or BRAVA doctor recommendations
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I had a wide excision of recurrent tumor which was under my arm so my (diagonal style) mastectomy scar was extended under my arm at that time (8/2010). Then I had radiation 10/2010. In 8/2011 Dr. K removed my implant using my existing scar but it was my under arm scar. So I am sort of the exception to this discussion. My underarm was so scarred up at that point I wouldn't have cared. But no new scar for me.
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Hi Roseann,
I'm doing great. I just spoke with dr Greenberg by phone. I don't think she's ready to tackle a situation like mine with rads damage yet. She's basically deferring to dr k. She did emphasize to me the importance of being at my "fighting weight" before doing any lipo or I might not love my results cause of sagging skin. I need to les 30 more pounds (I've lost over 30 so far). I' m really glad I got that input. Seems like I get some good info with each dr I talk to. Best bet for me right now is to take care of the weight first. But, I hate these expanders! But, basically implant only reconstruction won't get me anywhere. I need the fat grafting to heal the damage. I'm hoping if I wait longer maybe more info will come out about these armpit incisions. Maybe he'll change I directions.
Amanda0 -
MandaLynn- Yes, like Kate posted, I had my implants exchanged from 550 cc to 300 cc with 3 rounds of fat grafting (most FGing was done during the first session). Dr. K used the outer half of my MX scars.
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I have to give kudos to Dr K. I'm only at the beginning stages of my fat grafting (1 session this past month) he has already improved the look and feel of my breasts. After my 1 st reconstruction with another surgeon a year ago, 375 implants that looked like 2 lopsided balloons under my skin, and my 1st surgeons only solution was to lower the higher one and make it bigger on skin that was already too thin, he said he was afraid to touch the lower one. When Dr K asked me what my goal was, I told him I hoped for more natural, even breasts and eventually have nipple reconstruction. I mentioned lowering the right, he said why not raise the left? i told him bc my last doc was afraid...he scoffed and said he'll raise it and he did!
He did advise me at consult that he'd go under my arms to swap implants. I was fine with that bc i've been so scared to lose my implants all together due to thin skin. I understood too that if he opened my original scars it would be riskier to inject fat without the fat pushing on that fresh wound. Maybe there have been complications with other surgeries he now chooses to avoid? My scars under my arms are very small, i'm ok with them. He improved my port scar and breast scars with the fat grafting, so thankful for that.I now have 190 implants with approx 200 fat in each. My breast are a little lumpy on the outer sides so far but they've smoothed significantly sicnce my 1st grafting. I'm still debating whether to go implant free. Either way I will continue with Dr. K because at this time I think he's the best doctor in my situation. We are all different with different issues, different lifestyles, complications...Doctors are human, they can only do so much and some even make mistakes. My 1st surgeon showed me an extensive portfolio w great outcomes but I was not so fortunate.
Fat grafting is rarely a 1x fix for reconstructing breasts. I'm hoping no more than 1 or 2 more times but I know it could be more if I wish to get the best results possible and depending if I go implant free. Of course after I put myself through all this they'll be growing new breasts like shown in link above
I do think it's perfectly appropriate to share the good, bad and ugly here.I'm thankful for all those who share here and on the fat grafting site.
I hope i'm not jinxing myself! but felt I should share my experience thus far.
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wow Las,how great for you! im happy for you,and so well written, i noticed you are new on the threads you should let more people know on other threads too....you are a very lucky lady,oh forgot to ask did you have radiation im sure you did thanks
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Very nice story LAS, thanks for sharing!
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Hi, I did not have radiation. I had bilateral mastectonies, 2 tumors in each breast,8 lymph nodes removed on right side, 7 on other, 3 tainted, 4 sessions of chemo over a 3 month period, did zoladex shots w/anastrozole for 4 mos then quit in Aug. 2011 due to side effects.
Thanks, ladies
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thanks for the info! you are one of the lucky ones in one respect for reconstruction. Radiation is really hard on the tissueso you got nice squishies back
that does not happen with rad skin,except i am finding some flaps do help with it becase they actually take an artery and reatach it in the breast,rad skin need the blood supply, I may go that way ,really want the fat grafting but cannot find and ladies that have had it with rads 
i did find ine i think ,thats just not enough for me .but im very happy for you ....0 -
My 1st ps said my skin was so thin it was similar to radiated skin which is why he was afraid to do much after my 1st exchange. I do understand though bc my older sister had a lumpectomy and radiation at 40, 7 yrs ago. She's still trying to match her breasts after 3 surgeries. Her non radiated breast is fuller and lower w/same size implants. The ps she has chosen (top surgeons in ny) haven't been able to raise the lower one successfully. Dr Khouri did pursestrings ¿ on me and they seem to have held but still a bit uncomfy.
I still have a seemingly long road ahead but am hopeful. To those that have questioned me why i'm putting myself through these surgeries, i say i'l give up when i've given up hope.
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LAS123, thanks for sharing your story! I've had my first grafting and am coming up fast on my 2nd one (Dec 23rd!). And never give up! I like your attitude.
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LAS123-Very happy for you and thanks for sharing. You have a thorough and realistic understanding of this whole process. Yes, it isn't a quick fix and several sessions are necessary to give the best result, but so worth it! Dr. K loves a challenge - not surprised at all that he was willing (and able!) to do what another PS wouldn't touch. You are absolutely correct about the reason for the switch from re-opening MX scars to under arm incisions. Dr. K would never give us an additional scar if it weren't absolutely necessary. Like you posted, it's impossible to do effective fat grafts under a fresh incision, the fat would push through. With the old method (which I had) there tends to be an indentation all along the scar line. The tissue contracts as it heals and the lack of fat along that scar didn't produce the best results. Making the incision under the arm allows him to do the exchange PLUS do the fat grafting everywhere it needs to go for a smooth and undimpled result. I'm certainly not a surgeon, but some quick research confirmed that it is NOT easier to swap out implants through an axillary incision. See following link/quote:
http://science.howstuffworks.com/innovation/everyday-innovations/breast-implant10.htm
"Transaxillary Incision- Patients who want no breast scarring at all often opt for the more difficult transaxillary incision. This incision is made in the armpit and leaves a tiny scar that is virtually impossible to see.
The transaxillary procedure can be preformed with or without the help of an endoscope (a tube with a small surgical camera on the end). The cut is made in the fold of the armpit and a channel is cut to the breast. The implant is inserted into the channel and worked into place.
Transaxillary incision presents a greater challenge for surgeons because working that far away from the breast makes placement more difficult."I like your attitude as well, and I agree: Never give up!
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Lee- My scar is 2 inches long so not exactly what I would consider tiny nor is it virtually impossible to see. It makes it impossible to wear any sleeveless tops anymore. I wouldn't even describe it as being in the armpit (where it would be less visible) but more towards the front. If Dr. Khouri's reasoning for using this incision is to improve his ability to graft the fat he should tell patients this because that is not what he told me. During my initial consult in March he said he would use the IF fold. The day of the surgery, 6 weeks later, he backed off and said he was changing it to the armpit incision. The only reason he gave, though, was he didn't want to disturb my IF incision because it had healed so nicely. 3 different PS's I've consulted with, who all do FG, said it is easier to go through the armpit especially when there is already a pocket created. The article you posted is from 2004 when using the armpit incision was more common. The PS's I saw said this type of incison is outdated, and do not use it anymore, because there is risk of complications to the major nerve that runs through there and it is not aesthetically pleasing. And the article is only talking about breast augmentation, not reconstruction. For any of us who have had lymph nodes removed going through the armpit puts us at a higher risk of LE. LE precautions are no blood draws, BP readings, etc in the arm so surgery itself would definitely be risky. While it's true you can develop LE at any time I find it suspect that I didn't develop it until after the armpit incisions. Dr. K assured me the incision did not put me at a higher risk of LE which is not true. I consulted with the top LE therapist in Arizona and she said this simply is not fact. I think Dr. K is brilliant at what he does but he is not a oncology BS and may not know all the nuances or risks that BC patients face over his traditional augmentation patients. I'm not trying to bash him but merely make potential patients aware of all the pros and cons of this surgery. I still think the pros far outweigh the cons but do question some of his choices. Like I said, if there is a valid reason then he should be informing his patients what it is. All patients should be made aware of every risk and benefit so they can weigh them and decide what is right for them.
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Kate, I'm sorry that you feel the way you do. I've looked up and read LOTS of articles in the past few days on transaxillary scars. Even before I read them, I couldn't for the life of me believe that anything would be easier than going straight in through MX scars. In this case it doesn't matter if the incision is for augmentation or recon revision - it's still a much more difficult procedure. I've also talked to another PS, who shook his head and said the same, that it is MUCH easier to go through an MX scar. You are absolutely right about it being riskier. As far as Dr. K NOT being a breast surgeon? He's been one for over 20 years and over 10 years ago published the largest experience in the world with breast reconstruction using microsurgery & TRAM flaps. That being said, this still is a new procedure and for some the results may not be perfect. Sadly, the other options aren't great and for us who have already gone through a reconstruction process that was unsatisfactory, they become even worse. We are pioneers in this process and there have been and will continue to be adjustments and changes to protocol as more and more case studies are reviewed. Still, despite all the possible cons, the benefits far outweigh them and for those lucky enough to have it done at the time of mastectomy, nothing short of a miracle.
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Lee- We've always referred to surgeons on BCO as either a BS (one who treats BC through surgical means) and PS (those who reconstruct). Dr. Khouri is not a BS. He is a board certified PS. That is what I was referring to.
As far as you saying you're sorry I feel the way I do I'm not sure what you mean by this. I have said time and time again I am extremely pleased with the results of the fat grafting. My only purpose in posting about my experience is to let other women know that while some things may improve there is a risk that other things may not and may even be worse. Not once in my consult did Dr. K ever mention any risks, possible complications, etc. So if he is not doing it then this is the forum to pass on that information.
So again-
Fat grafting is wonderful!!! My breast looks and feel so much more natural. The skin is warm to the touch which I love. The benefits of lipo are great, too. I think of all the doctors doing FG Dr. Khouri is an artist as far as knowing where to place the fat.
But by allowing the armpit incisions you will have possible complications of nerve damage, increased risk of LE and an unappealing scar.
I am not a bitter disgruntled patient. I have always posted both sides of my surgery- things I think patients should be told before they decide on this surgery but are not. If you're warned about a risk and you proceed anyway that's fine. But to have an issue later you were never warned about is another story.
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Kate - glad you cleared that up. Just felt it was a little unfair to post that the reason he switched the incision site was because it might be easier to swap out the implants. The decision was based on better aesthetic result and it is in fact a more difficult approach. For women who have LE fears and are willing to accept the possibility of a less than perfect scar line and dimpling, I'm sure he would understand their hesitation. As you know, he's a perfectionist and always looking to improve the end result. Wish you were totally happy with your result, like I am. At least a lot of your previous issues were resolved. I"m sure with time this form of reconstruction will continue to get better - kind of cool that we are helping it along.
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Your posts were great! Knowing the pro's and cons is EXACTLY what we need!
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Kate-
I was wondering if you've followed up with dr k with your continued concerns. The reason I ask is that because of my knowledge of your experience, when I had my consult, I expressed my desire to not have armpit incisions. Lee-- he did not "understand my hesitation" at all and, in fact, didn't really seem willing to discuss it. I'm not saying he was dismissive exactly and certainly not uncaring, I just don't think he is getting how much of a deal breakers his is for a subset of reconstruction ladies. I really, really want to see him consider the fold incision. If I could get reassurance about this, I'd be there tomorrow. I'd take a dimply under boob scar line any day vs a swelling arm and more scars.
I'm hoping to do a little grass-roots consciousness raising on this issue with him. Anyone else going to be in contact with him soon want to take on this issue as well? I was considering emailing him but not sure what to do. I had radiation and 14 nodes removed---I'm at a very high risk for lymphodema. yikes!
Amanda0 -
Lee, can you explain what you mean by"over ten years ago published the largest experience in the world with breast reconstruction using microsurgery and TRAM flaps"? Do you mean he published an article? A TRAM is not microsurgery,a DIEP is.
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I believe the article Lee might be referring to is this one:
A prospective study of microvascular free-flap surgery and outcome. (1998, Journal of Plastic and Reconstructive Surgery)
Also, for anyone who is interested, a search of pub med revealed 60 articles published by Dr. Khouri. Note that Dr. Khouri also does microsurgery on the hand, so hand articles are included.
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Khouri%20RK%22%5BAuthor%5D
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MandaLynn- After my surgery I emailed several times with my concerns about the continued numbness in my arms and shoulder blades as well as the swelling in one arm. I told him my concerns with LE which he dismissed. He wanted to see some current photos which I sent and he said everything looked great. I said it was not how they looked but how other things were feeling that were my concern. He told me to either fly to Miami and see him (which wasn't financially feasible at the time) or consult with another PS which I did. After that I never heard from him again. The local PS is the one who sent me to the LE therapist who DX me with LE. She also said I had developed a lot of scar tissue that was running from the top of the implant down into the armpit and was tugging on the implant.
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As I saw the end of Dr. Oz Show today, I saw they were advertising Friday's show with Suzanne Somers who is going to talk about a revolutionary new way of breast reconstruction. I wonder if she is going to talk about Dr. K and the micro fat grafting. If so, it would certainly help to spread the word and create more of a demand. Anyone else know anything?
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I still do not understand what is meant by "published the largest experience in the world,etc.." This exact quote is on Dr.Khouri's website.Does it mean he published an article saying he had the most experience in the world with breast reconstruction using microsurgery? Seems odd he would say that as everyone knows Dr.Allen pioneered microsurgical breast recon.Kate,I am so sorry that you had some problems,but I commend you for posting about it.It is great to hear about perfect success stories,but even better when we learn about possible problems to be aware of and ask questions about.
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Kate 33:
Just deleted a long response, so will try again. I appreciate your honesty concerning your experience. This thread began as a source for others to post resources. At times it seems that Dr. Khouri is deemed the only worthy one and all others less so. For someone to state he is a perfectionist and yet he does not listen to his patients means nothing. Perfection might just be a strong ego.
An oncological BS is very different from a BS and vastly different to a PS. I have nothing but high regard for my PS, but hindsight has shown me I should have searched out an oncological BS to deal with my radiated skin. For those of us having nodes removed and working so hard to protect that arm/side and have someone refuse to discuss possibilities....to be dismissed for a very real concern. Does that invite trust and belief in the PS?
I have no regrets over attemping to have fat grafting as my second chance at reconstruction. I have no regrets over having bags of fat stored in Dallas that may not be used. The regrets I have are not asking more questions and being armed with more information before this journey began. But in the midst of trying to fight the beast, logic does not always come first.
There are new pioneers in this process who will develop techniques far beyond Dr. Khouri or my surgeon and that is exciting. But to tell those seeking information that Dr. Khouri is the one and only is doing a disservice.
I wish I had waited longer for reconstruction. I wish I had read more and asked more questions. I wish I had listened to my gut. But today is today. I have changed surgeons and will be looking for another way to acheive normal....not DD's but normal. I think trying to be perfect is creating more damage than perfection.
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Wow - where to start. I know for my part my reason for being here is to help other women find out about a revolutionaly procedure that can bring them back to where we all want to be when we hear our DX. Back to a sense of normal. If I had stumbled upon fat grafting earlier, I would not have implants. I would have been spared the trauma to my pectoral muscles, the pain of TEs and the anquish and disappintment with my initial implants. I have zero regrets and I am not a person to dwell on negatives, so I come from a position of intense gratitude and desire to share my blessing. It has been a true blessing for me to have found Dr. Khouri and that he has given me back my normal. This is my reason for remaining on BCO - to pay it forward so that women can know that there is a hope. Nothing is guaranteed - there is risk with every reconstruction procedure. Less with fat grafting than with any other method but it is new and as time goes by it will be improved and refined based on past results. I am not a doctor and I don't consider myself an expert. What I know I have learned through research, networking with other patients who have gone this path before me and from asking questions from ALL of my doctors. It is not up to any of us to question a surgeon's ability or credentials. I don't think any of us here should have the audacity to do that - we should be supportive of one another and most of all, we should be applauding that fact that there are surgeons out there willing to be pioneers and break out of their comfort zone in an effort to bring about positive change. They, be it Khouri, Delvecchio, Khoobehi, Rigotti, Rubin, and the many others on the forefront of change, are doing this for US. Take the time to search for plastic surgery and/or breast reconstruction conferences and meetings and look who the presenters, the teachers are! These are the surgeons working for us, finding better options - the ones who aren't content to sit in pretty offices doing the same procedures they are comfortable with. And these same pioneers are the ones we are being so critical of? Ladies this makes NO sense! I am truly sorry that not every one of you was able to obtain perfect results. There is nothing wrong with striving for perfection. Nobody has ever claimed that Dr. Khouri is the one and only surgeon qualified to do this. He is probably the best known so his name is synonymous with micro fat grafting to the breast. He is a teacher so most PS who are interested in this procedure know of him or have learned from him. This is bad? We are trying to define what constitutes micro-surgery? Really? Many skilled plastic surgeons are also hand surgeons. Would that meet the threshold of microsurgery for everyone? I am honestly wondering why I still stick around this board. Don't you all realize that most women who are happy with their results do NOT come back to post? Everyone stops by to find answers and help and once they are done, they move on. THAT is why I am so adamant about posting the positive results. Just like every other on line discussion group or forum, from kitchen appliances to moving companies, happy posts are rare - but woe be it if someone is unhappy. This negativity is ridiculous, uncalled for and does nothing to help others. Let me remind everyone - you have choices. You make your decisions. If micro fat grafting isn't for you, fine - get implants, get flaps, whatever you want. Just remember that the negativity you spew may just be enough to dissuade one of your fellow BC sisters to try this innovative approach and miss out on the opportunity to be normal again. For my part - PM or email me if you are truly interested in my experience. One of MANY positive, happy results. I am happy to post my photos and honored to give credit to Dr. Khouri who made them as perfect as they can possibly be.
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Negative spewing......not really. I have spoken what I feel. I had high hopes for fat grafting. I still have high hopes for fat grafting, but it will not be for me. I have high hopes my being willing to fork out $1600 and be a guinea pig to bank my fat, have it frozen, thawed and injected allows someone else to not have to have repeated lipo sessions. The fat I had frozen, thawed and injected did survive and thrive. But the damage from radiation and infection from the failed DIEP make this hope for me a pipe dream.
I could go to Dr. Khouri. But my gut tells me, that would not be a good fit for me. I have learned to listen to my gut. My choice has nothing to do with insurance, travel, cost....just a feeling. My choice needs to be respected and my reasons just like those who have chosen to go to him and their reasons. Perfection....I do not strive for perfection on my chest. I have a DH who would support whatever decision....a second mastectomy and beautiful tattoo or a new boob. And the size of that boob would be mine, not what is deemed perfection.
But again, that is an individual choice. Just as whom I choose to touch me again. I totally trust my surgeon, but he has suggested another flap procedure. I can do that with great surgeons less than an hour from home and will. I explored my options....nothing, I had the DIEP and it failed, fat grafting and without the implant---well, not going to happen.
I support fat grafting. I support one exploring to find that surgeon that they connect with. I don't support that Dr. Khouri is the only one who can achieve "perfection". Is that spewing negativity because I feel there are other options?
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Lee,
You said in your post that "these surgeons are working for us, finding better options." I totally agree! And, as a woman with a radiated breast at a high risk for lymphadema, I would like a better option than armpit incisions.
And, I definitely think dr k is an amazing pioneer. Hope he can help me in the cautious way I'd like to proceed.0 -
Is anyone planning to watch Suzanne Somers on Dr. Oz on Friday - talking about breast reconstruction?
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hrf, I think I will watch it - if not then, when it comes out reposted on his website. It will be about fat grafting, but not the kind Dr. K does - it is the stem-cell kind (which is more controversial, due to the concerns about possible interaction with cancer cells, but shows promise). Here is an article that reviews what she had done, and this is a snippet of that article:
Suzanne Somers Uses Novel Stem Cell Therapy During Breast Rejuvenation
Using an advanced technique conceived by Dr. Kotaro Yoshimura in Japan, Suzanne's American surgeon utilized a novel strategy known as Cell-Assisted Lipotransfer.8 Dr. Yoshimura's protocol utilizes autologous adipose-derived stem cells in combination with liposuction techniques.
With the Cell-Assisted Lipotransfer strategy, autologous adipose-derived stem cells are used to enhance survival rate of the fat grafts and to reduce postoperative atrophy (shrinkage).
Using the novel Cell-Assisted Lipotransfer technology, half the volume of the aspirated fat is processed to isolate the stromal vascular fraction-containing stem cells. During the isolation process, the other half of the aspirated fat is prepared for grafting. Freshly isolated stromal vascular fraction stem cells are attached to the aspirated fat, with the fat acting as a living "scaffold" before transplantation. Finally, the stromal vascular fraction-supplemented fat is injected into the breast. Therefore, stem cell-poor fat is converted to stem cell-rich fat in the preparation process of the injectable material.9,10
Note her doctor is Dr. Aronowitz, located in LA. Looks like he is running a clinical trial for this...
Here is an interview with Dr. Aronowitz: Cell-Assisted Lipotransfer Breast Restoration
Pretty fascinating stuff!
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Hey Lee, Don't leave the thread we need your positive input.
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Lee- I'm really puzzled as to why you're all up in arms and saying we are "spewing negativity" when we are merely trying to share information? None of us are striving for, nor expect, perfection but we do expect the best results possible. I really have to comment on some of the things you said-
You said that Dr. Khouri would certainly understand a BC patient's hesitation with an armpit incision. He may understand but according to others who have had recent consults he is refusing to do it any other way. You constantly say that you are extremely happy with your results yet he used your original incisions. If someone was willing to trade less than optimal results (i.e. the indentation you described on your own breasts) for no additional scarring in the armpit and no risk of LE) shouldn't they be allowed that choice?
You said at least my previous issues were resolved. I feel this really discounts my current concerns with my LE. Right now I am fortunate in that I have a mild case but this could change. So if it progresses, and my arm swells up to 5x it's size, I can say, "Well, at least my boobs looks good?"
You said "there is risk with every reconstruction". While this is true I don't feel a patient's health (possible LE) should be risked merely for a better aesthetic result.
You said "it is not up to us to question a surgeon's ability or credentials". If not us, then who? It is up to us to question everything! That is how things get changed. These surgeons are not God. And these are our bodies so we have a right to question anyone who treats us.
As far as you saying you have read numerous articles about transaxillary incisions. I would be interested in reading them. The only one you have posted so far came Discovery's "How Stuff Works" back in 2004- hardly what I would call a reputable medical site. I'm comparing that to 3 different board certified PS's (one who was trained by Dr. K) all saying that the armpit incision is easier for the surgeon when swapping out implants. (Not for placing implants for the first time in a breast augmentation.)
The recent discussions on this thread concern the armpit incisions and the possible complications from it. Since you were not given this type of incision by Dr. K, are not experiencing the SE's from it and are not on Dr. K's staff and able to comment on why he is choosing this sudden preferred method I again am puzzled why you are so upset about us sharing information on this and questioning its use?
I don't think anyone here has ever been negative about the fat grafting itself. For someone having immediate FG following MX it is nothing short of a miracle. The current discussions concern revisions and the best way to approach it. Everything I have read said that it can be more difficult to get asymmetry when using armpit incisions and that 20% of augmentation patients end up needing a revision because the implants aren't placed evenly. I've also read that it is not possible to re-use the armpit incision so am wondering what Dr. K's plan was to eventually remove my implants all together? It also stated that there is a risk of severing a nerve which runs through the armpit which can result in permanent numbness to the arms. And, overall, this type of incision results in a higher loss of breast sensation even for augmentation patients. Since Dr. K touts his method as helping to return sensation to the breast it seems like this would be counter-intuitive.
You seem to have a strong loyalty to Dr. K, and that is admirable, but we all have a right to voice concerns without being labeled as someone "negative". Everything I have stated is fact and I do have some issues with things I have heard from others, too. To make changes to a surgical plan 15 minutes before surgery, or while the patient is under and unable to give their permission, is unacceptable no matter how brilliant the surgeon.
I, for one, no longer want to "beat this dead horse" so if anyone is interested in any more information regarding my personal experience with Dr. Khouri and the Miami Breast Center feel free to PM me anytime.
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