Augmentation Options: Dr. Mancoll Talks a “Two-For-One” Solution

 Composite breast augmentation can be a “two-for-one” solution for some patients, but it is not without risks.

Bring up the topic of fat, and many women will joke that they wish they could move the fat around their middles to their breasts. Now that may be possible.

The composite breast augmentation, whether for cosmetic purposes or for reconstruction following breast cancer, can help produce a more natural look than breast implants alone, say some Coastal Virginia plastic surgeons. It can also act as a “two-for-one” procedure, in that liposuction reduces unwanted fat in problem spots, often the abdomen, thigh, hip or “love handles” areas.

The technique has been used for breast cancer reconstruction for more than a decade, but using it for cosmetic purposes is relatively new in the past few years.

“Augmentation has always been difficult for folks when they have something called constricted breast deformity, also called tubular breast deformity, when the bottom portion of a breast doesn’t develop three-dimensionally,” says Dr. John Mancoll of Mancoll Cosmetic and Plastic Surgery in Virginia Beach.

Mancoll says the condition is not uncommon, and many women don’t realize they have it. They only know that they aren’t happy with their breasts.

“You can put an implant behind the breast and the top and sides will expand nicely, but the bottom will still be very taut. By interlacing some fat into the breast pocket, you can fill that in and round it out better and get a nicer look.”

Other women will opt for the procedure when they are concerned about rippling, which frequently occurs with implants. “If you add a little bit of extra fat in there between the implant and the skin, you can mask the edge of the implant and hide some of it.”

Lambros Viennas, chief of the Division of Plastic Surgery at EVMS, says he frequently uses the procedure to improve symmetry. “Many patients have some degree of breast asymmetry due to breast size and shape,” he explains.

“Implants come in certain sizes, and they may not match perfectly with what the patient is trying to achieve. That’s where fat grafting comes in—it allows the plastic surgeon to adjust the shape of the breast by adding increments of fat to the breast where needed.”

Both surgeons say breast augmentation is generally not done with fat grafting alone—the implant is still needed. “You have a limitation of how much fat you can place in the breast,” Viennas says. “If you put too much, the blood vessels don’t have the opportunity to infiltrate and feed the fat cells, which then die.”

However, he says there are methods to optimize the viability of fat grafts including harvesting the fat and injecting through small tunnels into the breast to allow for blood vessels ingrowth into the fat cells. “With fat grafting you may gain a half a cup size. To make a noticeable difference, you have to rely on the prosthetic implant as well.”

“Fat is just not a substitute for an implant,” Mancoll says. “But it’s a nice alternative for women who just feel they’d rather go the more natural route. I explain to my patients that only about 50 to 60 percent of the fat survives the transfer. The rest is usually absorbed into the body.”

While there are advantages with composite augmentation, there are also disadvantages. Cost is one. “It costs more because there’s more work involved,” Mancoll says. “And the risks are higher.”

“While the procedure is pretty straightforward, there can be complications from liposuction in inexperienced hands,” says Viennas. “Liposuction, if not performed correctly, can produce depression and deformity at the donor site.” He says infection and blood loss are always a risk with any surgery, and there’s a risk, although rare, of fat embolism syndrome when fat is inadvertently injected into a blood vessel, which can be fatal.

Both physicians emphasize the necessity of working with board certified surgeons who are highly experienced in the procedure. “It’s really important to ask your surgeon, ‘How many of these procedures do you do?’ ‘Do you do it now and then, or is it routine?’,” says Mancoll. “Like anything in medicine, there’s a broad spectrum of what plastic surgeons do. Just because we carry the title of plastic surgeon doesn’t mean we do everything.”