The typical appearance of a single fat grafting treatment is demonstrated in Figure 1. The patient presented for a primary silicone gel breast augmentation procedure with a 450 cm3 smooth silicone gel implant. Preoperatively, her left inframammary crease was noted to be 1.5 cm higher than her right. Postoperatively, the double-bubble can be visualized on the left side as shown in Figure 1B and C. After a single fat graft procedure of 28 cm3 volume at 3 months postoperatively, partial improvement is noted, as shown in Figure 1D and E. The patient desired a larger implant with a textured surface, and an implant exchange for a textured 550 cm3 silicone gel implant and second fat grafting session was performed, placing 18 cm3 of fat. The double-bubble was managed by fat transfer only, with complete resolution of the deformity at 6 months after fat transfer, as shown in Figure 1F and G.
A more complex case is presented in Figure 2. A patient presented with a history of hypomastia and ptosis, treated with a subglandular breast augmentation performed elsewhere. She developed grade IV capsular contracture which was treated with movement to a subpectoral pocket without mastopexy. The patient presented to the practice with a grade II encapsulation and bilateral double-bubble deformity as shown in Figure 2A and B. The patient liked the position of her implants and nipple/areolar complexes and requested correction of the double-bubble. She was treated with 3 sessions of fat grafting bilaterally at 3-month intervals. The first grafting session placed 35 cm3 of fat bilaterally, followed by 28 cm3 in a second session, and 17 cm3 in a third and final session. Good results at 1 year after the 3 stages of fat grafting are demonstrated in Figure 2C and D.
A dramatic case is presented in Figure 3. A patient with hypomastia and breast ptosis who declined mastopexy, presented after breast augmentation alone. She demonstrated severe double-bubble deformities as shown in Figures 3A and 3B. Following three fat grafting procedures, and with five years follow-up, resolution of the double-bubble deformities and long-lasting correction is achieved as shown in Figures 3C, 3D, and 3E.
Patients presenting with postoperative double-bubble deformities after breast augmentation have had few options for correction without major revisional surgery and open procedures under general anesthesia. In this paper, a series of patients are presented who underwent correction of the double-bubble deformity successfully, with simple, closed, fat grafting procedures done almost exclusively under local anesthesia. Although the techniques presented are basic technically, this is the first series demonstrating the effectiveness of fat grafting the double-bubble area with MRI documentation of procedural safety for patients at the greatest risk of implant injury or perforation. The fat grafting technique is technically straightforward and well accepted by patients. Patients can see the results of the procedure immediately, and view the early results on the first postoperative day. With a quick recovery and limited discomfort during the postoperative period, patients are likely to request a second procedure to further improve their results. Our experience is that patients are very grateful for the correction, and most patients can be satisfied with 1 or 2 treatments.
We advocate the addition of small volumes of fat graft directly beneath the old inframammary crease to improve the long-term viability of graft material and reduce the risk of oil cysts or fat necrosis. The lack of oil cysts or palpable fat necrosis in this study may be due to the small fat volumes and the injection techniques used. The potential space for injection in many patients is quite limited, usually 3 to 4 mm of depth. Longitudinal injection technique is important to reduce deep injection. Deeper injections increase the risk of implant injury. It is also important to displace the implant superiorly away from the injection site and to lift the skin upward and away from the implant. These simple maneuvers may reduce the risk of implant perforation or injury. In our study, 12 patients with thin breast skin flaps at the double-bubble site underwent postprocedure MRI scans, and no evidence of implant disruption or perforation was noted. These were the patients most at risk for implant injury due to the thin nature of the soft tissue.
Capsular contracture of the breast makes fat grafting the old inframammary crease area at more risk for implant injury or disruption. We believe that it is important to displace the implant as well as elevating the skin away from the implant when injecting fat. With tighter breast pockets, it is more difficult to keep a safe distance between the injection cannula and implant. Currently, we do not perform the fat grafting procedure for patients demonstrating either Baker III or Baker IV contractures. In addition, patients who demonstrate textured implants with tissue adherence and thin overlying soft tissue flaps may be poor candidates for fat grafting the double-bubble due to increased risk of implant injury. For patients with textured implants with tissue adherence and thin overlying flaps, an open procedure, with or without fat grafting, may be the safest option.
From a medical-legal point of view, it is reasonable to suggest that a preprocedure MRI may be useful to document the condition of the breast implant before fat injection procedures. Plastic surgeons should weigh the advantages and disadvantages of this treatment option. Cost and other factors may limit pre-fat grafting MRI. In our practice, we have not found pre-fat graft MRI necessary. We explain to patients that there is always a small risk after primary breast augmentation that their implant may have a disruption. Manufacturing defects, trauma to the implant on insertion, injury to the implant on wound closure, and other causes can lead to implant disruption in a primary augmentation. The addition of injectional fat grafts certainly increases the risk of implant injury and perforation. Although the 12 patients undergoing MRI evaluation at the conclusion of fat grafting did not demonstrate implant injury or disruption, it is possible that the patients who did not elect to undergo MRI could have had a subclinical implant disruption. Therefore, the results of the MRI portion of this study suggest that the procedure may be safe in regard to implant integrity but does not quantitate or predict the risk to the implant. If desired, post-fat grafting imaging is more useful in evaluating the implant condition, but does not document that the implant was injured from the fat grafting procedure. We use a detailed informed consent in which a patient agrees to accept the risk of implant injury and disruption with fat grafting to the breast, as well as the costs involved in corrective surgery. The consent also reviews that the results of an MRI done after fat grafting may not provide a causal relationship to the procedure itself and can give a false positive.
The formula used in this study to estimate the volume of fat graft to be transferred with each treatment was developed after several years of experience with fat grafting the double-bubble deformity in augmented patients. It uses an estimation which provided favorable injectional volumes, good clinical outcomes, and minimized complications. Although most surgeons would describe the double-bubble as a rounded trough-like deficiency, volume estimation, using a simple elongated rectangular deficiency, (length × width × height), was chosen to simplify estimated calculation volumes. A factor accounting for the lack of graft density (times 2) and resorption estimation (times 2) were added to improve clinical outcome. Although this formula provided a “soft” numerical estimation of fat volume to be injected with each treatment, it was useful in individualizing volume needs for each deformity and provided good clinical results. Future study of double-bubble volume deficiencies with mathematical modeling may provide for more accurate estimation of fat volumes for transfer.
The data presented in Table 1 shows that the majority of treated patients required 2 treatments to achieve good results and patient satisfaction. A smaller group was treated with a single fat grafting session, with the minority treated with 3 sessions. The patients benefiting from 3 sessions tended to be patients with more severe bilateral deformities as demonstrated in Figure 2. Table 2 shows that patients requiring multiple fat graft sessions required less mean fat per treatment, when all sessions are averaged, than patients undergoing a single treatment. This makes sense as the fat grafts from each treatment will decrease the double-bubble deformity to some extent the residual volume deficiency with subsequent treatments.
The fat grafting procedure for treatment of the double-bubble deformity allows surgeons to make changes not easily achieved with other techniques. Invasive techniques, such as elevation and reconstruction of the inframammary crease for treatment of the double-bubble, are more likely to be associated with longer recovery times, more postoperative pain, increased risk of capsular contracture, and relapse or failure. Scoring of the breast parenchyma or old breast crease can thin the soft tissue in the lower pole, increase implant wrinkling, visibility, and still not fully correct the double-bubble. On the other hand, fat grafting is less likely to worsen the deformity and offers a faster and more pleasant recovery. The downside of fat grafting includes resorption of the graft, risk of implant injury, fat necrosis or calcification of fat graft material, and donor site problems. Even with these potential issues, the risks of fat grafting are likely more minimal than those of major implant revisional surgery. This is supported by the lack of complications in our study. We suggest that the more invasive procedures may play a role in more complex deformities, such as double-bubble deformity associated with implant malposition or animation deformity, not correctable with fat grafting alone.
Fat grafting for treatment of the double-bubble deformity is a simple technique which is highly effective in reducing the severity of the deformity. With staged procedures, the double-bubble can be effectively treated to the degree desired, and often eliminated. We believe that aesthetic breast surgeons should consider this technique for treatment of the double-bubble deformity.
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
double-bubble deformity; breast augmentation; breast augmentation complications; fat grafting; breast fat grafting; breast implant complications; treatment double-bubble deformity; treatment double-bubble