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Smooth operator: Fat transfer replenishes breast tissue volume to avoid post breast augmentation rippling

Article-Smooth operator: Fat transfer replenishes breast tissue volume to avoid post breast augmentation rippling

Key iconKey Points

  • Rippling is a common, undesired outcome of breast augmentation surgery
  • According to one expert, fat grafting is a simple corrective procedure that can be performed safely and effectively, achieving excellent aesthetic results


SANTA MONICA, CALIF. — Post breast augmentation rippling occurs more often than most cosmetic surgeons would like to admit. To prevent this unwanted adverse event, one surgeon expert maintains that approach — both patient and surgical — is crucial to achieving aesthetic success with breast augmentation procedures.

APPROACH DEBATABLE Rippling can be caused by thin breast tissue (less than a 2-cm pinch), thick-shelled implants, a supramuscular implant approach, a vacuum effect within the pocket created during surgery, implant collapse with resultant negative traction or a textured implant pulling on tissue when it collapses.

"Many surgeons who anticipate that a patient may have rippling will place breast implants underneath the muscle, using the muscle as a superficial top coverage to prevent this disfiguring adverse event," says Mark Berman, M.D., F.A.C.S., cosmetic surgeon, Santa Monica, Calif.



"The problem with this approach is that a lot of patients have breasts where the implant used is a lot smaller than the space of the pocket created during surgery. That may be fine for some but not a solution for all cases, as rippling may still occur, even with a submuscular approach."

According to Dr. Berman, there is an increasing trend for surgeons to use the supramuscular approach. While the submuscular approach may preclude rippling, the aesthetic outcomes are frequently unnatural and patients are simply not satisfied with the cosmetic results. Though opinions differ, Dr. Berman believes that a submuscular approach does not significantly impact capsular contracture rates, nor does he feel there is firm evidence to prove that this approach significantly compromises the accuracy of mammography examinations.

According to Dr. Berman, rippling will not occur if the breast tissue is thick enough. One of the fat grafting techniques he uses increases breast tissue thickness by transplanting fat into the subcutaneous space, especially in the superior part of the breast.



First, Dr. Berman harvests the fat using the Lipivage™ system (Genesis Biosystems; Lewisville, Tex.). Next, he makes a small incision at the areola and using a Coleman or Tulip cannula, he uniformly fans the fat out to the superior pole of the breast, like the spokes of a wheel, to thicken up the breast tissue (see figure). Approximately 30 cc to 40 cc of fat could be enough for the average breast to thicken the superior pole sufficiently to reduce the rippling.

"You just need enough thickness of tissue so that when the breast implant collapses, the vacuum effect it is causing is not enough to drag the tissues down with it. If the skin is too thin, the vacuum effect is more substantial. In my experience, only a couple of treatments are enough to correct the rippling," Dr. Berman says.

CHOOSE WISELY According to Dr. Berman, many years ago, no one really heard of rippling — probably because the available implants were really thin-shelled, as opposed to today's implants which are larger, stronger and thicker. Dr. Berman explains that a thin-shelled implant collapses in such a way that it does not result in the vacuum effect on the tissue that causes rippling. By contrast, some shells today are so thick that when the implant collapses the shell collapses and there is essentially enough force from that shell and the vacuum effect to pull the skin in.


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