28 March 2016 Inside Cosmetic Surgery Today on WebTalkRadio.net
Interview with Dr Barry Lycka & Dr Roger Khouri
Dr Barry Lycka cosmetic dermatologist from Edmonton, Alberta is talking today with
Dr Roger Khouri board certified Plastic Surgeon from Miami, Florida.
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please email Dr Lycka on [email protected].
We are talking today with an expert in breast augmentation, particularly using the body’s own fat to replace breast
tissue for a number of reasons – maybe one that never fully developed or one that has been damaged by cancer. Roger
has developed a successful method for performing this procedure.
Welcome, Dr Khouri!
How long have you been working with fat augmentation for breasts?
About 12 years. The procedure always made sense when we discovered liposuction but when it was first tried in the
early ‘80s we had disasters. So it was banned by the American Society Of Plastic Surgeons and therefore for a long time
nobody performed the procedure. And Dr Khouri picked it back up again about 12 years ago because he realized that
with proper technique and proper understanding, we could have excellent results. It makes the dream come true of
removing fat from where you don’t want it and using it in the breasts.
Standard augmentation has a lot of problem associated with it, doesn’t it?
Standard augmentation with silicone implants is a procedure that has stood the test of time. And in USA alone, there
are many hundreds performed. But the main problem is that we are putting in a ‘foreign body’ into the breast and so
it is unrealistic to expect 100% of patients to do well with a foreign body in their breast. There will be some that have
problems, and have a reaction. So a small percentage have problems with their implants, but since there are millions
of implants, that is still a sizeable number of women affected. So this is an ideal solution of replacing the implants with
their own fat.
It is a really appealing idea. Fat is moldable, it does very well. And sometimes the biggest problem is finding enough
fat to do the procedure with, especially for fairly thin people.
Well we have ways of harvesting fat even out of thin people! Even 1mm out of a palm is 20ccs! The trick of course is to
harvest with a very thin cannula by hand, with simple needle sticks. We don’t use the hoover machine. We are very
gently taking the fat out 1cc at a time. We need it to grow back when it is transferred elsewhere in the body.
Yes, that is certainly the key with all fat augmentation. It is the fat harvesting. The cells are living structures, so we really
have to treat them with some respect. And of course, knowing how to put them back is also a key element of this
procedure. It is very tricky and has to be done with a lot of craftsmanship. To get fat to survive is a bit like a farmer
planting seeds in a field. Firstly, we need to have ‘good seeds’ – we have to harvest the fat gently. But we also have to
have a field that is large enough, fertilized, and prepared to accept those seeds. Even the best seeds in the world will
not grow well in a small rocky plot! So preparing the breast to enable more fat to be input is important. We also have
to plant the seeds properly – one by one, not just put them all in one corner.
Dr Khouri found a way to prepare the breast so it was better prepared to accept the fat cells. He found a special
instrument called the Brava, to prepare the breast.
Yes, exactly – it enlarges ‘the field’, increases the blood supply so that the fat cells have a very good chance of surviving.
Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Roger Khouri, 28mar16
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Please tell us a bit about the Brava?
Brava is basically a bra that women wear over their breasts which is connected to a little suction device which exerts a
gentle force which stretches the breast tissue. There are a lot of biomechanics in there - if you just put a suction cup
on the breasts it will hurt like hell! There is a gel surface that interfaces with the skin and prevents it from being bruised,
and shredded by the pressure being applied to it. So it is a well-engineered device that has been around for 20 years
or so. It helps apply the tension on the breast that is required to enlarge it. It is worn a few hours a day, over a couple
of weeks, then the breast is significantly enlarged. It is enlarged only with edema – we haven’t grown the breast yet as
it takes a long time to grow breast tissue. But that enlargement, creates a larger field for the fat cells to be transplanted
into.
Well that makes a lot of sense. Suckling from a baby causes a breast to grow so constant slow steady pressure would
be a smart thing to do.
Yes, we know that tissue grows under mechanical tension. That is how we grow as children – a growth plate stretches
our bone and we grow. If that is destroyed, then that extremity will not grow. There are many medical devices based
upon that principle. Cells don’t like the feeling of being stretched so they multiply.
This idea of fat transplantation was turned down by plastic surgeons in general. Have they re-thought this issue at
all?
Yes.
In 1987 it was decided that it wasn’t appropriate to put fat in the breast. The procedure was banned.
It is only recently, 12 years ago, that Dr Khouri performed a well-controlled study to prove that if you use the Brava
device and prepare the breast properly, and the technique is correct, then it works, and is safe.
What other things, apart from the Brava device, are important?
Well harvesting the fat cells carefully, but just as importantly a doctor has to have the craftsmanship, the technique to
deliver these cells one at a time. It is not possible to inject many cells at once and expect them to survive. We have to
diffuse, spray in a fine mist of fat droplets, so every little droplet has a chance of interacting with the tissue around it
and take root and survive. This is important because the fat cells when they are input into the tissue, they need to get
a blood supply to them, which has to grow and nourish each cell.
Dr Lycka finds it interesting that once the fat cell is established, then it can grow – so if a person gains weight, then
those cells in the breast will grow as well. Yes, the fat remembers where it comes from. So fat from the abdomen will
grow tremendously. Some fat cells don’t fluctuate at all – and others will fluctuate with every BigMac! Ideally we take
the ones that DON’T fluctuate.
What are the best areas to harvest fat for this?
Well it depends from patient to patient. If they have a localized area of excess fat and they would benefit cosmetically
from removing it, then that is where we would go. Otherwise, if there is no particular lipodystrophy, (the abnormal
distribution of fat) then we go wherever we can, but we prefer to take the fat that will not fluctuate.
Fat is often viewed as being terrible, but actually it is rich and full of goodies, and can be used to great effect for
rejuvenation and replenishment. When we get an injury, there are stem cells in the tissue that makes the repair.
Grafting (transferring) the fat also brings in these stem cells.
Dr Khouri, are there special situations where you use fat to re-create the breast?
A lot of what Dr Khouri does is restoring breasts lost to cancer, through mastectomy. And here it’s not about cosmetic
improvement, it’s a lady who has lost her breast from illness. We can grow back her breasts!
Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Roger Khouri, 28mar16
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It is a terrible thing when a woman loses her breasts like that and Dr Lycka has seen patients who have been told
elsewhere that nothing can be done afterwards! Is that true, Dr Khouri?
No. That’s very sad. Dr Khouri can always do something. Typically, Dr Khouri is the person people come to when they
have been told there is nothing that can be done. So it is important for listeners to understand that there is always
something that can be done. There are women born without breasts - there is a syndrome that describes women born
without a breast or with very deformed breasts. And even for those unfortunate ladies, we can give them back a breast
and restore their confidence and self-image, and to help them feel more normal. That is very important. The alternative
ways before were with either an implant or a big flap operation but the beauty here is that without any incisions,
without any sutures, without any new scars, we can with just a needle and syringe take the fat and make it grow
somewhere else, and restore the breast.
Dr Lycka had a situation recently when he was doing a fat augmentation, in a lady that had small breasts. She really
didn’t have much fat left so she went away, gained 20 pounds, so he was able to harvest a superb amount of fat and
do a phenomenal job for her. So even if a person has to wait a while, there are things we can do.
Who is the ideal candidate for this procedure, Dr Khouri?
Well we have some contra-indications for this procedure.

If a patient is smoking, we can’t do it. Dr Lycka is so glad that Dr Khouri mentioned that because smoking robs
the body of a good blood supply, and prevents the fat cells from taking and growing.

We can’t do it for someone who is expecting a HUGE result. There has to be realistic expectations. If an implant
is being used, an implant can be 500ccs, 800 ccs, and so in one procedure… Boom… there is a massive
enlargement. We cannot gain that much per procedure. So the patient has to realize that and be realistic in
their expectations.

And the other important thing is that the patient has to realize that they are part of the cure. Unless they spend
time and expand their breasts with the Brava, then we can’t put more fat in. The limit to how large they will
be is how large they come to the procedure after the use of the Brava.
Are there some situations that you would recommend a standard implant procedure over this fat grafting
procedure?
Obviously most patients who want augmentation will choose silicone implants. It’s a simple procedure, and it’s more
predictable. The problem is as we mentioned before is that it is a foreign body and some patients don’t want a foreign
body in their body. So the patients who go to Dr Khouri are already pre-selected, they want to have the fat transfer. Dr
Khouri does mostly fat transfer natural breast enhancements now, although there are instances where he will combine
fat with an implant. An example is with a very skinny girl with no subcutaneous tissue. Just using an implant would
look fake, as there is no way to hide it, so putting some fat around it helps to camouflage the implant and make it look
more natural. It is a good idea to combine fat and implants.
Yes, combination procedures in medicine are really a better idea, than just doing one thing vs. the other.
Is there any advice you want to give to our listeners today? If someone is thinking about this procedure, what should
their next step be?
Dr Khouri recommends that people take a look at his website - http://www.miamibreastcenter.com/ - which explains
a lot of things about this procedure. It is very comprehensive, with lots of information about the different situations
and procedures. If they feel they are a good candidate, then they should call for a consultation to discuss it. Then he
can determine if they really are good candidates. Dr Khouri mostly treats ladies with implant problems – whether its
mastectomy implant problems, or cosmetic implants. And these patients don’t need to use Brava because they have
already been stretched by their implants. The other categories who Dr Khouri takes care of are the ladies who have
lost their breasts due to cancer, and thirdly, those ladies who just want larger breasts but who don’t want an implant
for their augmentation. In those cases, they would need to wear the Brava expander and invest some time to create
a larger area for the fat to grow in.
Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Roger Khouri, 28mar16
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This procedure is wonderful in that there is no incision, and really aren’t any marks left because very tiny cannulas are
used, so when the breast heals there are no marks left. And when an MRI is done, it’s just normal fat in there.
Is it possible to get a huge breast just by doing fat augmentation? Are there limitations to the sizes that can be
achieved?
Yes, there are limitations, but having said that, because Dr Khouri deals mostly with mastectomy, those patients want
a breast to match the other side. They can get there – but not in one procedure. Dr Khouri will serially add more fat in
a number of small procedures, and then the patient can get to a D or DD cup.
That is the key – a person shouldn’t expect this to be one procedure. They have to think of it as a series of procedures
to get the best result for them.
Please can you summarize the contra-indications for this procedure again, Dr Khouri?

Smoking

Unrealistic expectations

Not willing or able to comply with the use of the Brava device to expand their breast before the procedure. It’s
not painful BUT it is a commitment.
So one thing we should go through. Let’s suppose a person has lost a breast due to cancer surgery. What is the length
of time after a mastectomy that a person should wait before they get a fat reconstruction procedure?
Well ideally it should be done at the same time as the mastectomy. We put in some fat at the same time as the
mastectomy. They wake up after mastectomy with a small breast and so with a series of sessions, we gradually increase
the size. Reconstruction after mastectomy is rarely a single procedure. It typically takes a series of 3 grafts to regenerate
the breast after surgery. That is if the breast is not radiated. If they have radiation x-ray treatment, it can take up to 5
or 6 procedures to grow back a healthy breast that matches the other side.
Of course it all depends upon the treatment – chemotherapy, radiation, surgery, or combinations of those. And this
should be talked about in advance, with the doctor initiating the cancer surgery as well as doctors such as Dr Khouri.
It is very important to realize that they are not done in isolation. It really is a team effort.
Well thank you very much Dr Khouri for taking the time to help educate our listeners about this topic. This show gets
to a lot of people which means they are able to make informed decisions as a result of listening.
Well thank you, Dr Lycka for making this show available, and for helping to increase patient awareness.
Contact details for Dr Roger Khouri & Dr Barry Lycka:
Dr Roger Khouri
Telephone: (888) 355 8095
http://www.miamibreastcenter.com/
Dr Barry Lycka
Telephone: Edmonton: (780) 665 3546
http://www.barrylyckamd.com
Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Roger Khouri, 28mar16
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