Using artificial skin(alloderm) for breast re-surgery [KIES-U Korea]

We have been using the artificial skin in breast revision surgery since the early 2000’s. It was first used for the breast cancer patients but then the usage has expanded into the beauty area and is now applied on the breast surgeries.



The artificial skin is made by pig skin but has been biochemically alternated to fit into a human’s body, therefore, it is different from Alloderm that uses the skin from a corpse.
Alloderm is a brand name and the product from the brand is called Strattice.
Today, we will look into how the artificial skin is used for the breast revision surgery.





There are many causes that lead to breast revision surgery, one of which is the capsular contracture.
Also there are other causes such as the position of the implant, implant defect, leakage, hematoma / seroma.

The artificial skin(alloderm) is used when a patient’s skin becomes really thin so that the artificial skin is necessary to cover the implant.

This usage is rather an additional measure for the breast surgeries.

The position of the implant, such as going too much to the inside, lower bottom, or coming out, can be a problem, but this is caused because the pocket is too large compared to the size of the implant. So the artificial skin(alloderm) is used as a barrier for the implant to be fixed at the most appropriate position.




Capsular contracture is the main cause of breast revision surgery. Usually, we will cut off the epithelium or remove it and also change the plane of the implant, i.e. depth, during the revision surgery. Alloderm used in this case means that the implant would be covered by the product.

The artificial skin(alloderm) minimizes the possibility of the capsular contracture, and acts as a barrier between the implant and the patient’s immune system. Also, through this, the epithelium becomes really thin.

As for the reconstructive surgery, the incidence rate of the capsular contracture is decreased from 10~16% to 5% when using the artificial skin.

The sagging of the breasts is caused because the skin becomes really thin after the breast augmentation. The skin becomes thin quickly if the implant is too heavy or as the patient gets older. Normally, one would consider breast lifting is such cases but we could use the artificial skin(alloderm) so that it supports the implant therefore avoiding the sagging breast.



Rippling and wrinkling: This is normally found with patients who are thin. We use the artificial skin(alloderm) by covering the implant from the top on the part where there is refilling or wrinkling.

Many patients apply the methods mentioned above for the revision surgeries. Statistically, we have seen great improvements with the capsular contracture, and some with the sagging breasts and the wrong positioning of the implants.

However, we see many recurrences of refilling or wrinkling even after the artificial skin so we do not have much statistically significant data for such cases.




Today, we looked at how artificial skin is used on the breast re-surgeries. In summary, we can say that the artificial skin is used only when it is necessary for re-surgeries or re-constructive surgeries. Also there is a high cost for it.

Thank you for reading. Have a great day.

Bleeding after breast augmentation surgery [KIES-U Korea]

We do not call bleeding and pain as side effects. We need to know the cause of these problems.
All surgeries have bleeding. A good surgery requires how effectively you stop or minimize the bleeding. So the important thing is that the surgery be done without bleeding.

Breast augmentation Korea KIES-U Dr. Lee

What happens when there is much bleeding?

If there is much bleeding or if the bleeding is not stopped during the breast augmentation surgery, the blood builds around the implant.

The blood from the blood vessel becomes solid, i.e. hematoma.

The body can take it naturally if there isn’t much amount of hematoma, however the body cannot take in large amount of it so there will be some hematoma left. The large sized hematoma can force the implant to move into one direction causing an awkward shape and can be a cause of infection or inflammation. It also leads to pain as there is much pressure from the hematoma build-up.

If the hematoma is build up near the dissected part, then it can penetrate through the skin, finally leading to opening of the wound and worsening of the scar.

KIES-U Korea Breast augementation

What do you do when there is much bleeding?

We can diagnose if there is a problem with bleeding from 0 ~ 2 weeks of the surgery. Abnormal swelling or pain, change in skin tone, infection or inflammation can be examined. If there is not much bleeding or if the side effect is not severe, we can put pressure on it and stop the bleeding. However, if we find that there is much bleeding then we need to remove the hematoma.

If the surgery was done on the areola or on the bottom line, we use the same spot to check on the bleeding, use galvanocautery, and quickly remove the hematoma.

But if the surgery was done through armpit or the belly button, we cannot use the same spot. We would have dissect the bottom line and remove the hematoma.

Breast augmentation Korea KIES-U

If we dissected armpit in the original surgery and there is much bleeding, we can open up the armpit again, clean, and use the endoscope to stop the bleeding. If we are lucky, the surgery would be a success, if not, then we need to pull out the blood for a week and pressurize the part.

In such case, although we have saved the implant, the patient feels much pain and loses sense for a long period. Also there is a high possibility of capsular contracture.

How to avoid bleeding?

In the first two weeks of the breast surgery, one must be very aware of one particular problem, bleeding.

In order to avoid such happening;
The dissecting area should not big. The space must be appropriate for the implant size. (Minimizing dissection technique)
The implant, itself, should not be too big. (Large implant requires large pocket that leads to more damaging of skin and blood vessels)
You need to get the job done by an experienced and careful surgeon.

Bleeding in revision surgery

If the revision is necessary due to the capsular contracture, we need to remove the formed epithelium completely causing much bleeding. So we do not completely remove the epithelium but leave some that would help the new implant fit into the pocket. Removing the epithelium completely can be an another cause of the capsular contracture and also we need to change the method in order to minimize the bleeding as well.

Breast augmentation Korea KIES-U

One must be very careful about the bleeding in the breast surgery Bleeding can lead to other problems such as capsular contracture, infection, implant collapse, scar, opening of the wound, etc. The bleeding during the revision must be controlled properly as well. The result of the uncontrolled re-surgery would be obvious.

This is all for today. Thank you.

Selecting the Implant Height in Breast augmentation with anatomical Prosthesis

[KIES-U Korea]

Here in Korea, we have a short history of using tear-drop implant breast augmentation, therefore we limited know-how in various types of surgeries. In oppose to this, tear-drop implants have been used in Europe and North America for almost 20 years. Therefore, these countries have built-up knowledge and data that are important for the surgeons.
Today, we will look at a publishing by Jose Martin del Yerro, M.D from Spain and also criticize on it.




The satisfaction of breast augmentation is highly correlated with the beauty of the breasts after the surgery. This is because when you wear clothes, the upper breast can be seen easily and also the one can see the shape of the cleavage.
So this important upper breast is composed through the height of the implant, however, there isn’t much mentioning about it. The doctors do not consider this much and so does the patients.

Dr. Yerro published a paper that states that the height of the implant should be selected according to the body type.

Kretschmer and Sheldon were few of the people who divided the ‘body type’ into three. In easy terms, the types would be ‘thin’, ‘normal’, and ‘obese’.
Dr. Yerro stated that the pocket of the implant of a thin person is shaped oval vertically, round for normal person and a horizontal oval shape for those who are obese.



And through many analysis, he found that the ‘normal’ type is the majority, and the other two types of ‘thin’/’obese’ are rare. This is why there is much usage of round type implants rather than the oval shaped ones.

Dr. Yerro published his paper based on the analysis of 5123 patients that he has worked with for 13 years, starting from 1998.
This means that the thoracic perimeter has been divided by the distance between the center of the collarbone and areola to determine the height of the implant.




The result of the data can be seen in the image above. The ones with the ‘normal’ body shape were the most and the average length of the thoracic perimeter was found to be 80cm, with the average of the collarbone-areola distance being 20cm. Also, the round shaped implants were used the most.

I think that Dr. Yerro’s findings are very important in how we select the height of the implant. There aren’t many surgeons in Korea who are much experienced with using the tear-drop type implants. These surgeons only focus on the fact that they are using this type of implants and do not consider important 3 dimensional variables including the height.

 Dr. Yerro’s findings are not directly related to how we do things here in Korea, so some findings feel unrealistic. The biggest difference is that the Europeans and Koreans have different body types. My personal statistics show that the patients who want breast surgeries have average of 17.7cm in distance between the collarbone-areola, so this is much different from what Dr. Yerro has announced.

Also the thoracic perimeter is not as large as the average of 80cm. Most of these patients have very thin thorax as well. Many people with large thorax and those who are obese do not need breast surgeries.

One needs to know that most of the Korean women have short thoracic perimeter and narrow breast diameter. So, when we consider Dr. Yerro’s data, most of the patients that we have are composed of those who have ‘thin’ or ‘normal’ body type.

This means that most Korean patients need to use the vertical oval shaped implants





I will write another post to explain about how to select the appropriate height of the implant according to the various different types of the implant at a later date.
However, much of Dr. Yerro’s findings are those that have been neglected in our country, and I, personally, was glad to see such findings.
This is all for today.

Thank you.

Feeling of touch after the breast augmentation

There are three things that interest you the most when doing breast augmentation; shape, volume and feel. Today I would like to talk about this “feel”.
There are common questions that the patients ask about “feel”. Below are the questions.

1. Does smooth feel better than textured?
2. Does tear drop shape feel better than round type?
3. Does the touch (feel) get better with massage?



I sure that some of you have already realized what I am trying to say. We cannot say those 3 things above for sure.

Which implant has the best feel? 

The implant with the best sense of touch is not cohesive gel but basic silicone gel implant.


There are many who studied through the internet but do not know anything about cohesive gel.

Cohesive means cohesiveness. Cohesive refers to sticky silicone gel.

Why was it made this way?

This was made to avoid leakage of the inner substance when the exterior gets damaged.
The stickiness makes the substance stay together so that the substance does not come out easily. This helps maintain the shape of the implants and makes it more durable also.




The old type of silicone gel did not have any cohesiveness.

These products are not compact but disperse easily. Of course, these products are not manufactured any more.

But which do you think feels better? Cohesive gel or this old type gel?

I think everyone can guess the answer. The answer is the basic old type gel. Less cohesiveness, i.e. easily dispersed product leads to a softer touch and jelly like feel.
Cohesive gel cannot have a good touch feel compared to the old type. It has substance stuck together that does not disperse easily.

The first truth is that “Cohesive gel does not have good feel.” The implant with the best touch is the illegal liquid silicone.




The implants advertised on the natural feel and touch at first, but changed to focus on the safety and durability.

The conclusion is this. Why do we not use the liquid silicone or the old type? Although these feel better?

It is because these products have low safety and low durability. If the exterior is damaged, the substance inside leaks out and as a result, the shape is damaged also.

These implants have less durability so the re-surgery is necessary. This is why we hear that “the implants need to be changed every 5 years.”

The implants originally focused on the sense of touch but after the regulations set by the US FDA in the 1990’s the implants have been focused on the safety and durability. This is how the “cohesive gel” entered the market.
 


 
Differences between the round type and the tear drop type

Let’s talk about the 2nd “truth”. The implant that feels good has less gel inside it. Most of the round type implants imported to our country has less gel on the inside.
Let’s think about a balloon that is fully filled with water and the other that is less filled. Which do you think feels better? Of course, it would be the one with less water filled.




Most of the imported cohesive gel implants in our country are less filled also.
In opposite, most of the tear drop type implants imported since last year are much filled.

Allergan tear drop implant has the most cohesiveness. If you touch it, it feels hard. Polytech implant is one that is filled the most.

In conclusion, the round type implants in Korea are not fully filled and have less cohesiveness therefore; these implants feel “good”.

But the truth is that it does not matter.

There is not much difference. All cohesive gel implants are alike. The cohesive gel implants are not focused on this sense of touch.

The implants should not only focus on marketing the parts that attract the customers.

In order to feel good, dissection must be done properly and the appropriate level of epithelium must be maintained.

The sense of touch is not depended on the manufacturer.
This depends on how careful the surgeon is rather than which product has been used.





One must select an implant based on the durability, product life, possibility of getting damaged, shape stability, etc.

There are some patients who say, “I want to use the tear drop type, but I am hesitant to use it because I heard that it does not feel good.”

A patient needs to use the tear drop type if it is necessary to use it. This is not similar to shopping where a customer chooses and buys the one that she likes.

An implant, once put into the body, needs to stay in the body for a long time therefore, it is important that you have the accurate information when selecting one.

This is all for today.

Thank you for reading.

Does Breast Implant Manufacturer Matter?

Currently in 2015, there are about 5 companies that import implants to our country.
There are many products therefore it is difficult to know the characteristics of each of these products.

I get surprised at times when I talk to the patients. They ask me things that they have heard elsewhere such as in other clinics or the internet. It saddens me that there isn’t accurate information out there.

Below is the review of the products that these companies are selling.




1. Allergan 

The manufacturer was originally called Natrelle. But, Botox manufacturing company, Allergan, acquired the company and changed its name. It is a US market leading company along with Mentor.

The first 5th generation cohesive gel is Style 410.

It is a very tight, tear drop shape cohesive gel. It is obvious, but this product is very stiff.
Also most of the Allergan implants are not thick therefore does not have much volume. Most of the implants are not shaped round but are in oval shape.

As there were words that Style 410 is very stiff, the company produced a new model, Soft touch, and started selling it in the market. Soft Touch is softer than Style 410 and therefore provides that softer touch also. However, this soft feel is not all that good because it could give an impression that the product itself it not durable. The pros and cons of Style 410 are clear. If you have a severe case of sagging breasts then it would be good to use Style 410 that has stable shape.



2. Mentor 

Mentor is a US based company and has been a dominant one, along with Allergan, for a long period. Mentor implants are smoother compared to those of Allergan. Also these implants have less rough textures as well.

Allergan’s textured surface is rather rough. (The engineering method in the manufacturing plants leads to differences in the textures.) So, the skin does not grow into the implant. This has led to critiques that the implants may not be able to avoid the capsular contracture. However, I think that this is not true because there aren’t many statistics that prove the texturing prevents capsular contracture. So this cannot be the problem of the Mentor implants.

The top part of the Mentor tear drop implant seems a little thick. Although the shape is tear drop, it seems closer to a round shape.





3. Silimed 

Silimed is a No. 3 company after Mentor and Allergan. The HQ is in Brazil and has an office in California, US.

The characteristic of this product is that the top part is very sharp and thin. This leads to the upper breast line looking more natural. Silimed is more intense compared to Polytech and softer compare to Style 410.

There are many who say that this is a bad product because the company is from Brazil, but this is wrong.

It received US FDA approval earlier than Mentor, and Allergan. There is no proof that Silimed is worse than mentor or Allergan.



4. Sebbin 

Sebbin is a French company. It is a different one from the other French implant company that had a CEO sentenced for using cancer causing substance.

Sebbin has round top that is similar to Mentor. It is rather roundly shaped although it is a tear drop shape implant. The density is similar to Silimed and Allergan Soft touch.

There isn’t one dominant French company but there are many small sized ones across the Europe. These companies include Arion, and EuroSilicon, that do not have much presence at our country.




5. Polytech 

Polytech is a German company. It has the softest product, and can be put into the pocket easily. The sense of touch is as good as the round type but the stability of the shapes is not as strong therefore, it is difficult to say that this is a definitely a good product.

Polytech’s textured surface is rather smooth therefore many doctors thought that the interaction between the epidermises would be less likely. This can be both pro and con.
Polytech has many product categories. It has the most number of product types and it is rather surprising that Polytech products all these products.

Polytech is famous for its polyurethane exterior that avoids capsular contracture, but we do not know when this would be approved in our country and enter the market. This is necessary product for the re-surgery patients but it is sad to know that we cannot use it.

 
So we looked at 5 implant manufacturing companies. Which one do I like? I do not prefer any over another. I use them all. I need to choose the one that is most fitting for the patients.

The implants that you use do not decide the outcome of the surgery. The surgeon needs to match the implant and the body properly in order to get the best outcome.

This is all for today.

Thank you for reading, have a great day.