Q) If the revision surgery is necessary, who takes care of the cost? Is it the clinic or the patient?

A) This is a frequently asked question. I would like to discuss about this today.

There are many things to consider when answering this question so I would like to divide the content into several parts.




1. Does the 'Surgery cost’ include the costs that are related to the problems after the surgery? Or is it just for that one time surgery?

2. Which party covers the medical costs when there is a medical accident and when there isn’t?

3. If the hospital is responsible for the problems caused after the surgery in terms of number of days responsible, how long is this duration?

4. If there is a conflict between the patient and the hospital regarding the amount of costs that each are responsible for, how can this be solved?


I would like to summarize these contents as below..

1. Does the 'Surgery cost’ include the costs that are related to the problems after the surgery? Or is it just for that one time surgery?




Let’s say that you are purchasing a car or any other industrial product. There is a warranty period for the product that you are purchasing.
Hyundai cars have warranty period of 3 years or 60,000 km.
Of course, this warranty or the free after service is not available, if the driver is at fault. If you get into an accident by yourself, you will not be able to get the free after service although the car has been purchased for less than 3 years.

You can regard this as the the automobile maker has already included this 3 year warranty costs into the price that the customer is paying..

Other industrial products such as TV, home appliance, notebooks, digital cameras, etc all have this free after service and this means that all these products have the after service costs covered in the final price.




But, there is no such term as “warranty service” in the medical industry.

Let’s say that a patient diagnosed with 2nd degree colorectal cancer was treated and released from the hospital. She paid all her medical costs. However, the cancer developed again after 5 years and so she went to the same hospital as in the past to get her treatment. This would not be a warranty service, but she would have to pay the hospital fee again.

Why is the term “warranty-service” not applicable in the medical field?

Medical industry is not a sales industry but is a service industry. Service is not a laptop or TV that the consumer takes but is something that you need to pay for the labor of another person. Therefore, there cannot be an idea as” service for a product” in the medical field.

So it is impossible to include the warranty service fee in the initial hospital cost of the patients from the beginning.

Almost all the medical costs, whether they are related to a surgery or not, are provided through “a person’s labor” and this service is claimed in the cost therefore, the hospital claim this cost on the patient at every visit.
In principle, the surgery cost only covers the surgery itself.




2.  Which party covers the medical costs when there is a medical accident and when there isn’t?

Although it is a principle, that once you pay for the service (labor) you cannot get the money back, there are problems when the hospital (service provider) and the patient (customer) do not agree on certain factors before the service is provided.

For example, if you get a double eyelid cosmetic surgery but you do think that your new eyes do not look as pretty, you might demand for the revision or certain amount of the money that you pain back.
You might not like to sports massage that you got and you might ask for a refund or you might hire a housemaid but you do not like the cleanliness in your house and not pay for that work.

In such cases, it is common that the service provider and the customer negotiate and come to an agreement. The massage shop might offer an extended service or a discount in the next visit.

But, it becomes difficult to come to such agreement if there is a side effect after a surgery. If a patient gets a breast augmentation but finds that the breasts are opened up and the implant is exposed on the next day, this responsibility will be fully on the hospital.
In such case, the hospital would need to cover all the expenses related in order to ‘solve this problem’.




If the patient required 300cc implant and got the breast augmentation, but comes back the next day and request for a change to 350cc, the patient would be 100% liable for the expenses. The reason for this revision is 100% patient’s change in thought.

What if the patient needs a revision surgery due to the capsular contracture 5 years after the first surgery?
There is no medically proven cause of capsular contracture. We still do not know if it is caused due to the type of body that the patient has or the doctor’s surgery method. Therefore it is difficult to decide on who should be responsible for this cost.

Personally, I think that both the hospital and the patient are responsible for capsular contracture and both needs to pay the costs related. If the revision requires just the enlarging of the tissue then the patient should pay for the anesthesia and the revision should be free of charge. If the capsular contracture is severe and the revision takes a long time, the costs could be divided up between the hospital and the patient.

However, the costs related with the revision and such complications should be agreed upon before the original surgery. Therefore, it is important that the hospital explains all the complications that could arise after the breast augmentation.



3. If the hospital is responsible for the problems caused after the surgery in terms of number of days responsible, how long is this duration?

This is similar to the question above, but a lot of the patients ask it.
One can set the terms for the car, saying that the auto parts get old and the car can get into an accident here are there so we will take care of it for 3 years. But, this is difficult to do so for a human body.
"The effect of the surgery takes toll after a few years, and the body will go back into its original state after a few years as well.” This is a difficult condition to state.

Anyway, a lot of the hospitals do put such management duration after the surgery. (I do not know if this is well managed)

In Japan, a lot of the patients go to “my doctor” and so the doctor is able to keep track and take care of the same patient for over 20 years, however, this is not the same in Korea. The hospitals are also into capitalism. The patients do not have ‘one doctor’ who they can rely on and the hospitals do not think that it will take care of that particular patient for a long period of time.
The duration time of the patients visiting a particular hospital in Kangnam area is about 3  years. If they need to go to a clinic after that, they would look for a ‘better’ or a ‘hotter’ clinic (in demand) on the internet and visit a new one.

I think that it would be good to keep track of the breast augmentation patient and follow up on the patient from one particular hospital. However, I have never seen this happen. It would be good if Korea has that “my doctor” such as those in UK or Japan. This is why it is difficult to find any papers regarding the 20 year observation after a surgery.

It is difficult to observe a patient even for 5 years. All the medical systems and the medical culture are strictly into capitalism.
I hope that at least the patient can have the concept of “my doctor” or “family doctor” and the same for the doctor so that both parties can keep a strong relationship.


4. If there is a conflict between the patient and the hospital regarding the amount of costs that each are responsible for, how can this be solved?

If a 7 year old cohesive gel implant has a small rupture and this leads to a little amount of leakage, this would require a revision surgery.



If this revision is done in another hospital that is different from the original surgery, the medical costs could be higher than before. But if you go to the original hospital, you might not have to pay as much and solve your problem.

For example, if the 1st surgery costed you about 5 million won 7 years ago, the revision would cost no less than 7.7 million won as the revision would be more difficult and more time consuming than the first one. Also, there was no value added tax 5 years ago. Now there is 10% value added tax to all cosmetic surgeries in Korea. (Value added tax is imposed on the customer)

The patient needs to go through another long period of recovery, concern for the revision, pain, etc therefore it is a burden for the patient to pay for the revision surgery.
What is the cause of the leakage / collapse of that 7 year old cohesive gel implant?
Nobody knows the answer.

The implant might have been a defect, the doctor might have damaged the implant when putting it in, or the patient might have required too large sized implant. It is difficult to put all the fault to one side of the party.

All the implants within our country are manufactured by multinational corporations and provide life-time warranties. You do not need to be concerned about the cost of the implants for the revision surgery.

However, the problem is the costs of anesthesia and the revision itself. If there was no follow-up for 7 years, then it is difficult to say that the patient is at fault therefore, it would be ideal to calculate the related costs as low as possible for the patient.

Today, we looked at who pays the price for the revision surgery in breast augmentation. One needs medical and legal knowledge in order to take care of such problems reasonably. The more important fact is that the hospital and the patient needs to discuss about such problems before the first surgery.

This is all for today. Thank you very much.

Q. What is bottoming out of breast implants? Can it be revised?

A. Bottoming out is when the breast implant slips below the inframammary fold as the implant does not receive enough support to remain in the proper position.

Bottoming out is caused if there is an over-dissection of the implant pocket or if the upper epithelium pushes the implant downwards.





One can explain this effect with the image above.

If the original inframammary fold is clear and the implant was placed under the muscle, then it is highly likely to have the bottoming out and the double bubble effect together.

If the original inframammary fold is unclear, and there is no sign of double line effect, the implant slips downwards and the bottom part of the breast mound becomes hard with the upper part loosing volume. This makes the nipple face upwards.



One must first check where the nipple faces in order to diagnose the bottoming out effect. If the nipple points forward, then one can safely state that the implant is in the correction position. If the nipple points downwards, then the implant is pushed upward. If the nipple is facing upwards, then one should be suspicious about the bottoming out effect.

Bottoming out can be caused with the over-dissection from the first breast augmentation and it can also be caused as the implant slips down over time after the breast augmentation.

Less critical bottoming out effect can be treated with the correction bra over 2 to 3 months, but one would require revision surgery for a critical case.
 

Most common revision is the sewing of the capsule under the breast in order to push the implant higher in the pocket. If this is connected with the capsular contracture, the one needs to remove the implant, and remove the skin along the inframammary fold.





The degree of bottoming out effect would determine what treatment method could be applied therefore it is important for you to visit a doctor who is highly experienced.

Today, we looked at the bottoming out effect. Thank you for reading. Have a great day.

The FDA approved anatomical implant, Silimed cohesive gel 

As I talk to my patients, I feel that they are open to inaccurate and dangerous information from the medical related news, internet portals, and other sources of information.

FDA Good Manufacturing Practice (GMP)

This is the reason why I put information on my blog.

Silimed anatomical implant / round type cohesive gel implants were approved by FDA early last yeat and it was approved to be imported to our country late last year. This implant can be used in our country today.

Then what changes has this Silimed implant brought to our patients (customers)?

I would like to talk about this today.



Q1. Since Silimed is the only one that got the FDA approval, is it the best one?

There was a social issue in 1988 as Dow Corning, the largest silicone manufacturer, was faced with a lawsuit from 170,000 women around the world. After that, the FDA regulated the usage of silicone gel implants in 1992.

If such decision is made in a country like US, it becomes really difficult to overturn the decision and it takes a very long time to do so. After 14 years, in 2006, this decision was overturned and the FDA approved cohesive gel implants from companies such as Mentor and McGann(Allergan) to be sold in the country.
But, at this time, only the round type implant was approved.
The anatomical type cohesive gel implant was not approved until last year when Brazil’s Silimed got all their products, whether it was round type or not, approved.
If you compare this to that of our country, our country did not approve the sales of Samsung or LG phones but has approved the sales of Apple or Sony products. (Mentor and Allergan are US companies)

This decision was questionable by many, but nobody knows why this decision was made. I don’t think that anybody would know in the future as well. This type of decision is very political and is not made based only on research data.

Here is the answer to the question above. Silimed did not get FDA approval, because it has the best anatomical product.



Products such as Mentor’s anatomical implant CPG that is still not imported to our country,
Allergan’s anatomical implant, Stype 410,
Polytech’s replicon optimam opticon implant that was imported quickly to our country,
Sebbin’s Naturgel that is disliked because it is made in France,
Are all good products. There is no evidence that Silimed’s product is superior to these other implants.


Q2. What is the difference? Do the prices differ among the products?

You need to have a date with long time of observation in order to know the differences of all these implants. You need at least 10 years of data.
This is why it is difficult to say which company product is better than the other.
There is no one who can answer this question confidently.
We can only say some obvious facts such as  if the implant is thick or not when we touch it, or if there is any difference in spec according to the volume, height or width, or how the surface feels.




Oo product from 00 company has highest incidence rate of capsular contracture!
00 product has lowest collapse rate!
00 product has highest revision rate!

These are the important data....
But, we do not have any. Not as yet. It is difficult to compare such data.......
But those anatomical implants that are used in our country have been used and approved for a long time in the markets abroad, therefore, we can see them as best choices to use.

Although the price of these implants are different, the cost of the surgery does not depend on the price of the implants.




Q3. I have heard that Silimed is from Brazil, is it reliable?

Yes, it is reliable and you can trust the product. Silimed is a Top 3 company globally.
Doctors from Europe, South American, Japan and other countries have used many of these products.
The HQ is located in Brazil but it also has subsidiary, Sientra in California, US.
Anyway, it was funny and big news that US companies such as Mentor and Allergan did not get FDA approval but a foreign company, Silimed, did.


Q4. Then, which product is the best, and which one do you recommend?
There are few conditions of artificial substances in order to use them in the body.

No side effect, and fuses well with the body
Chemically stabled
Shape can be changed as you want
Strong durability
Easily removable
No illness caused



There are many people who are trying to make such a perfect product.
But, there is not one product that gets the score of 100 / 100. This applies to all the companies.

Mentor, Allergan, Similed, Polytech, and Cervin are all trying their best to makes better products than what is available today. I make careful decisions when selecting these implant and consider the spec (height, width, thickness, etc) a lot.
I try to find which of the 100’s of products that these 5 makers make are most fitting or appropriate to the patient.
Of course, this is nothing simple.

But not all problems are solved because you have chosen the best implant.
It is obvious, but it depends on how the surgeon performed the surgery.


Q5. I have used cohesive gel in the past, do I need to change the old one when a new one comes out?

Nobody should ask this. There are those who used saline bag type 20 years ago, but did not suffer any capsular contracture, implant collapse or other problems so far maintaining the beautiful look.
No matter how old the implant is in your body, if your current breasts do not have any problems, you do not need to touch them.
Reconstruction or revision can damage the body tissue and lead to other sider effect. You cannot disregard such risks.

Revision should be considered only if there is a definite reason. It is different from changing your smartphone because a new model comes out every year.

But, such news that the only FDA approved product is imported to our country is welcoming news for a breast correction specialist like me.
Also, it is good for the customer as she would have more choice of products.

This is all for today. Thank you very much.

Breast augmentation - About illegal breast implants

I have found few Chinese made cohesive gel implants when I conducted revision surgeries abroad.

I thought that China is a great country, because, it can make such fake products. There was a logo ‘Shanghai’ at the back of this fake Chinese implant.




It is not wrong to say that all the medical devices and the products that we used are all from the western countries. All the breast implants are from either Europe or US.
But, Chinese people do not consider western products good enough. They have such pride that their technical ability is not bad compared to those of the western countries. They are the followers compared to US or Russia in satellites or rocket physics but they still have good technical skills.




However, one can question Chinese techniques except for a few areas in the medical industry. The biggest problem is that the land is too large with great population so the political powers can only reach so much. It is difficult to know who is making what in that large country. This is why the Chinese people also do not rely on their Made in China products although they have much pride in them.

For the same reasons, I as a doctor, do not trust Chinese medical related product. There is no national restriction or certification on these medical products. This is a big problem.







Anyway, I was curious about this Chinese implant so I kept on touching it and compared it with other implants from US / Europe. There is not much difference in the products if you look at it vaguely, however, there are many problems that you can recognize.

First, the appearance of the exterior texture is not stable.
If you look at Mentor’s product, the texture is smooth and slippery. Allergan’s texture is a little bumpier but is smooth also.

However, this Shanghai implant is not uniform in appearance (similar to hair that you have not combed).

Also, it seems that there is shortage of gel in the implant. There needs to be enough gel within the product in order to maintain the shape. There are some doctors who think that there should be excess amount of gel. The Chinese product looks alright from the outside, but there is not enough gel on the inside.



As I conducted the revision and took out the implant, I have observed that there was much sticky liquid in the implant pocket. I think that the cohesive gel might have leaked out from the implant and this is why there weren’t enough gel in the product.

I do not want to judge this Shanghai product badly without any evidence. Also one cannot think that China is far behind Europe.
But, if the doctors in China are still using their local products today, they need to report their evaluation on the implants. There is not one report on this Shanghai implant. Nothing about collapse rate, capsular contracture rate, revision rate, etc….

Such implants without any data cannot be used in the actual cosmetic surgery.
Currently there are 4 products; Polytech from Germany, Mentor and Allergan from US, and Sebbin from France; imported to our country. All have been evaluated and used by many doctors.

KIES-U Mongolia Surgery room

Today, I posted on how I felt about the Chinese implant.
I don’t think that there is any doctor who uses this uncertified product in Korea but there are many news on it so I do not know what to say about it.


This is all for today.
Thank you very much.

Correction of Breast Asymmetry

There are many of those who are worried about “what shall I do with my breasts?” when they have uneven (asymmetry) breasts. (There are those who want anatomical implant for the uneven breasts as well)

It is obvious that a person has two different sides. But there are different opinions on how the two breasts can be different.

The two lower lines are never at the same level (height). 1000 patients out of a thousand would have different heights.
The lower lines are different after the breast correction as well, but this has absolutely no cosmetic influence.





The positions of the two nipples are different as well. This is the same after the breast correction also. If you know this, then you are right.

We do not need to have a cosmetic surgery in order to make the lower lines or the nipples come up to be at the same level. It is alright to be at a different level, and the first correction does not try to correct the two locations. The purpose of the cosmetic correction is not to change something that is common to everyone.

The problem exists when there is difference in volume of the two breasts.
If the difference in the volume is easily visible, then you need to use implant to make up the lost in volume.



 

If you use the saline bag type, we can control the volume up to 1cc by controlling the amount of the liquid. But if you use silicone gel bag implant that has already been filled up, it is difficult to fill up the minor difference with the cohesive gel.

But there is one important fact that you need to know. The two breasts under the same condition do not have difference in shape or the size. (Most patients do not know this)
Your spinal might be leaned on to one side of the body, the two ribs might be asymmetry, or the sternal rib might not be positioned correctly in the middle.




This problem applies to the face as well. There are some celebrities who only take pictures of the left side of the face because the left side looks better than the right side. Just as the two sides of the face are asymmetric, it is common that the same applies for the body.

Let’s say that you are constructing a 2 storied building on the ground that has different levelling. Which side do you think would look taller? The side with higher leveled ground would look taller.

The side with lower ribs needs more volume implant. If you had an accident or got injured ribs, the injured part might stick out more than the other. In this case, you would need a less volume implant.
If you have a nipple with no volume on the lower part and the other that has no volume on the upper, you might need anatomical implant for the lower part and the round type for the upper part.




We conduct correction for only one side of the breast if you have a Poland syndrome.
If the shape is asymmetric but only the volumes are different between the two breasts, we just consider the volume of the round type or the anatomical type and go on with the procedure.

The process of selecting the implant size for uneven breasts is

1) Measure the diameter of the breast and then decide on the volume size of the implant
2) Use the Sizer in order to measure the volume and the shape of the breast with the saline bag liquid after the desquamation
3) Then input the cohesive gel. Final decision is made with the visual guide and experience of the doctor

Normally the measurement is important for me. But is the asymmetric is severe, the experience and the judgment of the doctor becomes really important.





Anatomical implant is different from round type in that we need to put in the implant by tilting it.
There are many of those who think that the 6 o’clock side of the anatomical implant needs to be positioned at 6 o’clock side of the breast, but this does not apply to the uneven breasts.
The implant can be positioned at 5 o’clock or 7 o’clock position in order to make the two breasts look similar in shape and in volume.




Then does the implant remain at that tilted position? This may be the question that you have. Textured implants rarely change its position or rotate once put into the breast. It is difficult to rotate it by hand purposely.

Anatomical, in such sense, might be better for those with asymmetric breasts. It has directional nature so it can be used to match the asymmetric breasts.

This is one topic that many do not understand during the interviews. Has this blog been helpful to you?


Thank you very much.