Propofol_ is it necessary? (IV sedation for Plastic Surgery)

There are many negative articles on the propofol these days. It has a nick name “milk injection”.

People who are addicted to propofol, hospital that black-markets the propofol, criminal activities that take place in plastic surgery clinics with the usage of propofol are some contents that are on the news. Today, I would like to share about the use of propofol that is necessary in the plastic surgery clinics.
 
What is IV sedation.....?????

I have heard that IV sedation is dangerous. Can I not do it? There are some patients who ask such question. Also there are those who ask me to put them to sleep completely so that they do not know what is going on. Let’s looks at different anesthesia methods that are used in the cosmetic surgeries.


First, local anesthesia
We do not inject the anesthesia for the whole body but for a particular part. For example if you are having an eye surgery, the anesthesia would be injected on the eyelid. This is widely used when we conduct scar / wound reduction, skin tumor removal, or such surgeries on small parts of the body.

Second, Spinal anesthesia 
This is widely used in the obstetrics. The anesthesia is injected in the spines paralyzing the lower body so that the pain cannot be felt. This is used for abdomen / thigh fat transplantation in the plastic surgery clinics.

Third, General anesthesia 
General anesthesia paralyzes central nerves therefore requires breathing tube during the surgery. Therefore, the anesthesia and intubated. One can use the ringer solution but the breathing tube is safer.

Fourth, IV(intravenous) sedation
We use the intravenous injection with sleeping drugs for anesthesia. The most representative substance used is the propofol. If there is a respiratory problem, there would be big trouble. There is no breathing tube used. therefore, one must be aware of the anesthesia usage during the surgery.



As you can see in the graph above, if you go from sleeping stage to no breathing stage, your life becomes dangerous. This is IV sedation. So if the surgery is not a major one, then is would be safe to perform the surgery during the light sleeping stage. If you think that the surgery would be too painful and you want to sleep completely then general anesthesia is recommended.
You can find many articles to well know celebrities who abuse the usage of propofol. Actually, today, one cannot discuss about the IV sedation without the propofol.

Characteristics of propofol

1. Quick and smooth
2. Long lasting effect
3. No displeasure when awake

One can easily know why propofol is sued a lot. It has a quick effect on the body, lasts long and once you are awake, you do not feel bad.

If you watch the movie, Hannibal, there is a scene where an injection is used to make a person unconscious but there is no problem with breathing. Of course, such substance does not exist today. It would take another few decades for such substance to be made. But one can say that propofol is one that is really close to this substance. Therefore it is used a lot.

There are disadvantages of propofol as well. 
1. The injection is painful
2. Too much dosage can stop breathing (Dangerous to life)
3. Anesthesia status is not stable

However good a medicine is, it can be good or bad according to the person who uses it. Drinking can kill if one drinks it too much. It can be good for the body if you drink appropriately. Propofol is similar to drinking.

There are people with misperception. Propofol is not always good for the patient. Some do not remember anything and some feel unpleasant after using it. There are those who feel good after drinking and those who do not feel good as well.

All the substances that human make act differently from one person to another. However, there is one majority opinion.

Propofol being used as a drug to feel pleasantly good is wrong. Whether you are addicted to nicotine or drug, a human being has an ability to control one self. It is dangerous to think that one can escape the reality with the help of a medication.

Propofol is perceived to be a devil’s medication but if you manage and control the
usage properly, it is something necessary and useful. Actually, all medication are like that.

Today, we looked at IV sedation and propofol.

Thank you very much.

Choosing your implant for water drop breast augmentation 

It is not easy to make a normal person who is not professionally knowledgeable in medical field to understand what a doctor wants to communicate. I get quite surprised that my patients do not understand me.

Today I look like to share something that the patients have most difficulty understanding, making it easier for you to understand. It is about selecting a water drop implant.

Water drop implant is 3 dimensional, so you can select the implant according to 3 stages.


There are those who are quick to ask “are you not going to decide on the volume (cc)?” If you think about the three stated above, you will be able to know the volume instantly.

You will be able to know what a diameter / height / thickness are with the help of the image below.





You only need 2 parameters for the round type implant because the diameter and the height is always the same.

But you need to decide on the diameter, height, and thickness for the water drop type.

First, the diameter refers to the width of the implant. The diameter of the implant should be selected first. It cannot exceed the diameter of the breast. If the diameter of the breast is 10.5cm, the diameter of the implant should be equal or less than 10.5cm. From the 3 parameters of diameter / height / thickness, the diameter should be chosen first.

Second, the height of the implant is related to the type of the implant. The one with short height would be the ‘short type’, mid height would be ‘Normal type’, and the long length would be ‘tall type’. So one would measure the upper body and if it seems long, you would select the tall type, or if it seems small, you would select the short type. The normal type is the most common one. You will be able to understand this more easily with the help of the images below.







Third, we refer to the thickness as ‘profile’. Low profile refer to the one that is really thin, Moderate profile for normal sized one, and the high profile for something that is thick. The volume of the implant depends on the thickness.

So, if you want a large sized implant with increased cup size, you would select the high profile.

If you aren’t too greedy about the up size and want something that is more natural, you can select the moderate profile. Low profile is used if you have asymmetric breasts or sagging ones.

But, there are some who are not satisfied with the new volume although they use the high profile. So there are some manufacturers who make Extra high profile, i.e. very thick implants. Extra high profile cannot be used without much thinking. It is used for those who have thick skin tissue and want large volume.



The sizing of the water drop type implant is selected according to the following order.

1. Measure the diameter of the breast then select on the diameter of the implant

2. Measure the distance from the collarbone to the nipple and the distance between one nipple to another. Decide if the upper body shape is wide or long in height. Then decide on the height of the implant

3. Ask the wanted cup size of the patient and then decide on the implant profile

This is how we select which implant to use.

Let’s try going through the three phases for an example.

Before Breast augmentation Surgery

Let’s analyze this patient.

First, the diameter of the breast is 11cm. We can use any implant with diameter of 11cm or less.

Second, the distance from the collarbone to the nipple is 17cm. if we draw a triangle, we can see a tall isosceles triangle. This means that we can use a round base type or the tall type implant.

Third, the patient does not want to increase the cup size much. The patient did not like to have big breasts originally, but as she gave birth and breast fed her child, her breasts sagged. Therefore she wanted the upper breasts to look bigger. In such case, the moderate profile would be appropriate.

This is it. We can select an implant that is 11cm in diameter, tall type and a moderate profile.

Polytech 260cc implant has a height of 12.2cm and a thickness of 3.7cm.
Natrelle 235cc implant has a height of 11.5cm and a thickness of 4cm.
SiliMed 275cc implant has a height of 12cm and a thickness of 4.2cm.
Servin 285cc implant has a height of 11.cm and a thickness of 4.6cm.

You can select one from any of the four above. But a patient should put each of the implant inside her clothes to see the volume and check on the size.
So it is better to see the actual size in person and then decide on the volume and the size. This patient liked the 260cc after the size test.

The implant has been selected and the result of the breast augmentation is as below.

Before and after Breast augmentation Korea KIES-U

The patient has a rather long chest but this is due to the sagging breast after giving birth. You can see that the upper part of the breasts have been filled up. The patient wanted more of a natural look so she was very satisfied with the result.
In summary, you need to measure the width of the breast and decide on whether to use the oval type or the round type and finally select the thickness profile according to the volume that you want.

In reality, the selection is not as simple because there are many patients with asymmetric breasts, and the tightness of the skin was to be known. There are other variables as well.

Therefore, the experience of the doctor is very important as well.

This is all for today, have a great weekend. Thank you.

Why is the upper pole fullness caused?
Breast augmentation Korea KIES-U

What is an upper pole fullness?

The breast looks good when there is a straight line that links the upper part of the breast from the collarbone to the nipple, and round line that covers from the nipple to the bottom of the breast.



But if there is much filling or volume on the upper part or the breast, we call this upper pole fullness.

How is the upper pole fullness caused?

1) It is caused when there is a mismatch of the breast of the implant after the breast augmentation. It happens if the implant is too big.

The chest can only accept an appropriate size but if a very large volume implant is used, the body cannot take it in properly causing upper lift on the breast. The bottom part of the breast is round shaped but if the upper part also becomes round, this is an upper pole fullness.




2) If a patient is in her 20’s and has not given a birth yet, the skin of the breast is very tight and elastic. If a round shape implant is put into the breast, the skin does not extend but pulls more tightly causing upper fullness.


3) If the doctor did not desquamate properly after the augmentation – especially when putting in the implant from the armpit – the implant moves to the upper part of the breast causing the upper fullness. The upper fullness does not get better even with time in such case.

4) There is some level of swelling after the breast augmentation therefore, there is also some level of upper fullness. However the upper pole fullness caused due to swelling gets better after a few weeks.

Breast augmentation Korea KIES-U

5) At times, you can have upper fullness in a few months or years even after the swelling has disappeared from the surgery. This happens although the surgeon did proper procedures.

This is caused due to the capsular contracture that pushes the tissue into one side of the breasts. This direction can be anywhere. If the upper part is pushed then the upper pole fullness becomes more severe.

How to avoid the upper pole fullness? 

1) Do not use too large sized implant. When you consult with the doctor, the doctor will take proper measurements of the chest, breast and try to match an appropriate sized implant. Of course, the patient’s opinion will be taken into the consideration but the patient should not require too much. Such greed might lead to upper pole fullness that lasts for a long time.

2) If you want breast augmentation before giving birth, you would have tight and young skin. Water drop type implant would be appropriate. If you choose too bi sized implant, whether it is a water drop type of not, the upper pole fullness might be caused.

3) The surgeon needs to desquamate properly. The surgeon must be more careful when the dissection and the input is done through the armpit as it is less visible on the eyes as well. Therefore, much knowledge and skill is required of the surgeon.

4) The upper fullness caused right after the augmentation disappears after 2 to 3 weeks as the swelling comes off.

5) If you are certain that you have a capsular contracture, and have a severe case of upper pole fullness, then you need to consider reconstruction.

The reconstruction would require epidermis removal or opening.
But it is important to do everything you can in order to avoid the capsular contracture.

Today, I shared on the upper fullness. Thank you for reading.

Have a great day.

The types and differences of breast implants II 

Plastic surgery Korea KIES-U

Which implant looks and feels the most natural? This is a frequently asked question. My answer is always the same. There aren’t many differences in the 5th generation cohesive gel implants.

If you put a smooth type and a texture type implants on top of the table and touch them, you would feel a lot of differences. Also if there is less substance in the implant, it would be feel softer and better.

Some consultants train the nurses in such aspect and say that the smooth type feels better.

	If there is less gel in the implant, it may cause a rippling effect

 But the result of the breast augmentation is different from what you think.

The Allergan type that is perceived to the hardest one becomes soft once put inside the body. Therefore, it is difficult to make out if the implant feels good or bad by touching it from the outside.

I cannot know that implant had been used on the patient unless I look at the patient’s chart.

Breast Surgery Korea KIES-U

The softness of the breast is not depended on the type of the implant that you use, but by the skin that covers the implant. Although you use jelly like implant, but you have a hard skin covering the implant, you would feel that the breast feels hard.

So it is wrong to say that you need to use the smooth type for better sense of touch.

The answer to the good feeling breast is not to choose a soft implant, but to conduct a smooth surgery so that there is no bleeding or no trauma on the body. This would lead lower possibility of stronger epidermis.

The sense of touch is not depended on the manufacture but how the doctor performs the surgery and how the patient’s body reacts to the surgery.

Problem of durability

Which implant has the best durability?

There is no answer to this question as of yet. One can estimate it but there is no statistics to prove it. We can compare the implant not collapsing easily and lasting longer to that of a bicycle tire.

If you are riding a cycle on a road with a lot of substance on it, and you have a high pressure tire on the cycle, the small sized substances bounce off easily having less possibility of the tire being punctured. In opposite, if you have a low pressure tire, it would step on the substances directly leading to a higher possibility of a puncture.
If the implant is filled up with silicone gel there wouldn’t be any folds leading to no friction therefore leading to no breakage. But if the implant is not filled up, there would be many folds leading to more friction and higher possibility of breakage.

Breast augmentation Korea KIES-U

Also the gel has strong agglutinability therefore if the implant maintains its shape there would be no folds whatsoever avoiding any damage. But if there is less agglutinability meaning that the implant cannot maintain its shape, many folds are made leading to damage on the implant.

The implant with the most agglutinability is Allergan’s water drop type implant. I cannot say for sure but I can estimate that it as a good durability. SiliMed from Brazil has high agglutinability but not as much as the Allergan’s. The other implants are much alike.

Sadly, all the round type implants that are imported to Korea do not have high agglutinability.


In all cases, the water drop type (ones that are imported to our country) have stronger durability than the round type implants. 

Which implant leads to better shaped breast?

This is the part that bothers me the most. All the water drop type implants imported to Korea have the same level of durability, sense of touch, and side effect incidence rate. The biggest problem would be which implants is the most appropriate one according to the body type.

KIES-U Plastic surgery Korea

There isn’t much to think about when considering the round type. They are all the same. Whatever the manufacturer is, the shape and the volume are all the same. But the water drop type is made 3 dimensionally therefore there are a lot of differences.

There are two types of patients who want breast augmentation that requires implants.

First are those who want to look good and thin.
Second are those who want to fix the sagging breasts after giving birth.

For both the groups, it is better to use long height implants.
The think patients usually have long torso.
Therefore, it is more appropriate to use implants that are thin and long.

Also sagging breasts have empty upper part therefore it is good to use oval type implant that fills up the upper part of the breast. If you look at the breast, you would know that the breast is not shaped in perfect round shape. It is closer to long oval shape.

Germany’s Polytech oval shaped implants are long shaped that are fitting to the Korean women. Brazil’s Silimed water drop type has a good shape but does not export oval water drop type to Korea. If all the products from Silimed are imported to our country, I think that there would be a good market response to all the products.

Breast surgery Korea KIES-U

Sebbin from France has strongly filled implant that is round and thick. So the patients who have thin breast and cannot use wide implant but want to increase the cup size can use this implant.

The cancer causing agent from PIP in France that was reported early last year is not related to Sebbin implants.

Allergan implants have best stability and durability but have wide width when concerning the profile. The patients in Korea have narrow upper body, so they need to use rather small volume implants.

Conclusion

In conclusion, there has been many implants in the market, but there isn’t one that is 100% fitting. Also, one cannot say one manufacturer product is better than the other therefore it is important to find an implant that is most appropriate to your body.

Also, whatever implant you select, the skill of the surgeon is the most important factor.

We looked at the type of implants imported to our country and their differences. Has the post helped? Thank you.
Have a nice day.

The types and differences of breast augmentation implants Part.I [Breast augmentation Korea KIES-U]

In Korea at present, there are 4 water drop type brands, and 5 round type of breast augmentation implants ones imported. There are many patients who ask about the differences in these products whenever I talk to them. Surprisingly there are many doctors who are unaware of these differences. Today, I would like to share about the imported implants that are used in our country as of 2013.

Breast augmentation Korea KIES-U

I think that there were a lot of implants used at our country before the official registration in Food and Drug department in 1990’s. Those who had breast augmentation at this time do not know the origin of the implants that they used.
In 1993, FDA in US restricted the usage of silicone gel implants and only allowed the saline bag type. Korea followed this act and allowed only the importing of saline bag type while restricting the silicone gel. (Korea tends to follow US restrictions)
So as the breast augmentation became popular (in early 2000’s), we could only use the saline bag type therefore, most of the patients had them.




Then in 2007, FDA neutralized this restriction leading to a trade of cohesive gel, i.e. silicone gel implants, causing a great demand and interest of breast augmentation due to the “good feel on the breast”.
At this time, Mentor and McCann (Known as “Allergen” today) were the two companies that were approved in Korea. Both manufactured only the round types.

As time passed, the interest grew and in 2012, Germany’s Polytech silicone gel type ( = water drop type) was approved leading to greater variety of the product in Korea.

Breast augmentation Korea KIES-U plastic surgery clinic

Reason why we still use the silicone type today

A good implant:
First, it does not harm the body or cause side effects.
Second, it should look similar to the body so that it looks natural
Third, the price must be reasonable
Fourth, it should have the durability which the shape does not change over long time period
Fifth, it should be easy to replace for reconstruction
Sixth, it should be adaptable to the body so that it matches well

These are the characteristics that an implant should have. But there is no such one right now. This would only be possible in Sci-Fi movies and it is difficult to make something that is perfectly fitting for the body.

So we still use the silicone type today. The silicone type is soft and feels very much like our body. It is separated well from the body and is well fitting with the body causing no harm, and it can be removed easily.
But there are some disadvantages as well. Separation from the body means that it caused metabolic effect of the body by creating a barrier that leads to capsule. This capsule can become stiff at any time lading to capsular contracture.

Therefore, silicone gel separating itself from the body can be both advantage and a disadvantage.






Entrance of Texturing technology

In order to overcome the limitation of the silicone type, texturing technology on the surface of the implant was applied. The idea behind was that the tissue would grow into the different textures leaving no space therefore avoiding the capsular contracture.

But in conclusion, this was not a successful effort. Textured implants did not have better incidence rate of capsular contracture compared to the non-textured types (especially for the sub-pectoral).

But the textured form prevented the changing of the location or the move abouts of the implant in the body. The main objective behind the usage of the textured type today is to securely fix the location of the implant.

Mentor has a textured implant named Siltex. It has small pores with smooth surface. So there is a lot criticism that it cannot stick to the body properly.
There is a water drop type form Mentor as well called CPG, but this cannot be imported to our country. (I do not know why)



The textured type from Allergen is called Biocell. This is different from Siltex in that it has big pores and rough surface. So Biocell sticks well to the body and has strong texturing. But as always, advantage and disadvantage is like the two sides of the coin. Some say that the rough surface on Boicell causes trauma on the surrounding cells that may cause capsular contracture.

Polyurethane

Since long time ago, many people thought that is there was a coating on the surface of the silicone implant so that the coating extends to the body having one natural feel of the breast and the implant itself that this might lead to the avoidance of capsular contracture.

There were many substances used for the coating material, but the only certified one was polyurethane.

The Polytech’s implant from Germany is known for the polyurethane coating implant. There isn’t much findings or results from the lab experiments for this product at our country so we cannot import it. But I have seen it used in Germany and Hong Kong. The capsular contracture incidence of this polyurethane coated implant in near 0%. The capsular contracture is almost not caused on the body. But we still need to know what long term effect polyurethane has on the body, and the durability of the implant in order to know that it is secure and use it.

We will share more in Part 2.