Removing the breast implant [KIES-U Plastic surgery Korea]

Q. Can I have my breast implants removed? What side effects can there be if I remove the implants?

A. There is no implant that you cannot remove. There is not much side effect after removing the implants. But there may be some change in the breast cell structure.

There are many news regarding silicone implants today, therefore there are many with such questions.



I will avoid the scientific truth, mistakes, problems in expression of these news and just focus on the theme itself.

Artificial hand or leg, facial implant, artificial breast implant, and etc. There is a reason why silicone are used a lot for medical purposes around the world.
 
The first reasons is that it is most similar to the body.
Second, it can be produced in any shapes.
Third, it is cheap and easily acquired.
Fourth, it is chemically stable and there is not much problem when used in the body.
Fifth, it does not degenerate or decay.
Sixth, it can be removed at any time easily.

“It can be removed at any time easily” is a great advantage. Silicone doesn't stick to the surrounding tissue. You might ask “doesn’t textured implant stick to the fat?” The textured implant interacting with the fact is more like velcro effect. It is not like rice cake sticking to one another.



If you do not separate the gore tex, it will tear off the fat when you try to separate it from the skin. This is a big headache. Some ask if the newly introduced polyurethane does not stick to the skin. Polyurethane implant is silicone implant with polyurethane coating. The coating avoids the formation of the epidermis therefore the contracture. This coating makes the implant stick strongly more than the textured type and makes it even more difficult to separate.



Then how is saline bag type different from silicone type? Saline bag type is consisted of salt water but the bag itself is silicone elastomer. The epidermis is formed around the saline bag and whether the surface is smooth or textured, you can easily separate it.

As such,it is important that silicone be separated with the skin. There are problems such as capsular contracture and seroma but we can always remove the implant if it is a severe case.

Then what are the side effects of removing the silicone implant? 
The most important one is the contraction effect.
As the silicone implant positions itself, it gets much pressure the fat at the top and bottom.



Tissue organization also takes time for adjustment. There are differences in the formation of back and arms of modern people who sit behind the desks and those primitive man who ran around a lot. As such, the implant pressures the breast tissue causing the skin layer to become thinner. We call this contraction effect but honestly, I cannot say that it is a side effect. It is more like an adapting effect.
This is why to is correct to say the when you remove the implant (especially the large ones) after a long time of its usage, the breast does not come back to its original state but can get smaller.

There are very rare cases where the patients want to remove the implant when there is no problem. Implant removal is done when there is a severe case of capsular contracture, or implant collapse, shifting of location, double line and other serious shape change in the implant, or opening of the wound after breast cancer surgery or inflammation related to it.



Apart from those problems stated above, the removal of the implant is a solution to other problems. In case of capsular contracture, you would need to remove the implant and then decide on what to do with the epidermis.

Contracture is formed when the epidermis becomes too thick and strong. Usually I do not remove the epidermis completely. The breast contracts by itself so if I remove the epidermis completely, the breast would look even smaller.

Also, it is not easy to remove the epidermis without damaging the surrounding muscle and other tissue cells. There is much bleeding, and it is both time consuming and costly.

Most cases of implant removal are short and simple. General anesthesia is recommended. Implant removal is also a surgery, so there might be some unexpected situation that we need to prepare for.
 
This is all for today. Thank you for reading.

There are those who just want to take care of the sagging or there are those who want to take of both sagging and volume. There are also some who want to take care of sagging and contraction.

Those who are interested in correcting the sagging and increasing the volume have had to deal with breast sagging after giving birth as they lose volume in the breasts as well. There are those who go on a severe diet that leads to loss of volume as well.



Pretty looking breasts need both rich volume and shape therefore sagging correction and implant augmentation are both necessary.

But of the patient has much volume and sagging breasts, she would only be interested in the correction.

Let’s look at the various cases that may arise.




If you have a small volume, you would consider implant, not concerning the sagging degree. If the sagging is not severe, we can make the breasts look less sagging with the use of the implant.

I think that I have stated this before. If you use just the implant (stable implant, dual plane), you cannot lift up the breast. The implant can help the skin stretch out so that there are no wrinkles on the breasts. But is the sagging is severe, the implant does not provide any visual help. You would need correction (that result in wound) and you would only need to use the implant.

 
If you have large volume breasts then there is no need to use the implant and the patients also do not want to use it. Contraction is done and at the same time lifting is applied. In most cases, contraction leads to the lifting of the breasts.

It is not easy when the volume is moderate. In this case, the patients do not know what they need to get. If the volume is moderate, and you have minor case of sagging breasts, then it is better to use the implant. Lifting causes wounds therefore, using implant is less resistant by the patients and it is also cheaper.

 
What if you have minor level of both volume and sagging breasts. We need to decide whether you would need both enlargement and correction or you would just choose one of them. There is not one right answer. If you want large volume, then you would need the breast augmentation. If you just want the sagging to be correction, then you should just get the correction done. If you want both so much, then you can get both.

So the key question that I raised, is using the implant meaningful or not, is not something that is easy to answer.




But the breast augmentation and correction methods are different on those with sagging breasts and on those without. There are more things to consider when we conduct breast augmentation on sagging breasts. We have to improve on the sagging with the usage of the implants. This is where we apply dual plane procedure. We removed the point of interaction that becomes loose and make contact with the implant. The new interaction with the breast cell and the implant would avoid the sagging. But this is not applicable on the severe sagging breasts.



Also all sagging breasts do not have volume on the upper side. The implant needs to fill up this upper side of the breasts therefore, the implant needs to be stable in shape. We all this “shape stability”. Allergan’s Style 410 is one of the most shape stable implant. There is also Mentor’s anatomical type, Silimed’s both anatomical / round type that are stable in shape. All these productions have FDA approval as well.

There are also many sagging corrections according to the degree of sagging. Simple incision around the areola or incision on the bottom of the breasts, T-shape incision on the bottom of the breasts, and etc. There are various methods that could be applied.

Today, we looked at how implants can be used for the sagging breasts and somehow we got to cover more than necessary. This is all for today. Thank you for reading. Have a great day.

Consumer Report : The dark side of breast surgery. Hoping for a TV program that provides the essence of the problem

I would like to share my reviews of Consumer Report on KBS that was aired on March 3rd titled ‘The dark side of breast surgery’ as a cosmetic surgeon.

The first story was about a lady named Ms. Choi who suffered from capsular contracture.


The lady got breast augmentation with saline bag type implant in 2012. Within a week, the breasts became real hard. The clinic where she got the breast augmentation, decided that it was due to capsular contracture and conducted correction. The implant then collapsed so she visited another hospital to replace the old implant. The new implant used was a cohesive gel type. However, the pain still existed and she finally decided to have the implants removed. In september, she got the implants removed, but the pain did not go away.


The Consumer Report also showed that Ms. Choi did “think about suicide” and “that one out of every 4 patients get correction. There is more behind all the sweet talks about breast enlargement”.

The program says the Ms. Choi get contracture within the first week….

This is something really difficult to happen.

Capsular contracture is formation of epidermis that becomes really thick and strong due to metabolism. It takes about three weeks for the epidermis to completely surround the implant. . Having felt something similar in 1 week seems that this is not a capsular contracture, but a mis-match of the pocket size for the implant and the implant itself.

Wouldn’t you understand better if I said that the pocket was too small for the implant to go it therefore the breast became real tight because the implant that is larger than the pocket?


If the patient’s breast skin became thinner then maybe the epidermis was removed by too much force due to the judgement that there was a capsular contracture. I think that the skin stuck on the epidermis was removed togethers. (This happens a lot when the correction is done through the armpit)

In the meanwhile, a nerve might have been damaged so that there are no senses. The patient might feel like she got burnt while bathing in a sauna - A burn can lead to contracture as well - and the 4 or 5 corrections could pull on the scar a lot, making her feel that kind of pain. I think that Ms. Choi’s case is all due to the problem of the surgeon being careless.

There was a snapshot of 2016 Reports of the side effects caused by medical equipments. I do not think it is right to show such simple data and make the viewers thinks that implants are dangerous.



This is like saying that there are 100 times more cold patients that cancer patients therefore cold is 100 times more dangerous than cancer. I think it would be better to compare medical equipments used inside the body such as dental implant, artificial valves, artificial neves, artificial joints and artificial breasts and seeing how many reports each of these equipments get.

Also, the statistics that one out of every 4 breast augmentation patients need correction looks wrong There is no such data or statistics in our country. FDA in US gathers such data. In 1993, there was a ban on silicone implants and the data then was about 20%. This was 24 years ago. That is a long time. What do you think it is like now? (This was US not Korea)

American Society of Plastic Surgeons (ASPS) gathered reports from 4990 plastic surgeons on reoperation rates of breast augmentation. This data was published in PRS 2011 October edition. .



The reoperation rates announced by ASPS was 1~5%

The second most common reason for reoperation was to change the size of the implant and the most common reason was capsular contracture.
We cannot neglect even one patient who has side effects. But because of one careless mistake, we cannot judge that these surgeries are really very dangerous. We cannot make the patients feel concerned because of this. I am also not sure whether this is something that journalism is to take account for.

The second story was about Ms. Kim who received fat transplant on the breasts. It was about getting fat transplant twice with frozen fat leading to a flare in the breast and opening up the stitch causing exudation.
The program stated that the fat stored was in a real bad condition that led to inflammation which could also lead to severe damage.




I have studied science. Science starts with rational doubt and analysis on the doubts. So I had much doubts when I was watching the program. Is this true? Can the fat of bad condition cause inflammation and infection making the patient suffer that much?

The first and the second story from the Consumer Report put much focus on the medical equipments. This is the approach that non-professionals take on some professional area. Equipments are something that are visual. Implants, fat, etc. But the specialists focus on something that are not visible, like what did the doctor do?

If the fat became bad because it was stored in the residential refrigerator and was used for transplant causing infection, why did the exudation only come out from the right side?

It was the same material. The fat with same materials was used on both breasts. Then why wasn’t there infection on both sides?

Actually, it is difficult to analyze the details with the contents provided in the program. We cannot know what caused the infection. If the nutrition from the good fat did not spread out properly into the breasts but died out, we could still have the problem of infection.



It seems like much fat was used. We need metal cannula in order to use this much fat. We cannot ignore the mechanical trauma that may have been caused.

The cannula has to move in order for the fat to enter the breasts. This may damage the cells and cause bad environment. Such could result in infection as well.



I always think like this.

All complications and side-effects are related to how careful the surgeon was.

Fat transplant on the breast is not something that is bad. The fat needs to be stored carefully, the input process should be done carefully, sterilization should be done, the patient needs to take antibiotics, there should be proper dressing for the wound, proper monitoring to lead to good result for the patient. This is all done by human.

The third story is a lot worse.

It is about a filler used on the breasts. There is no details on the safety of the breast filler in any journals published around the world.

I still think that this should not be conducted in some cases. If there is a problem with the breast regarding shape and you want to make it more contour, then we can consider the filler.
But, if you want to change the size of the breast in terms of cup size (it said 700cc in the program) then I would oppose the idea of using the filler.

There was a small detail about UK gynecology journal in the expert interview. The substance in the filler was liquid silicone which has been banned in usage for a long time. (Today hyaluron is used)

I think that what Consumer Report is trying to say was that the practice of plastic surgery for commercial reasons can be dangerous. I agree with this effort.

But, the program kind of got out of hand in sharing about the danger.

I feel kind of empty after seeing medical related programs (including dramas)
There is no essence in the program but only non-important contents.

The most important thing is whether the patient met a good doctor or not. Everything is done through the hands so one must be very careful because something that has never happened before, could happen. One should not be too greedy but be satisfied with the current status. I think that this is the essence.



My hope is that we abandon consumer targeted promotion in plastic surgery. I hope there is a medical law or regulation for this.

Thank you and have a great day.

How can we treat Poland syndrome?

[Breast surgery Korea KIES-U]

Q. I have Poland syndrome. What can I do about it? Can there be any more problems in my body?

A. Here is the answer.

Poland syndrome was discovered by an English doctor, Patrick Clarkson in 1962. He had observed patients with abnormality on hands and hypoplasia on the breasts.



Clarkson found out that he saw was discovered about 100 years earlier by Alfred Poland. Poland reported it as just one of some cases and did not think that it was a symptom of some other illness. So it is correct to say that Patrick Clarkson was the one who found this Poland syndrome.

Guy's hospital in London, UK

As you can see from this background information, Poland Syndrome is not something that is common. Poland syndrome involves hypoplasia of pectoralis muscle and symmelia of your fingers.

It is a state where you are missing an big muscle between brachial and breastbone. There are at times where more muscle is lost near the breastbone making the shoulders look deform.

Also the ribs can be shorter than usual and the subcutaneous fat may be thin. You can find abnormalities in the areola and the nipple. You might not have any hair or too much hair in the armpit.



In most cases, we do not bring about the problems that may happen on the chest.Poland syndrome commonly happens on the right side and it is more common with women than men.

There is no accurate cause of Poland Syndrome but there are opinions that it is caused because there is a blockage in the subclavian artery blood flow during prenatal life. Subclavian artery is known to be somewhat involved in the growing of the hand under the chest during the prenatal stage.



There are many types of treatments (but we are only going to cover about the breasts)

We put implant in the greater pectoral muscle where there is a loss of volume due to the missing muscle. There is no Ready-made silicone implant for the greater pectoral muscle therefore we need to make CAD designed implant.
These implants are not made of cohesive gel but by silicone elastomer that feels similar to rubber and acts well like a strong muscle.
At times, we use TRAM flap or LD flap where we use the fat from abdominis muscle or latissimus muscle to fill up the pectoral space.

Axillary hyperhidrosis is cut in order to put in the implant. For women, we not only need to fill up the pectoral muscle but also provide more volume therefore second surgery might be necessary. The 2nd surgery could require cohesive gel implant or fat transplant.



It has been reported that women suffer Poland syndrome three times more than men and it happens on the left side twice as much than the right. The incidence rate of this illness is one out of every 7,000~10,000 newborns.

There is no limitation to daily chores for those with Poland syndrome. Fernando Alonso, F1 racing driver, suffers from this as well. He does not have right pectoral greater muscle. There are famous Olympic boxer and PGA golfer with this as well.



You cannot be differentiated as a disabled because you have a Poland syndrome. The surgery is done just to make the appearance better. It is for the balance of your body. (Your hands might require more microsurgery)
 

Female patients with Poland syndrome might require latissimus dorsi muscle flap surgery or pectoral implant surgery. If you want to fill up the less generated breasts, then we can use the cohesive gel implant on one or both your breasts and conduct breast augmentation. If you have a lot of fat, then we can also consider fat transplant.

This is all for today, thank you very much.

Uneven breasts; how to correct them
There are patients who have a complex with uneven breasts as much as those who do with small or sagging breasts. Today I would like to share about the uneven breasts.

People think of uneven breasts as breasts with different volume size but there is a lot more to this. Let’s look at them one by one.

Breast surgery Korea KIES-U

1. Uneven thorax
2. Different location or inframammary fold or nipples
3. Different degree of sagging
4. Different original shapes of two breasts
5. Uneven breasts caused by breast cancer surgery or other treatments
6. Uneven breasts caused by breast augmentation, contraction, correction

There are the main factors of uneven breasts

1. If you have two sides uneven thorax then you have uneven breasts by default. This is because left and right sides of your body are uneven naturally.
You need to understand this properly. All human being and all living things do not have perfectly even two sides of the body. Only the mannequins and dolls have perfect even two sides of the body. Your face, hands, and legs are all uneven.




As you can see in the image above, the left and right lungs look differently. The heart is not in the middle but is little closed to the left. The main artery and the main vein are also positioned towards one side.
 
This is why the ribs that protect the inner parts of the body look differently as well. The left ribs that protect the heart usually stick outwards more that the right ones.
This is why about 90% of the people think that their left chest sticks out more than the right. But there is not that much difference to say that both sides are uneven. However, we tend to use different size implants in order to make the two volumes the same.

From my experience in consulting with the patients, about half of them know that they have uneven breasts and the other half does not.



2. There are very rare amount of people who have the two inframammary folds lined up in a straight line. This means that one inframammary fold tends to be positioned higher than the other. Therefore, the nipples are located at different level of position as well.

From my experience,  the distance between the nipple and the inframammary fold is about 1 cm or less. We can say that this much distance is within the error range therefore, we do not need to focus on the cosmetic beauty regarding it. But if the distance is greater, then you might have to consider getting a correction done.
You can consider areola movement and implant surgery simultaneously. We can correct the location of both areola and nipples and make the inframammary folds line up straight as well.
 
3. It is common to see different degree of sagging as well. One breast may sag when you are going through puberty, but this usually happens after breast feeding as mothers cannot balance out the breast feeding evenly on both sides.
It is natural for the bigger breast to sag more after giving birth. The loss of volume is noticeable as well. Using implants on both the breasts cannot solve this problem. The sagging needs to be corrected so they are even therefore we need to conduct breast augmentation on the more sagging breast simultaneously with correction.
Many think that breast augmentation just involves putting in of the implant. But they do not know how the sagging breasts are corrected. We can design the correction in a shape of concentric circle and move the location of the areola and the nipple. We can gather or pull up the derma from the bottom part of the breast to correct the sagging. There are many techniques as such.
We can also apply different level of lifting to make the breasts even. At times only one implant is used for a particular side and we conduct correction on the other.

 
4. Two sides with different shapes mean that one side is conical and the other is sagging. Or one side might have the areola and the nipple located away to the left of right side of your breast, and the other in the middle of the other breast. This happens because you are born with uneven thorax.

We can move the location of areola and the nipple more towards the middle of the breast or we can make the implant pocket size different on each breast or even use different types of implants. We can apply dual plane on one side and under/above pectoralis muscle method on the other.

Reference from an essay in Brazilian Plastic Surgery Journal

5. We must consider many methods for uncorrected breast after breast cancer surgery or one that needs correction for unevenness. We can change the skin flap, or can use implant by estimating how much fat can be regenerated. We could also add fat transplant.

Reference from an essay in Brazilian Plastic Surgery Journal

 
6. There are times when you get uneven breast because of some cosmetic surgery or your uneven breast may look worse after the surgery. You need to compare your breasts before and after the surgery properly so that you can know the cause of the unevenness and find exactly what needs to be done to correct this.

You might need to have different planes on each sides for the implants. You have might to consider relocating the position of the areola and the nipple. You could consider fat transplant or you might even have to replace the old implants. You need to think about all these addtional alternatives.

Lastly, uneven breasts is a problem that most women have therefore you should not think that only you have this particular problem. Every person has uneven two sides of the body. You breasts are to look good with cosmetic surgery and not to look even on both sides.

This is all for today. Thank you for reading.