Microthane breast augmentation – Fact Check 2. Is it good for sagging breasts?

Hello, everyone. Today I would like to share about microthane, i.e. microurethane shelled implant and how it is effective on sagging breasts.

Sagging breast is caused by three dimensional shape of the breast, therefore, tissues such as Cooper’s ligament lose strength. In most of the time, when a woman gets pregnant or does breast feeding, the breasts swell causing elongation. After the pregnancy or the breast feeding is complete, the breasts lose volume and become smaller. The ligament tissue cells are not rugger therefore, they cannot go back to the original shape. This causes the original breast tissue cells to fall downwards and this is the starting point of the sagging breasts.


The original breast tissue falls downwards, but the skin tissue cells still have the original level of elasticity. We call this glandular ptosis. Such breasts would not have much upper volume but the areola is placed somewhat above the inframammary fold.

As time flies and you get older, the skin loses elasticity and the strength to hold the composition leading to a change in the shape of the breast. This is a little different from glandular ptosis in that the areola drop down below the inframammary fold and you cannot see the white part of the skin from the front side.

There are many patients who consult on what to do during the glandular ptosis stage. A lot of these patients have spent few years after the pregnancy and they have loss in upper volume of the breast with a feeling that the breasts are sagging down with a loss of volume compared to before marriage. At this stage, we need to complete a few tasks in order to recover the breast volume, regain the elasticity and fill up the upper volume.


First, we need to make sure that the implant does not collapse but stand still filling up the upper volume of the breast. Second, the breast tissue must stick to and hold the implant. If the skin loses strength, the implant would fall downwards causing the ptosis to be worse.

In order to achieve these goals and not fall back to the sagging stage, we recommend form stable implants that can be stably place on the muscle. The interface point can become loose therefore we need to provide the tightness by dual plane method.
But, there are conditions in using the form stable implants and applying the dual plane method. First, the skin elasticity must be maintained and the original breast volume should not be too big. Also, we cannot use too heavy (big) implant.


If your skin elasticity is not reliable and you want to use large sized implant, then I would recommend polyurethane to you.

When we use the polyurethane implant, it immediately sticks with the bottom (bone) perfectly. No exterior pressure or strength can change the location. It is very applicable for breast ptosis.

Microthane implant firmly holds the position as soon as it is used. This position does not change at all. The skin layer is supported by this implant therefore we can avoid breast ptosis. (Dual plane method must be applied)

As a result, this is very effective in filling up the upper volume as well. Microthane never sags downwards.

There are some who question if the textured implant that sticks to the skin leads to sagging. The textured implants do not have all the power to stick to the skin. The textured implant would slip away if you widen the pocket with your hands. Such stickiness is not enough to hold if there is much gravity.
 

What happens in the second type of breast ptosis? A case where the breast tissue and the skin all sag, i.e. natural ptosis. We need to provide solution on the skin extending. The usage of the implant cannot solve the problem. We need to cut off the skin surrounding the implant. We need to apply breast ptosis correction. Implant itself only cannot be a solution.

Let’s summarize. There are many situations where we can solve breast ptosis with the usage of microthane implants. This can be the best method for glandular ptosis where the skin does not loose elasticity 100% and you want to fill up the upper volume. This is the simplest of all methods and best method for improvement.

This is all for today. Thank you for reading.

Microthane breast augmentation – Fact Check 1

We know that something is good, but there are many situations where we do not buy that good product.

There are many companies in Korea that utilize marketing that lead to purchase. The customers (patients) purchase based on the brand popularity rather than quality. Also
the doctors do not tend to recommend the implants that they do not have experience with.

Breast augmentation Korea KIES-U Plastic surgery

But, sadly, there are many online rumors on polyurethane (microthane) implants that are going around. Therefore, I would like to provide you with the facts.

1. There is no silicone in microthane implant  (False) 

Micro polyurethane foam in applied on the surface of the silicone gel implant.
There is silicone inside the microthane. The surface of the implant is not silicone but polyurethane.

Microthane breast implants surface

If you look at the surface of the polyurethane implant (microthane) with a microscope, you will be able to a hive-like structure. This structure minimizes the capsular contracture. Only the surface is different, the composition is the same with silicone cohesive gel implant. [Breast augmentation Korea]

2. Is microthane a new product?  (False)
Breast augmentation in Korea
The first modern silicone gel implant was introduced in 1964. The polyurethane implant was born next around 1967. The textured implant developed from polyurethane was introduced in the 1980s. This means that polyurethane as a history of about 50 years. This is not a new product but is an implant that has been used by many doctors over many years around the world.
 Breast augmentation in Korea
J.B.Tebbetts, Maxwell, P.Tonnard and other breast augmentation specialists around the world published their research results on the polyurethane implants. Therefore, this implant is not in the clinical test stage. There have been many publishment in world known essays for many years and the safety and the effect of the implant have been researched on continuously. This implant is new to few countries, including Korea.

3. Does microthane implant reduce the capsular contracture? (True)
 Breast augmentation in Korea
In 2009, clinical research date from Allergen showed that the incidence rate of Core study Stage 3~4 capsular contracture in the past 10 years was 19.3%.

The incidence rate of capsular contracture builds on therefore, the incidence rate would be much higher if you look that the past 15 years. However, the incidence rate with the polyurethane implant over the past 15 years was not more than 1%.



This is about 1/20 of silicone implants therefore there is a concrete result of microurethane implant capsular contracture. You do not need to worry about capsular contracture.
 
4. Does microthane cause cancer? (False)
 Breast augmentation in Korea
At first, there was a critique that polyurethane caused 2,4 TDA after animal tests. But the results from clinical tests showed quite the opposite on the patients. This has been certified by FDA also. Polyurethane does no lead to cancer. This is a scientific proven fact.

5. Does microthane disappear over time? (False)
 Breast augmentation in Korea
This is one of the most common misunderstandings of polyurethane implants. The outer layers of polyurethane implant dissolves with the epidemis. It does not disappear. It cannot be found in the blood or in any part of the body.

6. Is microthane more difficult for breast surgery? (False)
 Breast augmentation in Korea
We cannot say that the procedures for microthane and cohesive gel implants are different. The methods are rather the same. But, there are know-hows of the surgeon that lead to the best outcome possible.  You need to make a larger pocket for microthane implant compared to the cohesive gel implant. Also the incision must be longer (not as much as to lead to a wound)

7. Is microthane harder than the silicone gel implant? (False)
 Breast augmentation in Korea
When the polyurethant surface grows with the skin tissue for 6~9 months after the surgery, your breasts may feel hard. But after this stage, your breasts will feel the same as always.



In fact, the incidence rate of capsular contracture decreases a lot, therefore, there is a less chance of your breasts feeling hard. The augmented breasts must avoid capsular contracture in order to feel good. Therefore, it is rather wrong to say that the polyurethane implant feels less good.

8. Is it impossible to remove microthane implant? (False)
 Breast augmentation in Korea
There are some situations where it is difficult to remove the implant but most of the time, it is rather easy. The microthane is very flexible therefore it is easy to remove the implant from the body. There is more difficulty in removing the silicone gel implant if there is a capsular contracture because the epidermis becomes thick, hard and strong making it more difficult to remove.

We went through facts and rumors of microthane implants. I hope that the contents have helped out on your understanding. We will keep you updated with more information.

Thank you very much.

Important scientific discoveries have always started with an observation. Profound scientific advancements have begun with an observation of a seemingly mundane phenomenon and testing a hypothesis formed from intuition. 

It is significant that several recent studies reported that patients who received breast augmentation surgeries using textured implants experience a higher incidence of ALCL (anaplastic large cell lymphoma). Comparing the properties of the textured shell to the smooth shell and analyzing how they can relate to the pathophysiology of ALCL can help us find important clues for preventing serious complications such as capsular contracture. In Korea, ALCL is not given enough attention and it is important that more plastic surgeons started learning about ALCL.

The first case of breast implant associated ALCL (BIA-ALCL) was reported in 1997 by John A. Keech Jr. He reported a case of anaplastic T-cell lymphoma developing in a 41-year-old woman who received a breast augmentation using saline implants (John A. Keech Jr., ANAPLASTIC T-CELL LYMPHOMA IN PROXIMITY TO A SALINE-FILLED BREAST IMPLANT. Keech, John A. Jr. D.O., F.A.C.O.I. Plastic & Reconstructive Surgery: August 1997 – Volume 100 – Issue 2 – ppg 554-555).

Previous to the above report, a dermatologic study reported three cases of cutaneous T-cell lymphoma in association with silicone breast implants. However, the association was only a conjecture and was not scientifically supported (Duvic, M.,Moore,D., Cutaneous T-cell Lymphoma in Association with Silicone Breast Implants. J. Am. Acad . Dermatol. 32:939,1995).

Keech reported that a small mass was felt in the lateral right breast of a patient who received bilateral breast augmentation with McGhan’s textured shell round type implants 4 years ago. In 1996, the mass grew larger and excisional biopsy confirmed anaplastic large cell lymphoma.

Image 1. ALCL CT image (Source: Keech’s report).

On CT imaging, lymphoma is seen surrounding the right breast implant and scattered axillary lymph nodes can be observed (Image 1). The patient received chemotherapy and achieved complete resolution. Radiation therapy was carried out and complete clinical recovery was achieved. Implants were not removed and did not obstruct chemotherapy or radiation therapy. The aesthetic appearance was not compromised after cancer treatment. However, the association between saline implants and non-hodgkin’s lymphoma could not be clarified with this single case.

At the time of publication of this study, there was a growing concern over a possible association between silicone breast implants and autoimmune diseases and breast cancer in the US. The academia was too preoccupied with in this concern that the rare association between silicone breast implants and ALCL seemed much less important at the time. 

However, other reports of ALCL developing after breast augmentation with silicone implants followed. In 2011, FDA issued an announcement recognizing breast implant associated ALCL. However, the association was not scientifically confirmed. 

The science of plastic surgery is rapidly changing. The changes are so fast-paced that I started comparing today’s trends to last month’s, not last year’s. Things that were thought impossible before are becoming reality before our eyes. In such a volatile environment, we are pushing on without knowing where we are going. However, we still need to prepare for the future and that starts with reviewing the past. Dr. Joo-hyuck Lee of KIES-U Plastic Surgery Korea leads a new series on the present and future of plastic surgery.

What is behind the recent popularity of microtextured implants?

I am seeing more and more patients asking about microtextured implants for breast augmentation. Sebbin or BellaGel products are some of the most popular. Many doctors may still be unfamiliar with the term ‘microtextured implants.’ In the past, Allergan’s Biocell was categorized as macrotextured implants and Mentor’s Siltex as microtextured implants [Derby, Brian M.; Textured Silicone Breast Implant Use in Primary Augmentation: Core Data Update and Review, PRS Jan2015;135(1), 113-124]. However, such categorization was used within the academia and was not widely used by the public.

The current popularity of the term microtexture does not accurately reflect the scientific concepts and is being rampantly used as a marketing keyword by distributors and even some plastic surgeons.

The microtextured implants of Sebbin, a French manufacturer, have become very popular in Korea. Advertisements claiming they offer a natural texture with a lower risk of capsular contracture have successfully won over the public. And naturally, Sebbin’s implants have become very hard to come by in Korea. Catching on to this new trend, BNS Med quickly developed a microtextured implant line called BellaGel and entered the Korean market.

These microtextured implants have micro bumps on the surface that are only 30-40 micrometers wide. This creates a very smooth surface. What is the reason for designing the bumps to be that small?

Sebbin’s product catalog does not mention “natural feeling” anywhere to describe their microtextured implants. 

1. Ease of insertion and less friction on the tissues.
2. Minimizing the rate of capsular contracture.

It does, however, explain that the implants are “textured and are not prone to capsular contracture. The microtextured surface makes it easy to insert them.” However, there is no clinical or scientific data supporting this claim. It is surprising that many people have accepted as a fact that microtextured implants are safe from capsular contracture due to aggressive marketing.

 Any surgeon specializing breast augmentation would know that the resistance of textured implants to capsular contracture is irrelevant in Korean patients who mostly go through submuscular placement. When McGhan first developed the textured shell, the primary goal was to promote tissue ingrowth and prevent capsular contracture. However, there is a growing consensus that they failed in achieving this goal. 

Early on, Tebbetts already explained that the textured shell is not effective in preventing capsular contracture.¹ He found that some plastic surgeons mistakenly think that tissue adherence of the textured shell is important for preventing capsular contracture. However, FDA’s PMA study (comparing textured and smooth saline implants) already found there is no difference in the incidence of capsular contracture between the two types. 

Image 1. Source: S. Barr, BSc, Current Implant Surface technology: An Examination of Their Nanostructure and Their Influence on Fibroblast Alignment and Biocompatibility,; Open Access Journal of Plastic Surgery, 2016:9:198-217.

Image 2. Source: S. Barr, BSc, Current Implant Surface technology: An Examination of Their Nanostructure and Their Influence on Fibroblast Alignment and Biocompatibility,; Open Access Journal of Plastic Surgery, 2016:9:198-217.

Image 3.

Image 4. Source: S.Barr, BSc, Current Implant Surface technology: An Examination of Their Nanostructure and Their Influence on Fibroblast Alignment and Biocompatibility,; Open Access Journal of Plastic Surgery, 2016:9:198-217.

Image 5.

Table 1. The 14 point plan for preventing capsular contracture. It cannot be said that all surgeons agree with this but various peer reviews have mentioned similar measures for preventing capsular contracture in the past few years (Source: William P. Adams, Jr., Macrotextured Breast Implants with Defined Steps to Minimize Bacterial Contamination Around the Device: Experience in 42,000 Implants., Plast. Reconstr. Surg. 140:427,2017).

Things to consider when conducting inframammary fold incision

In the first surgery, I tend to select axillary / inframammary / areola incision in ratio of 4:4:2. I tend to hear some weird informations when I talk to the patients. Some tell me that “inframammary fold incision is only for the beginning surgeons because it is a basic skill.”



I thought that this was some nonsense when hearing it from a perspective of a well experienced surgeon. This is why today, I would like to share about the things to consider when conducting inframammary incision.

Inframammary fold incision is not something good for beginners to perform.

All surgeries have some things that are easy and not, but we cannot say that appendectomy and cesarean or any other operations are easy. Nothing are as simple as you say.

The problem with the inframammary fold incision is the location of the incision.



Desquamation and putting in the implant are enough for areola or umbilical incisions. But for inframammary fold incision, first we need to estimate where the inframammary fold is and then conduct the incision.

So if the incision itself is done is the wrong place, there is no turning back. When we design the surgery, we need to exactly estimate the correct incision spot. This requires much experience.

This is not something that can be done lightly. There are many different variables for different patients such as the area of the implant and the other is how elastic the skin is.



The area of the implant can be found in the information provided by the manufacturers and we refer to that when drawing out the location where the implant would be put in. The problem here is that when the implant goes in into the breast, the skin gets pulled and becomes tight causing the areola/nipple to shift from the original location. So we need to foresee this change and know where the areola/nipple to shift to in order to draw out the implant housing position.

There is another variable. It is the distance between the nipple and the inframammary fold. The skin in this area extends in different degree from one person to another. So when we design the procedure, the assistant has to pull the breast skin towards the collar bone and measure the distance from the nipple to see where the new position of the inframammary fold would be.

In most of the time, the doctor uses formula of implant height and others in order to find out the distance between the areola and the new inframammary fold. The number would increase for aged patients who have loose skin and decrease for those young patients who have tight skin.

It also becomes difficult if the location of areola and the breast mound are different. If the right breast is rather higher than the left, then the implant pocket of the left breast would have to be made below the pectoralis muscle and there should be dual plane on the right breasts so that the right breast is pulled up more with the usage of the implant. We consider this point and design the procedure so that the left and right breasts are at the same height level after the breast augmentation.



It becomes a little easier if the left breast if lower than the right but it is larger than the right breast. If we put in larger sized implant on the left breast than the implant would pull down making the inframammary fold of both breasts at the same level.

Suture is also important in inframammary fold incision. It is different to that of axillary and umbilical incision. The incision is done on the bottom part of the breast and this has to hold the implant. If there is some inflammation caused or the stitch loosens then the whole surgery must be conducted again.

Not only is stitching necessary, but we need to maintain the capsule and others as much as possible along with precise desquamation. We need to suture all the structures in the body in perfect shape. The surgeon needs to be careful of all these factors in order to avoid any complications that might be caused.

Inframammary fold incision can be applied to any shape of breasts and any situations with many different techniques to come up with best possible result. But, one must be more careful about the things that you do not need to be careful of in other incision methods in order to avoid any complications and problems.

This is why inexperienced doctor cannot perform with good result.

I hope the contents have helped you today.
Thank you for reading and have a great day.