Current selection for implant depends on whether the product is “new or not”. The customers are less interested in types such as “smooth” and “anatomical” therefore the clinics use the term “new product” in order to gain more interests.

Microtextured product is not a new one. It was produced by Arion in France more than 10 years ago. Eurosilicone, Sebbin, Motiva and Bellagel followed after and the product has been popular in Korea.



Let’s look back about 6 years ago, when anatomical implant was first certified in Korea about 2011.
Everyone was talking about the anatomical type ever since.

Those who did not have any knowledge about breast augmentation somehow related “breast augmentation” and “anatomical implant” together.

There was a reason for its presence and its value was great for those who needed it. This applies to all type of products.

A general storyline was “Anatomical implant = Natural looking breasts” which appealed to the general because the people thought that it would just provide natural looking breasts. Of course, anatomical type was more expensive than the round type.

However, such process is not appropriate. What you see cannot be the judgment for what happens in the future, the effectiveness and complications that may come up.

Our population is small and so is our country, therefore there is a “wave” of customers going into a certain “hit item”. In this case, it was the anatomical type implant.



Such trend lasted for about 3 years.
Anatomical implants have its defects as well. When a product is used for a long time, people tend to find out the defects and the prices tend to go down.

As the prices went down, the clinics that used this implant did not find it appealing. They all looked for highly priced new product that could fulfill the high expectation of the customers.

This resulted in the microtextured product that we have today. (Sebbin, Motiva, Bellagel, Eurosilicon, etc)

Soon the popularity of microtextured products will settle down, and there will be a new product in the market.

Today, I do not want to share about a “new product” but something that has been in the market for a long time. And during this time, this product has resulted in some good outcomes. However, the surgical procedure is rather difficult.

The name of the product is Polyurethane foam coated breast implant.
The inner substance of this product is silicone as well. Just the outside has been coated with polyurethane.

1. Is polyurethane safe?

There has been a report that TDI from polyurethane caused cancer in animal testing which led to recall of its products from BMS in 1991.

FDA soon studied for cause of cancer on human body soon after.

In 1995, FDA announced that the polyurethane implant from BMS had very rare chance of causing cancer. This certified the safety of polyurethane implants. But the company did not manufacture the polyurethane implants.

There was a huge class action on silicone breast implants at the time in US. The largest medical product company, Dow, went into bankruptcy due to this class action.

But, this was a witch hunt. Soon after, people found out that the silicone gel did not have any influence on the health of the people.

Polyurethane, too, does not have any effect on health. FDA clarified this as well. It also was studied that polyurethane has very low incidence rate of complications such as capsular contracture, collapse, damage, bleeding, infection, etc.

2. Why is the incidence rate of capsular contracture low?

Many are interested about capsular contracture. We need some explanation on why polyurethane implants have low incidence rate of capsular contracture.




There is no clear understanding of the cause of capsular contracture but we do not the process of it. We see it as a resistance to foreign substance. Macrophage, one of infection cells, plays the main role. The infectious cells surround the implant heavily, and release substances that the fibroblast get attracted to.

When fibroblast gather, it generated collagen that grows into same direction making strong and tough capsule. This is the start of the capsular contracture.

But polyurethane has a surface that is not smooth but sponge net-like structure.
The infectious cells fill up the net-like structure therefore they cannot grow into one direction. The collagen grows into all different direction.



The capsule formed cannot be strong or tough but is very weak. This is why the incidence rate of capsular contracture on polyurethane implant is low.

3. What happens to the patients who use polyurethane implants after a long period of time?

Polyurethane is a type of coating material. The coating dissolves into the capsule after 2 years. The coating cannot be visually seen after 5 ~ 9 years.
The polyurethane disassembles therefore the capsular contracture starts to form when the polyurethane disappears.



Dr. Don Parsa from University of Hawaii released a report of 30 year study on polyurethane implants. The earliest period where the capsular contracture was found was after 9 years of its usage. After 9 years, the incidence rate of capsular contracture increases year by year however, there was not one case of capsular contracture within the first 9 years.



Although the polyurethane coating cannot be seen visually, it does not mean that the coating has been completely disappeared.

You can see it through the endoscope. The polyurethane remains on the capsule. The invisible polyurethane must have resisted the formation of capsular contracture for 30 years.

Dr. Parsa stated that incidence rate of other complications such as collapse, inflammation, and etc is also lower on polyurethane implants.

4. Why is the usage rate so low for polyurethane implants?

All the readers might feel the same. If this product is so good then why don’t the doctors use it?

There are various reasons, but first, technically the polyurethane is more difficult to use than the silicone type. The surface texture is very rough therefore it is difficult to put in the implant. (We can use funnel to put in the implant which makes the process easier) The price is relatively expensive as well.

But I think the more important reason is the habit of the doctors. Silicone implants have more variety and there are many producers and many promotions for the product. But polyurethane implant has low level of awareness and it came into the market rather late therefore it is not the “core product” in the hospitals.

There are many doctors who think that there are other products that can be used rather than the polyurethane implant.



However the incidence rate of capsular contracture on polyurethane is 1/20 of silicone implant. Of course there has been many developments in silicone implants to lower the incidence rate of capsular contracture, but the capsular contracture itself is a scare to all patients. This shows how much great a value the polyurethane implant has.

5. Rumors on microthane implants

Microthane implant is the only product that improved on the problems on silicone implants. There has been numerous trials in 60~80’s with no success. Microthane product is the only successful product.
Microthane is the only product with 30 year research data as well.

Also, FDA is certified that there needs to be no concern on if the product caused any form of cancer.

There are rumors that microthane implant is difficult to remove, but this is not the case with the doctors who have actually done it. There are saying that the incidence rate of capsular contracture is low, but high for inflammation or seroma. This rumor comes from those doctors who have never even touched the microthane implant once.

Those who have only touched the silicone implant think that the microthane implant would feel hard, but this is not the case. Microthane implant feels very soft and good. There is no feeling of foreign substance.

As a cosmetic surgeon who conducts breast augmentation, I hope that more people use polyurethane coated breast implant.

The product has been certified for a long time and it has value for those patients who need reconstruction due to capsular contracture.

This is all for today. Thank you.


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We have shared about many problems related to breast augmentation but I don’t think that there were any proper explanations on symmastia(uniboob). Today, I would like to share contents on symmastia.

- What is symmastia?
; It refers to the condition where the breasts are too close together.

Then why does this happen? This happens when the fascia separating the two breasts collapses. The skin that divides the breasts cannot hold on but lifts upwards. So this division skin part is the important factor that we consider in symmastia(uniboob). The implant can also move from one side to another of the mid-line. This happens when the mid fascia of the chest collapses.
 


As the image above, your breasts may not look like there are close together but if you push the inner fold inwards, you might notice the problem.
 


In a severe case of symmastia, the implant might cross the mid-point and go to the opposite end. We can check how severe the symmastia is by measuring how much the mid-line is lifted upwards from the bottom side.



- What is the cause?

This happens when the surgeon dissect the inner part too much. If the part connecting the pectoralis muscle and the breast bone is removed a lot and dissected, the film in the middle gets disconnected and the division part disappears. 

There are some cases of symmatia without such dissection. Such can happen to those with funnel breasts or if the implants are too big.

- What is a common cause of synmatia?

According to Dr. Spear’s research, symmatia is common among those who got breast augmentation with implant located below the pectoralis muscle, if the patient got multiple breast augmentations, if the implant size is too large (400cc or larger), if there is some problem on the breast bone or if the patient received breast augmentation and saggy breast surgery simultaneously.

- How can we prevent or treat symmatia?

We need to avoid the means of the causes stated above. When dissecting, there needs to be as much skin tissue left on the inside. You should not get multiple breast augmentation surgeries. You should avoid using large sized implants, etc.

Symmatia results in follow-up surgeries. We need to dissect into a new spot which is above the original spot and make a new plane. The new smaller implant will be placed on this new plane. Although the facsia dividing in the mid-point is damaged, the new capsule formed holds on strongly into the surrounding skin tissue therefore this could be used as the new dividing film. If this does not work out, we need to make a new capsule by lifting up the skin, but this method is highly difficult.



There are many who wish that their breasts do not look too far apart. There is a simple solution for separated breasts by controlling the dissection size, but the breasts that are too close together is very difficult to work on. Therefore those with funnel breasts and those who are thin should avoid large sized implants.

This is all for today. Thank you very much.


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Breast Augmentation Korea. Let’s find out about how it feels

There are many who question about how the breasts feel after the breast augmentation in Korea. “What is the best method that makes the breasts feel good?” Patients want their breasts to be as natural as possible.

But it is really difficult to find information on how the breasts feel. The sense of touch is very objective from one person to another therefore there are various opinions such as “@@@ thinks that the breasts feel good”, “XXX does not think that the breasts feel good.”

Today I would like to share about how the breasts feel when you touch them after the breast augmentation. I would like to share how you can judge if the breasts feel good or not.

First, I think it is appropriate to share what is the worse sense of touch that you can feel. This, as all of you know, is when there is capsular contracture.



What is capsular contracture? Capsular contracture happens when the wound inside becomes stiff or contracts forming capsule.

The most famous one, Baker contracture is as below.

Grade 1 ; Normal
Grade 2 ; A little stiff/hard
Grade 3 ; Feels stiff/hard and the shape changes
Grade 4 ; Feels very stiff/hard, shape changes, and there is pain

But such expressions as “little”, ”stiff”, “very” do not have much meaning because most patients who get breast augmentation would be first-timers therefore they would not be able to judge if the breasts are little stiff or not. The doctor needs to judge this.

“Stiff/hard” means that the implant inside does not move about but stays at a solid position. When you touch the breast and feel that it is really hard, you will know that the implant does not move but stays at that particular spot. You can feel this when you grab the breast or push it to one side.
“Resistance to movement” would be the first characteristic of the breast that feels bad.

Second is the ‘feeling of irritation’ from foreign substance. When you touch the breast, you do not feel the fat but feel something inside. Such would not be satisfactory. The foreign substance can be felt well when you grab the breast.

The breast that does not feel good is one with no movement and feeling of the foreign substance. Actually, you can feel something insider the breast after the augmentation. But if this feels too much, then the person touching it may feel irritated. This is what we call “feeling of irritation”. 

In oppose, “the breasts that feel great” have some movement to any direction and there is no feeling of foreign substance inside the breasts. What is the movement is really severe?
Let’s say that you push the breast to one side and the implant inside moves close to the collarbone or even to the stomach. We cannot say that this is good. “Appropriate movement” is important.



Such “appropriate movement” can happen when there is no capsular contracture. First of all, it is important that the surgeon makes good sized pocket for the implant. If the implant size is that of your first, then you would need to have a pocket that your fist can fit it. The implant would look like it is trapped inside that pocket and it would feel unnatural when you touch it. This cannot be corrected in the long term as well.

What if the pocket size is larger than you fist? The implant would move around here and there. You would be able to notice such active movement.

Appropriate size of the implant requires certain area space but it should be just right for the implant. This would result in the breast feeling good.

But this is not simple. The skin tension surrounding the implant differs from one person to another. This is like wearing a dress that does not stretch at all and wearing a wool shirt. The same doctor uses the same method to put in the implant to the pocket on two different patients. You might think that the result on both patients would be the same but this is not the case. Each patient has different skin tension.
 


We can check on this in the doctor’s room. We can how much stretch ability and elasticity your skin has. It is not 100% accurate but we can know how tight the skin is.

As the image above, we pull on the nipple to see how much movement there is. If it gets pulled easily, there is less elasticity. In such case, your breast would feel very soft no matter what type of implant you use.

If the nipple does not get pulled, there is no stretching but much elasticity. The implant used on such breast would be positioned solid without any movement and it would not feel soft also.

We also need to consider the characteristics of the implant. If the gel charge rate is high and the shell is thick, the implant would feel hard. If the gel charge rate is low and the shell is thin, the implant would feel soft. 

Implant itself is not the only cause of how your breasts feel after the breast augmentation. There are various reasons combined together that lead to the outcome. 

Most ‘soft’ implants have less form stability. This could make your breasts sag. The shell of the implant is thin as well therefore there is high possibility of implant collapse.

The most important factor is making your breasts feel soft is the ratio of your breast tissue cells. If the area of the implant is larger than that of your original breast tissue , you would feel the foreign substance more resulting in less natural feel. If the original breast tissues are thick and implant small, you would have more natural feeling of touch.



In the image above, each alphabet represents a measurement; P (Thickness of original breast tissue cells) ,  I (Thickness of the implant).  F (feeling)

If the thickness of the breast tissue cells is greater, your breast would feel more natural. If the implant thickness is greater, then this natural feel would be worse.

All implants from all manufacturers are made of silicone. It is not part of your body, but it is made in a factory. The implant cannot be felt like your body skin. Therefore if your skin covers up the implant as much as possible, then your breast would feel as natural as possible.

If your original breasts are small with less fact, then you would be better off to use small sized implant for natural feel. But if you have large original breasts and use large sized implants, you still would have augmented breasts that feel natural. Therefore, when you are choosing the size of the implants, it is better to choose small ones if you have small original breasts.

Let’s summarize,
There are 2 factors to how your augmented breasts feel; (1) Appropriate movement of the implant (2) No sense/irritation of foreign substance.

In order to have much movement, there needs to be low level of skin tension (if the tension is too low, the breasts would be those that of old woman). The shell thickness of the implant must be thin and the charge rate has to be low (if the shell is too thin then it could result in implant collapse). The most important one is the “appropriate movement”.

If you want the breasts to feel natural, then the implant size should not be too large compared to the original breast skin.

This is all for today. Thank you for reading.



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Is it OK to get breast augmentation in the summer?

There are many patients who consider the weather for breast augmentation.
There is peak season and off season in breast augmentation also where peak season is the time when everyone wants to get the breast augmentation and the off season is the opposite.



The peak season for breast augmentation is during the school break.
Like the school break, the adults have much time during the New Year’s and Thanksgiving.

Also in December, when most college students have winter break until February. This is a very important peak season.

Now-a-days, there are much difference in peak season and off season, also we have 40 hour week with many replacement holidays therefore the busy seasons are not what they used to be.

Why do you think there are many who want breast augmentation during the cold season?
The schools have longer winter break than summer here in Korea, but there are particular reasons why the patients do not want cosmetic surgeries during the summer.

What are the reasons?
When it is hot, you sweat a lot. The sweating can lead to infection and there are those who think that scars or wounds get worse during the summer. Some think that the cold weather kills bacteria and the wounds can get treated better.

Such perception arises from the thought that wound recovery can be delayed due to infection and inflammation and that this infection and inflammation get worse during the hot weather.

It is very discomforting to have bandage around the body during the summer. It is difficult to have shower as well.
But, what about the wound?



It doesn’t get any worse.
There are hotter countries around the world. Currently it is 32 degree in Seoul and 37 in Tokyo.

Hong Kong, Philippines, Taiwan, Thailand, Brazil, Florida, Singapore and all hotter than Korea. You would not be able to breathe properly in Hong Kong during July because of the heat and the humidity. If you do not turn on the air conditioner throughout the day, you will find mold on the walls.

So if the people in these countries get cosmetic surgeries, there should be much news about wounds not healing, and high incidence of infection and inflammation. But, we do not hear such information. There are no recording of doctors in such hot countries that state ‘patient’s condition gets worse due to the heat”.

Actually, healing takes longer during the warmer season than the colder one.
Hot weather increases superficial hematocele in order to release the body heat. Nerves coming out during the hot weather are caused by the enlargement of the nerves under the skin. This would help the blood flow and if there is good blood circulation, the bacteria causing the infection would not be able to penetrate easily.

Bacteria getting into the body are called infection and the immune system fighting this bacteria is called inflammation. Pus is the dead exposal of bacteria from white blood cell and others. Therefore inflammation is something necessary and it is not a bad thing. Infection is a bad thing happening to the body. Active inflammation can kill the infection that penetrated into the body.
 
The body must not lose heat during the cold weather therefore it decreases the amount of superficial hematocele. Not much blood flows through the skin therefore the skin becomes white. There is not much blood circulation into the wounds as well. This makes the body weaker to infection. The support of immune system is slower meaning not much oxygen and nutrition are provided to the damaged cells.

We use air conditioners when it is hot and use heaters when it is cold, therefore there aren’t much differences in what happens to the wound due to the weather. This is just the principles that I wanted to share.

There are some differences in how experts think and normal people think. But there are no evidences that surgeries in summer are worse or dangerous. Wounds can be healed without much trouble during the warmer days.

The recovery may take longer during the colder days. Sweating is the exposal of liquid in our body. This is not harmful or a bacteria. There is no evidence that sweating causes more inflammation.

Due to the usage of air conditioners and heaters, there are not much differences in the body heat during the different seasons. Therefore, there is no better weather or season for cosmetic surgery. But, if you ask me in which season the wounds get healed quicker, I would say warmer days without any hesitation.
 
I hope that you don’t get sick from the heat. It might be better to restrict outdoor activities in such hot weather.
Thank you and have a great day.

Microthane implant – is it safe to use in the long term?

Today I would like to share about a writing from Dr. Pompei from Rome, Italy, who is a World known specialist in microthane implant augmentation. As you read this post, you will be able to understand the characteristics of microthane implant better.



Ashley first adopted breast augmentation with polyurethane implant between 1970~1972. This is about 50 years ago, a very long time ago. Since then, there has been much advancement and improvement in the technique.

The first implants introduced were hard and had no elasticity. Glue was used to stick the polyurethane on the gel bag. This was not safe. The first generation implant with time would change shape, foam would fall off and also the silicone gel would be separated. This could result in silicone leakage.

Loss of foam in 1st generation polyurethane implant would make the shell become similar to smooth type implant. Some believed that this would increase the possibility of capsular contracture.

But this is not an accurate hypothesis. Capsular contracture is not formed due to the smooth shell but because of the silicone leakage, i.e. implant collapse.

1st generation polyurethance implant was made by BMS (Brystol-Myers-Squibb). I shared about this in my post of 30 year experiment on polyurethane implants used in breast augmentation.

Recently, Dr. Pompei announced his result on 10 year monitoring of more modern product, Polytech’s microthane implant. The essay was published on 2016 Aesthetic surgery journal  (Oxford Press).

131 patients (255 implants) received breast augmentation with microthane implants between 2000~2012 in Sandro Pertini Hospital, Rome. Most patients used round type polyurethane implants with dual plane or above the pectoralis method.

After an average of 110 month follow-up survey, there were 4 cases of malpositioning, 4 cases of rippling, 2 cases of capsular contracture after hematoma, 2 cases of collapse, and one contracture. There were total of 19 complications. Bottoming out effect due to malpositioning was found only on one patient but the cause is unclear.

But when we consider the characteristics of microthane implants, it is unusual that there were 4 cases of malpositioning.

Once the microthane implant is inserted into the body, it immediately sticks to the surrounding tissue therefore the implant does not move about although the patient takes some aggressive actions.

It could be assumed that the surgeon was not careful with the implant insertion during the surgery. The surgeon could have placed the implant in the wrong spot and the implant remained there. If the microthane implant was inserted into the accurate location, it does not move around.

Microthane was larger barrier between the polyurethane foam and silicone gel compared to the predecessor. Also the sticking process was largely improved. The possibility of gel leakage due to the separation of shell and foam greatly decreased.
This is why many expect that the chances of having capsular contracture also greatly decreased for microthane implants.
Of course, we need data that has been gathered for more than 10 years.



Capsular contracture was found in total of 3 breasts. 2 breasts had capsular contracture after hematoma. There was much bleeding during the augmentation that led to the forming of hematoma. The hematoma interferes with the polyurethane foam sticking to the skin tissue. The capsular contracture was formed within a very short period of time (less than 1 year).

The result of this experiment showed that the incidence rate of capsular contracture during 14.6 years is 2.3%. According to MD Spear, an expert in breast augmentation, the 10 year incidence of capsular contracture with textured silicone gel implant is 17.2%, and smooth silicone gel with 19.9%. But microthane implant had incidence rate that is about 1/8 ~1/9 of silicone gel implant.

The structure of micraothane implant is very active and strong. It is very difficult and time consuming to remove the microthane implant after the breast augmentation. The implant holds on to the skin tissue cell tightly.

If you remove the microthane implant from the breast after a few years, you would be able to fine urethane foam tangles with the epidermis. You would see the rest on the implant exterior. We cannot remove this tangled part with scissors or any other equipment.



The information that removing microthane implant harming the patient or that it is impossible to remove the microthane implant is not true. It is difficult to be removed right after the breast augmentation but after some time, it can be removed rather easily.

MD Pompei shows much confidence on his microthane implant research after performing many breast augmentation surgeries. There are some doctors who use microthane implants on capsular contracture patients, but it can be used in the 1st breast augmentation surgery with good results.

Today, we share about polyurethane foam coated implant, i.e. microthane implant and the research from Italy.

This is all for today. Thank you very much.



KIES-U Plastic surgery Korea
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