Hello everyone, today, I would like to share about cellular fat graft.

Fat graft has 100 years of history. In the early 20th Century, Eugene Hollander wanted to retain the lost sink hole type fat on the breast and conducted fat graft for the first time. (1912) Ever since, injections were used for fat graft more and more.



US had the most advancement in fat graft. The breast augmentation was very popular in US and at first, fat graft was mainly used for breast augmentation. However, the doctors realized that the injected fat did not last for a long time and turned their attention to implants.

In 1987, ASPRS announced that fat graft would influence of having breast cancer and pushed for a ban in fat graft for breast augmentation. Since then for about 20 years, there were no practices of fat graft.




In 2000, Prof. Sidney Coleman from NYU announced findings on his study on fat grafted patients. The finding was that fat graft can have enhanced prompt engraftment and there is no problem in detecting the severe case of seroma.

There were many critics that were already expected and in 2009, ASPRS retracted the ban on the fat graft for breast augmentation. ASPRS accepted Prof. Coleman’s findings.
Prof. Coleman’s fat graft gained momentum.

He became a pioneer and his technique called “Coleman technique”, which involves low pressure fat collection, centrifuging, 17 gauge thick pipe injection, became a standard for fat graft worldwide.
The official name for Coleman technique is “Structural fat graft” or “Coleman System”.



Much time passes since then. Doctors all over the world studied the effectiveness, safety of fat graft and the methodology in detail as well. There were many doctors who judged that Coleman technique was good and retained it, but there were many doctors who believed that the technique had to be changed.

Then in the early 2000’s, Plastic surgery team from Pittsburg, US finds out about ADSC. It finds out that fat is the largest storage module for stem cells. This was the most innovative turning point in fat graft technique development.

The history of fat graft is divided between before and after of this finding on stem cells. In WW1, the soldiers with facial damage used fat graft for treatment that resulted in very positive end but nobody know how that had happened.



Today, many doctors think that ADSC has expedited the growth of stem cells.
In 21st century, we accept that there are 2 large concepts to fat graft.

First is the “filling” and the second is “cell growth”. When you get fat from somewhere and inject it to another spot, the fat must be preserved in an undamaged state and engraft filling up the wrinkle or breast. There is 1 million stem cell per ml of fat and this must be preserved properly and injected. There must be both “filling” and “growth” effect achieved in this process.



Then what is the methodology? Traditional fat graft method is made with a few changes. Fat graft should not be perceived to be just for “volume up” but maintaining the state of the cell and leading to cell growth. We call this cellular fat graft. This is the biggest attractive point of fat graft compared to filler injections.

1) Fat can be collected from any part of the body; Stomach, thigh, waist, knee or elsewhere. There is no fact that fat from a certain part of the body is better than another. Fat should be collected from the body part that has the most fat.

2) Recompressed fat collection is the basic method with the usage of injection (Do not use any mechanical equipment)

3) There is no evidence that centrifuging is necessary for better engraftment. Do not enrich the fat cells but let them swell down naturally. Both the surrounding environment and the fat must be well preserved.



4) Fat collection should be done as quickly as possible. One must meet quick freezing conditions if wanting to use frozen fat. Therefore it is dangerous to use any normal freezer for such case.

5) Fat engraftment cannot be enhanced with the help of using stem cells or medication. It is important how much fat can be used and live to grow in the new spot for better engraftment.



6) Most people to not apply more than 100cc of fat on midface. About 30-40% get engrafted permanently.

Today, there are many patients who are interested in filler. The process is quick, cheap, and there are no complications followed.

But this commercial purposed filler cannot be injected too much into the body as it is a foreign substance. Also it causes some damage to the skin.

Also there is no connection between filler and cell growth. It is not effective for anti aging. You could say that it is currently in a transition period.

Fat graft involves moving fat from one part of the body to another so if there is no engraftment, the fat gets removed. Condensed substance such as filler tend to build-up together therefore cannot be removed at times.

Also, as stated previously, stem cells have the ability to reproduce damaged cells.



There are some discussions on whether fat stem cells can lead to anti-aging. We do not have the medical ability to avoid aging, but we can expect the stem cells to help in reproducing the damaged cells on the skin.

One example can be skin damage from ultraviolet. We expect that stem cells could help recover the damage skin. It may not be rejuvenating but there are certain expectations.
'Cellular fat graft' has two goals of filling up the volume and recovering the damaged skin tissue.

It is not important to control the state of the fat in some way, but it is more important to maintain its natural state without any damages for engraftment. Exact amount that can be engrafted on the face or breasts much be used and the injection needs to be quick as the fat should not be contaminated or damaged.

The main objectives of Cellular fat graft are recovering the damaged skin tissue, anti-aging through filling volume and improving the shape. Another goal is to enhance volume through high engraftment level in breasts or buttocks.

This is all for today. Thank you very much.

Some characteristics of microtextured implants

Hello everyone. Today I would like to share about the characteristics of microtextured implant along with its advantages and disadvantages.

1) What is microtextured implant?

Texturing in implant is uneven surface where the skin cell can grow into. The purpose of texturing is to avoid capsular contracture. As the tissue cells grow into the surface without any uniformity, we can avoid the development of strong and tough capsule.

The only surface that truly avoids the capsular contracture is the polyurethane. Silicone texture was made in order to do what polyurethane can achieve. You can see this in the image below.



This is an endoscope image of polyurethane structure that is complex and maze looking like. The body has its tissue cells grow into the spacing in the structure. No matter how good the texturing is on the silicone implant, it cannot be as effective as the polyurethane when the tissue cells grow. The silicone texturing has some level of smoothness therefore there is a limit to how much the tissue cell can grow into and ending up with just sticking effect.

The most representative texture surfaced implant is Allergan’s Biocell. It has the roughest surface and the depth of the texture is few hundred micrometer making the tissue cells grow into it. Other companies applied other methods in making the texturing. Mentor made Siltex texturing product but it has less rough and smoother surface compared to Biocell.

But European companies made smaller textured products. The sales were not good and they were not popular. French companies such as Sebbin, Nagor, and EuroSilicone continued to make such products. These companies made products with texturing that is 2 digit micrometer which is not comparable to Allergan or Mentor’s products.

It is difficult to make out if there are any texturing on products from Motiva and Arion. Such products rather have smooth surface instead.

Reference : SEBBIN homepage

2) Why was microtextured implant produced?

As stated in Sebbin website, the microtextured product causes less friction when inserted into the pocket. It also was produced to avoid any scar making activity and to minimize the incidence rate of capsular contracture.
But such marketing and production does not take place in France. Microtextured products are not popular in US or Europe.

There has been much variety of implant products and new products have been launched in the market for a long time. From all those new products, only 1/10 had much success in the long run. Then can microtextured implant stay in the market for a long time?

Nobody knows that answer to this question yet. We need to wait few more years in order to know this. The history of implant is very long and interesting. Once the implant gets inserted into the body, it remains in the body for a long time. When there is a class action lawsuit, the manufacturer can go out of business instantly. This is why the manufacturers focus more on safety rather than innovation.

The opposite of microtextured implant is macrotextured. It is a silicone implant with surface that has characteristics similar to that of polyurethane. Polyurethane is the only type that has success in avoiding capsular contracture, therefore macrotextured copied this concept. But as time passed, many problems started to arise.
 


World known breast augmentation specialist, Dr. Elizabeth Findlay found problems of double capsule and seroma. The largest company in the world with macrotextured implants is Allergan and this company suffered much damage. Many researchers supported by Allergan published critics to what Dr. Findlay discovered.

As times passed, Dr. Findlay’s findings did not suffer any weakness but gained more momentum with other findings that followed. There were many Me too! Me too! findings. The finding that macrotextured implant resulting in double capsule and late seroma became more firm and solid.

Also, recently there were findings that macrotextured implants were related to severe case of lymphoma. Smooth type implants gained more popularity in US and many questions on texturing products arise in EU. Microtextured products do not have much texturing therefore, are much close to the smooth type implant. With many critics focused on texturing implant, maybe there is a chance for microtextured product to gain some spot light.



3) Advantages and Disadvantages

The advantages are that it can be inserted easily, feels good when you touch it and that there is no disturbance on the skin.

We still need about 10 years to know if it causes capsular contracture less or more. There are not much sufficient data yet. Tissue cells not growing into the surface means that the implant cannot stick to the skin. There is not much difference compared to the smooth type implant in such regard. What is the collapse rate of microtextured implant? We do not have much data on this as well.

4) Then for what cases is the microtexture implant good?

I recommend form stable (round or anatomical) implant to those patients who gave birth, lost skin elasticity, or need to fill up the upper volume.
I recommend smooth round type implant to those patients who are young with tight skin and want soft feeling on the breasts.
I think that microtextured implant could be recommended for the latter as well. There is not much difference in the surfaces of the smooth round type implant and microtextured implant.

Also, the microtextured implants introduced in Korea have much viscoelasticity. So when you touch the augmented breast, there is that more feeling of stickiness which many patients prefer. But such viscoelasticity does not help avoid rippling or enhance form stability. There is no data that state viscoelasticity helps provide better feeling in the long term.

In conclusion, microtextured implants require much research in the future. When data are gathered along with many clinical testing from the doctors, we can provide you with more accurate findings.

This is all for today, thank you for reading.


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Is the result good?

This is one question that everyone would ask after a cosmetic surgery. Whether it is the nose or the eyes or any part of the body, the patient would be curious about how his/her body has changed.

Today, I would like to share about “what is a good breast augmentation?” and “what is the standard of a good surgery?” All results can be objective at the earliest between 2 to 6 months.



1. Location of the implant

Breast augmentation involves making a pocket and putting a foreign substance, implant, into that pocket. This is rather a simple procedure. The surgical method is not too complex. It may be one of the simplest surgeries.

But the problem arises after the implant is put in. The implant does not stay in that particular location. As times passes, the implant tends to move to another spot. We can estimate such movement. Capsular contracture is one of the main reasons that lead to this movement.

If the implant is out of its location, the breasts may look asymmetric, look like the upper volume is lost, and the breasts may look too far apart or too close to one another.



This happens when the capsule formed, pushes the implant to one side.
We can know the exact location of the implant by observing where the nipple is pointing towards. When you look at the breast gland, the nipple should be located in the middle. If the implant is located at the upper part of the breast, then the nipple would be pointing downwards. If the implant moves to lower part, then the nipple would point upwards.

If the implant moves more inside, then the nipple would point outwards. As such, one can know if the implant is in the appropriate position or not, by looking at where the nipple is pointing.



Just talking about it is easy, but one needs to consider many factors of the breast before the augmentation surgery because of all the complications that may follow. There are many cases where the patients have unaligned breasts before the surgery.

Therefore, we need to look at each breast separately; right one by itself and left one by itself. But the patients take a look at their breasts together at a glance and state which breast or nipple is higher than the other. Also, your eyes are positioned higher than the breasts, therefore when you see the mirror, it is difficult to judge the position of the implant objectively. It is better to take a photo in order to make more objective judgement but the position and the direction of the camera lens has to be horizontal with the position of the nipples.

2. Feeling of the breasts

There is no objective way to determine this. Everyone feels different towards whether the breasts feel soft or hard when they touch them. How soft should the breast be for you to feel that it is good? How hard should the breast feel in order to know that it has capsular contracture? What is the accepted level of feeling that there is a foreign substance?

There is no answer to all these questions. This is the difficulty of judging how the breasts feel after the breast augmentation. Below is the relatively simple standard that I have made.

1) When you push the breast to 12, 3, 6, or 9 o’clock position, it should not feel that the breast is stuck down or be resistant to the push

2) The implant should move together with the breast skin (If there is a capsular contracture, the implant would not move but the skin will. If the pocket is too large, then the implant would move far greater than the breast skin)

3. Infection and inflammation

I have shared much about infection in the past. There are 4 symptoms of infection : oppressive pain, swelling, red reaction and fever.

“Pain” itself cannot mean that there is and infection. There needs to be some symptom of infection in order for you to know accurately.

When you push a certain spot on the body and if that hurts, we call this oppressive pain. But we need to know for sure if that particular spot is hurting or not. When we put in the implant into the body, there is a high possibility that germs build up around the implant.

There are findings that these germs are the source of capsular contracture and when they become active, they could lead to severe case of infection damaging the tissue cells around. This can be notices with in the first 2 or 3 weeks of the breast augmentation. After this period, capsule is formed around the breast that stops the oxygen and nutrition reaching the germs, making them obsolete. The wound or puss from the infection is already formed at this stage.

The infection is at the peak level within the first few weeks of the breast augmentation.

4. Breast symmetry

There are many reasons on why breasts on each side look different.
First is the asymmetric position of the two nipples. This is important because there are many patients with one nipple higher than the other. In most cases, the left nipple is higher than the right nipple because we have different organs located at different sides of the upper body. There is a heart on the left side, and the lungs on each side look different as well. Most people have left rib that is higher than the right. The skin acts as a cover therefore the skin on the left side is tighter than the right.

For the same reasons, the inframammary folds are asymmetric as well. You can find this 90% of the time.

Second is the bone asymmetry. The bones composed in the chest are, sternum in the middle, ribs on the sides, and spine on the back. There are very rare amount of people with sternum exactly in the middle. Most people have sternum a little to the right or left. This limits the area of the implant pocket that can be made on each side. The side with a larger chest would have more space for the pocket, vice versa. This is why we also need to limit the size of the implant.



Also, there are many with curved spines. It may be because of the computers, but there are many patients with bend neck and spines. Curved spines mean that the breasts cannot be symmetric. This cannot be treated in cosmetic surgery.

Third is the volume asymmetry. Most patients have left breast that sticks out more than the right. The left chest is larger therefore the bottom area of the left chest is higher than the right. In most cases, we use small volume implant on the left to match the size of the right.

In order to fine out the symmetric result of the breasts after the augmentation, we need to know that original status of the body before the breast augmentation. If you have smaller chest and lower inframammary fold on the left, you may have a dilemma. Using a larger size implant would pull down the inframammary fold more downwards. You need to talk about such things with the surgeons beforehand. Of all the problems that you can have after the breast augmentation, breast asymmetry is the most difficult one to treat. Your original breast and chest are all asymmetric.

Today, we looked at what a ‘good surgery’ is. I hope the contents have helped you out.
Thanks a lot and have a great day.

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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