Bloodless surgery is a ground-breaking approach to surgery that improves the quality and safety of the procedure being performed. Avoiding blood loss during surgery reduces stress on the patient’s body and increases the visibility of the area for the surgeon. Both of these advantages result in a more efficient and effective surgery with less discomfort and a dramatically shorter recovery. Dr. Kenneth Kim has pioneered this technique during his impressive medical career, during which he has implemented countless other valuable techniques in order to offer patients procedures and results that are unattainable at other surgical practices. As a clinical faculty at the UCLA School of Medicine and at Seoul National University, Korea’s leading academic institution, Dr. Kim has the advantage of working closely with the highest caliber of medical professionals nationally and internationally, in addition to his own research and prolific publications. Dr. Kim is a leading authority on surgical techniques and has presented research on the topic at conferences for the American Society of Plastic Surgeons, Korean Society of Plastic and Reconstructive Surgeons, Korean Society of Aesthetic Plastic Surgery, Cedars-Sinai Medical Center and at both of the universities where he teaches. He remains dedicated to sharing these techniques with the medical community. The surgical skill required to implement these approaches successfully has made him among the very few surgeons capable of executing them.
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The complex network of nerves and blood vessels and the many layers of tissue that contain them must be approached carefully and strategically in order to avoid complications. But in addition to knowing where and how to begin a procedure, they must also be well-versed in the body’s many cellular and even molecular mechanisms and the reactions that are triggered by surgical interventions. This includes how the body responds to injury and the processes that accompany the healing process. Even the best intentions and most delicate approaches do not change the fact that surgery is a traumatic event for the body. The body responds to surgery as an injury. This is an essential part of the natural healing process but also poses challenges to the surgeon, and can complicate the procedure as well as the patient’s recovery. The addition of general anesthesia further complicates the process, as it causes changes in the natural functions of the body, and can lead to additional unwanted physiologic changes. Bloodless surgery performed with Awake anesthesia minimizes injury signals from occurring while keeping the body stable for safer surgery. Dr. Kim has been studying this for over 20 years, first as an elected fellow for the Howard Hughes Medical Institute (HHMI) where he conducted a year long research on the molecular mechanisms of tissue regeneration and repair. He has comprehensive and detailed understanding of how cells and the body respond to injury, alterations in cellular and physiologic changes, and how repair mechanisms occur.
There are many fluids in our body that while totally natural, can be devastating when introduced to the wrong part of the body. One of these is blood: blood belongs in blood vessels.
The linings of our blood vessels are specifically adapted to contain this substance. When blood vessels are severed during surgery, blood comes into contact with the surrounding tissues, known as interstitial space. Components in the blood interact with this tissue and are the chief cause of the inflammatory response. Inflammation is in fact an immune response and is crucial for the healing process. Blood is a nutrient not only to our cells but also to bacteria. Once an injury has occurred, immune cells are signaled to eliminate blood (where it does not belong) and bacteria (which is attracted to blood for nutrients) to prevent infection and to begin regenerating damaged cells. However, when this occurs in interstitial tissues during surgery, those tissues become unnecessarily inflamed. When this becomes excessive where too much blood is in the interstitial space, then excessive inflammation occurs. The white blood cells (e.g. cytokines and macrophages) become activated and propagate the inflammatory process. This causes swelling in the tissues, which leads to additional discomfort/pain for the patient after surgery.
One of the most important aspects of Dr. Kim’s approach is to operate within a tissue layer that glides or separates easily. Our body is made up of layers and there are certain layers that glide with relative ease. In these gliding planes, there are significantly less blood vessels and nerves. The problem of finding this gliding plane is that it is so thin for our eyes to see. Dr. Kenneth Kim has developed a method where he delivers energy to drive fluid to find this gliding plane. Fluid always egresses to the area of least resistance. You can demonstrate to yourself by pouring water on a counter. The water will migrate to various areas and dissipate. The force in this situation is gravity. In surgery, Dr. Kim delivers special energy that will drive the fluid to move forward and locate the gliding plane. Dr. Kim will then follow the fluid path and operate within this exact gliding plane. Again, it is important to understand that this gliding plane cannot simply be opened up because the layers separating this plane is so thin and not linear, as the body does not follow a straight line. By staying perfectly within this tissue plane, there is minimal tissue damage and disruption to the blood vessels. Thus, changes in hemodynamics are minimized. Hemodynamics is the study of the movement of blood throughout the circulatory system, and the speed and pressure at which it moves throughout blood vessels. Not damaging or not losing blood flow to skin and subcutaneous tissue allows maintenance of healthy tissue as one ages. In addition, optimal blood flow to tissues minimizes postoperative infection and optimizes tissue healing as it maximizes nutrition and oxygen delivery. An example to better illustrate the importance of maximum blood flow is by looking at the opposite as is the case with severe diabetes. People with severe diabetes have poor blood supply/narrowing of blood vessels. This makes them more susceptible to infection and prone to poor wound healing/scarring.
Less blood staining (from not cutting blood vessels) in the treatment area allows Dr. Kim better visibility as he operates. Blood stains the surrounding tissues during surgery and can make it difficult to distinguish important anatomical landmarks and structures. Poor visibility during surgery is the main cause of surgical error. For example, driving with poor visibility due to snow and fog will increase the risk of accidents. Surgery is no different. Once the blood leaves the blood vessels, it stains the surrounding area and makes various structures indistinguishable.
In addition, decreased blood loss allows for faster recovery as the patient is not tired from unnecessary blood loss. Whenever there is blood loss, we experience fatigue as our key organs such as the heart, lungs, and brain receive less oxygen and nutrients. With Dr. Kim’s approach, the patient’s physiology is not altered during surgery and blood flow remains consistent. Therefore, following surgery, the patient is not fatigued and will feel the same as before surgery.
Again, the key factor of accomplishing minimal blood loss is staying within the gliding plane. During procedures that require manipulating the underlying layers of tissue, such as facelifts, there are several different “planes” in which a surgeon can work in order to make the necessary adjustments. Ideally, the surgeon should work in the layer of tissue without major blood vessels in order to avoid severing them during surgery and prevent blood loss altogether. Dr. Kim’s expertise allows him to locate and operate within these crucial layers of tissue. The way a patient can determine whether proper surgery with minimal to no blood loss was performed is by taking note of postoperative bruising and the speed of recovery. Bruising indicates broken blood vessels and staining of tissue while increased postoperative swelling demonstrates excessive inflammation. If surgery is done with the bloodless technique, the patient will have minimal bruising and swelling.
With clear visibility during bloodless surgery, not only can the surgeon find the gliding plane, they can also safely dissect the tissue and go beyond the typical boundary that other surgeons face with bleeding. This is especially important in Facelift surgery as releasing retaining ligaments/structures is key to optimal vertical lift, smooth appearance (not appearing pulled), and longevity of results. The most common cause of postoperative scarring is due to tension. By releasing the retaining ligaments freely and redraping (not pulling) the tissue, there is no tension in the incision area and one will heal with minimal scarring. With bloodless surgery, the surgeon is able to release more and can operate further into the face towards the jowls. They can contour the fats of the jowls to create a smoother, more slender jawline and alter the lip depressor muscles to elevate the corners of the mouth.
Facelifts are delicate procedures, and because the results will be on full display, surgeons must use extreme care when performing facial procedures. The face has many vital structures and requires utmost precision. In order to access the tissues that must be repositioned, incisions are made around the ears and then an extensive amount of undermining, or tissue layer separation, must be performed. The minimal blood loss that occurs during bloodless surgery allows the surgeon to make adjustments with clear visibility. Less staining and inflammation allow for more precise and successful redraping of tissue. This allows patients to achieve smoother, more natural-looking results, and significantly reduces the risk of complications.
One of the body’s natural healing responses can lead to complications following a breast augmentation. After a synthetic (silicone) implant is placed, the body responds to the foreign object by forming a capsule of scar tissue around the implant. When bleeding in the breast pocket occurs during surgery, it leads to inflammation, and the regenerative elements produce scar tissue. Too much scar tissue produced around the implant can cause the implant to become distorted and hardened, a complication known as capsular contracture. With bloodless surgery, less inflammation results in less scar tissue forming around the breast implant. This allows for significantly softer feeling breasts and reduces the risk of asymmetry. The surgeon is also able to place the implants with more precision for optimal results.
Eyelid surgery (ptosis) involves placing tiny sutures in the fascia, muscles, and other tissues to help lift the eyelids. This all occurs on an extremely small scale and requires extremely clear visibility so that the surgeon can identify and stimulate the fine muscles present in the eyelids as he makes the necessary adjustments. Bloodless surgery allows Dr. Kim to perform eyelid surgeries using the advanced techniques that he has developed, as well as ensuring a faster recovery for patients.
Inflammation caused by blood creates scarring. A scar is excess collagen which has intrinsic weight. The eye is extremely sensitive to any additional weight. Excessive weight in the delicate eyelid will make it more difficult for the eye to open with ease. For instance, if someone has a stye, their eyelid will droop due to the weight. Additionally, scarring can create lumps/bumps under the skin and when one closes the eye, these can be visible. Scarring can also impede the lymphatic flow which can produce persistent or permanent swelling of the eyelid. When practicing bloodless surgery, there is minimal excessive weight and therefore the eyes can open with ease and the incision will appear as natural as possible.
One of the most common complications with lower blepharoplasty is scelera show / ectropion. This is when the lower eyelid drops below its normal position after surgery. The mechanism behind this is due to inflammation from bleeding. If there is bleeding during surgery, one of the side effects is contracture/scarring. To better understand how inflammation induces contracture is looking at burned skin. Burned tissue becomes tightened and short. The lower eyelid is soft but with bleeding and inflammation, the lower eyelid tissue stiffens, contracts and pulls downward. The sequela is that the patient will develop dry eyes and discomfort.
Dr. Kim performs bloodless surgery using Awake anesthesia. By carefully targeting the individual nerves in the treatment area, Dr. Kim is able to perform surgeries using only local anesthesia. This negates the need for general anesthesia or IV sedation, which carries a concerning amount of risks. With general anesthesia or IV sedation, surgeons are relying on the brain to be numb; however, the nerves in the body are still stimulated during surgery and the pain fibers become activated. Therefore, the patient awakens with pain and must be immediately treated with narcotic pain medications. Patients would need to then continue to take these medications to manage the pain. Some of the risks of narcotic medications are nausea/vomiting, constipation, dizziness, and addiction. According to the American Medical Association (AMA), an estimated 3-19% of people who take prescription pain medications develop an addiction to them. America’s current opioid epidemic is a convincing argument for just how dangerous these drugs can be. On the contrary, if a patient opts for bloodless surgery with local anesthesia, then the pain fibers are blocked before the nerves are stimulated and the body and brain do not experience the pain during surgery. Following surgery, since there is significantly less inflammation, the surrounding nerves are minimally stimulated. Postoperatively, pain is controlled with over-the-counter Tylenol.
When the surgeon is able to perform at their best, the patient receives the best treatment – and that’s exactly what every patient deserves. Surgical procedures are typically performed using an electrocautery device, which uses heat to create burns in the incised tissue in order to seal the blood vessels shut. Unfortunately, burns are also injuries, which can lead to the formation of scar tissue and further damage the area. The process of incising is also usually performed in two phases. The surgeon makes the incision and then they must pause to cauterize the active bleeding. This intermittent progression of surgery prolongs surgery. As surgery becomes longer, the tissues dry out and can lead to cellular degeneration.
One of Dr. Kim’s chief assets as a surgeon is his ability to operate with both hands. As he incises tissue, the few blood vessels that need to be severed are coagulated prior to cutting the vessels, preventing any blood seepage. This allows for a continuous flow of surgery. Dr. Kim uses a vessel sealing energy device. This device delivers energy in a closed circuit, which allows surgeons to only seal off extremely small targeted areas, and avoid damage to the surrounding tissues.(4) This technique also allows him to perform a procedure faster and accomplish more while still reducing the duration of the surgery. During surgery, internal tissues are exposed to the air and moisture evaporates. By operating as efficiently as possible, Dr. Kim is able to maintain the necessary level of hydration in the tissues (preventing desiccation) and cellular and extracellular matrix health. Hydrating the tissue and minimizing thermo damage are important for postoperative results as it minimizes internal scarring and maintains the suppleness of the tissue.
If you’ve been considering a surgical procedure, there’s no reason not to take advantage of the most advanced surgical techniques available. Bloodless surgery elevates commonly performed procedures to their optimal potential, making them the ultimate in safety, efficacy, and patient comfort. This technique requires the combination of advanced technology, detailed understanding of anatomy and physiology both at the macro and molecular levels, and surgical precision.
With an extensive array of aesthetic procedures and leading medical talent, Dr. Kim provides the most advanced and elegant techniques to achieve optimal results. To learn more about the other state-of-the-art procedures and technology that Dream Medical Group offers, browse through the many informative posts on the blog.
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