Breast augmentation is the most common aesthetic procedure worldwide and as such it is often perceived as a simple procedure, where the same technique is applied to every patient. This is a common misconception – as with any procedure, the technique needs to be tailored to each patient’s individual needs. My clinic has recently become a referral centre for revisionary breast augmentation procedures and I have been shocked at some of the things I am seeing, all of which would have been easily avoidable had the patient been aware of all the options available in the first place. There are many important decisions that need to be discussed, often during multiple consultations, to determine the most appropriate size and shape to give a long lasting natural result.
The size of the implant is determined by the width of the implant base, the implant height and the implant profile. Although patients will request certain cup sizes, the width of the chest wall is the most important factor in determining the maximum size of implant possible. Once the base diameter or width has been assessed, the height of the implant and the profile of the implant can be altered to give the overall shape. Shape is altered by not only the implant but the anatomical position of the sternum, the height of the chest wall and the position of the nipple or breast tissue. Nipples and breast tissue can be lifted using certain implant shapes and/or by altering the position of the inframammary fold on the chest wall. Certain implants can be chosen to create fullness in the top or the bottom of the breast. One of the most important discussions centres around the sternum and the width of the sternum in relation to the muscle insertion.
It is this anatomical position that determines how the implants will sit to create the cleavage. Often patients request ‘overs’ or ‘unders’, i.e. implants positioned either over or under the muscle. A careful examination of the amount of breast tissue, the location of the pectoralis muscle and the position of the sternum will dictate the pros and cons of the pocket placement. The benefits of ‘unders’ are that the implants at the top and in the cleavage have more coverage with a muscle layer and so there is less chance of feeling the implant. ‘Overs’, although more prone to be palpable at the top and in the cleavage area do allow one to create less of a gap and more of a cleavage, especially in a bra. A combination of both these techniques, called a ‘dual plane’ technique, allowing a more reliable positioning of the breast tissue than the solely ‘under’ technique, has become the preferred method when a patient wants to have the implant under the muscle or has minimal breast tissue. It still has a tendency to produce slightly more of a gap in the cleavage area. If the breast tissue and nipple lie below the level of the inframammary fold then it is important to discuss the benefits of a mastopexy at the same time as a breast augmentation and patients consulting for breast augmentation should consult with experienced surgeons with experience in mastopexy implant to obtain a full understanding of the limitations of breast augmentation alone. This will avoid the need for revisionary procedures at the outset. Revisionary procedures are extremely rare if the correct implant and the correct technique are performed. This often requires multiple consultations to determine the individual needs and expectations of each and every patient.
Mr Ross was part of a multidisciplinary advisory panel to discuss the role of new therapies for melanoma.
Consultant plastic surgeon Mr Gary Ross describes how he combines these techniques to provide individualised results. The eyes are one of our most striking facial features and rejuvenation of the eyes in the form of blepharoplasty helps to provide a more youthful look with minimal downtime. Upper blepharoplasty is a common procedure where the skin of the upper eye is removed, placing the scar in a natural crease line. It is one of the commonest aesthetic procedures and results in minimal downtime with minimal risks and complications. It can often be performed under local anaesthetic. Sometimes small amounts of fat need to removed and occasionally fat needs to be added in the form of autologous fat transfer. The ageing process leads to weakening of the muscles of the eye and drooping of the contents and this is particularly important in the lower eyelid. Lower eyelid blepharoplasty is often performed in combination with upper blepharoplasty. In lower eyelid blepharoplasty, the contents of the orbital septum need to be tightened and patients often need treatment of eye bags and hollowing, which result from ageing of the lower lid and sagging of the mid-face.
This lid-cheek junction and mid-face sagging often is not addressed by a standard blepharoplasty technique but by using the same minimal scars as a lower blepharoplasty the mid-face can be lifted so that the sagging tissue of the mid-face can be repositioned into the lid-cheek junction, disguising the hollowing and rejuvenating not just the eyes, but also the midface. It is well known that the ligaments of the mid-face relax as we age, with thinning of the tissues and sagging of the soft tissue. The aims of mid-face rejuvenation are to reposition this sagging tissue. Previously, facelifting techniques would be required to lift the mid-face through separate scars and although in certain patients this still remains the best option – especially in patients with drooping of the jowls and lower face – the mid-face can often be addressed adequately through this minimal scar technique. The mid-facelift in combination with blepharoplasty can tighten the sagging lower eyelid and the mid-face through a minimal incision with a net effect that minimal tissue needs to be removed and the tissue is simply repositioned into a higher position. Sometimes additional tissue in the form of autologous fat needs to be added. The recovery following this surgery is a lot quicker than standard facelifting techniques.
Many people who have lost a substantial amount of weight are overjoyed at their success. But after losing weight you may still have some to lose due to the heavy folds of skin left that can be left behind, reminding you of your former self. Surgery can remove the extra skin and improve the shape and tone of tissue in your arms, thighs, breasts, buttocks and abdomen. Plastic Surgeon Gary Ross explains to The Cosmetic Surgery Guide what options are available to patients after bariatric surgery.
Body contouring after major weight loss reduces the excess skin and fat that is left behind after a major weight loss. The expansion of skin, loss of fat and lack of tissue elasticity results in sagging skin that commonly develops around the face, neck, upper arms, breast, abdomen, buttocks, and thighs and can make your body contour appear irregular. The success of body contouring, whether it is done to reduce, enlarge or lift, is influenced by your age and by the size, shape and skin tone of the area to be treated.
Some contouring procedures leave only small, inconspicuous scars. More noticeable scars may result when surgical removal of fat and skin is necessary to achieve your desired result. Most patients find these scars acceptable and enjoy greater self-confidence. Any area that affects the patient could potentially be treated by surgery. Generally the abdomen is probably the commonest area that patients wish to have addressed. Options involve panniculectomy (removal of overhanging tissue only), abdominoplasty (tummy tuck) and total body lifting (removal of tissue circumferentially around the body).
Arm lifting and thigh lifting are also commonly performed to remove excess tissue and improve contour while mastopexy implant is the most commonly performed rejuvenation procedure for the breast. Above all, body contouring surgery must be tailored to the patient’s individual needs and requirements, and treatments must be individualised accordingly.
A cadaveric workshop aimed at training consultants in breast surgery, and breast augmentation. This received excellent feedback
Revisionary breast augmentation is an increasingly specialised field of breast surgery. With all breast reconstruction one must consider the patients wishes for improvement in terms of size, shape and symmetry. Both clinician and patient need to establish what can be achieved and whether all expectations can be met.
Mr Ross was an anatomy demonstrator and member of the faculty
Keynote speaker for arm lifting and thigh lifting at the Royal Society of Medicine
It is one of the most drastic and, some might say, barbaric cosmetic operations: the body lift.
Used to tackle the legacy of dramatic weight loss – the unsightly apron of flesh left behind after skin has stretched to accommodate fat – the four-hour procedure involves virtually cutting the patient’s body in half to remove the unwanted tissue and tighten the underlying muscles, before stitching it back together.
Mr Ross was senior author of a number of presentations and key note lecturer