Month: November 2015

COSMETIC expert, Mr. Gary Ross, has recently been awarded ‘Best for Breast and Tummies’ in the 2015 Tatler Beauty & Cosmetic Surgery Guide, and has received global recognition through RealSelf as being one of the top 100 doctors. Here we talk to the plastic surgeon about the every-popular ‘mommy makeover’ as a rejuvenation procedure.

 

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Choosing a surgeon and the importance of outcomes and new techniques.

Never before have clinicians been more highly regulated. Doctors in particular must set the standard against which others are to be judged. The production of clinical outcomes is an essential part of a doctors appraisal and revalidation and increasingly we need to provide these for patients (see link to my outcomes). Patients should be guided by these outcomes in choosing a surgeon.

New techniques are increasingly being scrutinised within aesthetic practice. The use of autologous fat transfer for breast augmentation is one such procedure. Mr Ross in this article explains the limitations of such a procedure and how new techniques can be incorporated into clinical practice. It is important that patients are given adequate information and undergo a detailed consent process in order that they can be empowered to make decisions regarding new techniques.

 

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There has been a rapid increase in Body rejuvenation techniques in weight loss surgery. Mr Ross explains in this article the different options for patients, whom to choose and talks about the pros and cons of the different options.

 

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Often excess skin or fat can be a problem for patients in the upper arms. It can lead to patients limiting the clothes they wear ; women especially find the aging changes related to the upper arm disturbing. The most common complaint is not feeling comfortable wearing short sleeves or not liking the appearance of the arm/chest junction in a bra. Providing an improved contour in the upper arms can rejuvenate the upper arm and provide an improvement to a patient’s quality of life.

This excess fat and/or skin in the upper arms can lead to poor definition of the arm/chest junction. Excess tissue at this junction can also lead to a discomfort in bras and can be both uncomfortable and unsightly. For patients with excessive weight loss arm lifting can be combined with other procedures in other areas of the body.

The location of excess fat and skin and the quality of skin of the arms and chest wall often determine what are the best options are for patients. Liposuction on its own can reduce the volume of fat and where skin tightening is performed simultaneously improvements may be gained. Usually in the upper arms excess skin is present and surgical excision in combination with liposuction is often the only reliable way to improve contour.

Where only skin excess is apparent surgical removal offers a permanent solution.
With surgical removal scars need to be placed in the armpit.There may be only a short scar limited within the armpit – short scar armlift. Often the scar needs to be extended but this can be limited to avoid extending thescar towards the elbow – armlift with limited incision. For excess fat and skin one often needs to extend the scar down the arm and/or down the chest – armlift with extended scar. It is important to place these scars in such a way that it is difficult to visualise these.

Short scar arm lifting with placement of scars in the armpit gives limited results and does not address excess tissue on the chest or the majority of the skin of the upper arm.There are also occasions where patients are not happy with a bulge in the upper part of the chest near the armpit.Where this is not related to issues of skin and fat excess in the upper arm a short scar arm lift can help to improve this contour by a short scar approach.

For the majority, armlifting requires a scar that extends down the arm.This can be limited or can be extended down to the elbow, into the armpit and down the side of the chest.This scar often heals extremely well although it can take a number of months / years for the scar to fade into a white line.The scars can often be initially tight and it is important for patients to mobilise immediately to prevent any form of contracture. In the armpit and the upper part of the arm there is a tendency for the scars to stretch. For patients these scars are very well tolerated and it is extremely uncommon for patients to complain about these scars long term.

It is rare for skin excess to be present in the forearm and one must weigh up the pros and cons of removing any excess tissue below the elbow that would require a scar that crosses the elbow. Scars that cross joints can cause contracture and may result in limited mobility.

Arm lifting can be performed alongside other body rejuvenation procedures and it is important to discuss these options with someone with experience in all body contouring procedures. It is recommended that all surgical times should be less than 4 hours to limit anaesthetic issues. For the majority of arm lifts the procedure is carried out under general anaesthetic. Although there is swelling and some discomfort arm lifting is relatively not a painful procedure. Patients may be able to go home the same day and currently I do not use any drains and use minimal dressings.The reduction in drains and dressings allows patients to mobilise immediately.The recovery following arm lifting is relatively quick. It is uncommon to develop excess swelling (seroma) and although there may be small areas of the scar that take some time to heal the wound complications are usually minimal.

 

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Breast Cancer Awareness Month As part of breast cancer awareness month Mr Ross has published alongside the Genesis in Manchester looking at the role of contralateral mastectomy for breast cancer prevention. (link to publication list). Drawing awareness to the role of prevention and helping patients who have had a diagnosis of breast cancer or a potential risk of breast cancer and providing adequate information is an essential part of care. Only with accurate information will patients be empowered to make their own decisions.

Mr Ross has been featured in BAPRAS voice discussing how patient focused models of care is changing treatment for the better:-

”Breast cancer remains the most common malignancy for women in the UK and the leading cause of death for women aged 34-54. Increasingly genetic testing has been used to help determine risk and target women who can be offered treatment prior to the development of breast cancer. Recommendations are available through the recently published NICE guidance For patients who develop malignancy in one breast genetic testing can also help to determine risk and target women who can be offered treatment to prevent the chance of another malignancy in the opposite or contralateral breast. Although through the 1990s there has been a shift from mastectomy to breast conservation, the rates of mastectomy – especially of the contralateral breast – appear to have increased. The management of the contralateral breast remains controversial and we have recently published evidence to suggest that a survival advantage does exist for patients who are genetically tested positive for the BRCA 1/2 mutation carriers who have chosen to undergo contralateral mastectomy.

Patients are increasingly more aware of the advancements in the management of breast cancer and across the UK there remains a need to provide patients with unbiased, evidence based advice on the pros and cons of contralateral mastectomy. The decisions need to be discussed at a multidisciplinary meeting and require the involvement of dedicated breast care nurses and patient support groups. Together a patient focused model of care will allow patients to make important choices in their own management.

Having encouraged patient empowerment and patient focused groups throughout my career, the Breast Cancer support group ‘Keeping Abreast’ is one example of a successful patient support model. It has enabled a number of my patients, who have helped each other through the reconstructive process, to further develop this patient focused model across cities such as Manchester. Keeping Abreast was founded in 2007 in Norwich, by three women who recognised the need for peer support for women living with breast cancer. It is crucial for women both newly diagnosed with breast cancer and facing the possibility of mastectomy, as well as those considering reconstructive surgery, to meet and talk with women who have been through similar experiences and view reconstructions first hand.&lquo;

The launch in Manchester for keeping abreast was highly successful and there is hope that this avenue of patient delivered care will be developed further in Manchester.

Liposuction is a technique that removes fat from unwanted areas. The key to liposuction is to abstract the correct amount of fat, to cause the least disturbance of neighbouring tissue, to leave the person’s fluid balance undisturbed and to cause the least discomfort to the patient. Mechanical energy has been the mainstay of liposuction for many years but modern refinements utilising ultrasound, laser and water assisted techniques have helped to improve outcomes. By using additional energy sources one is able to disturb the neighbouring tissues less and reduce the discomfort. Patients tend to experience less bruising and swelling than traditional liposuction.

Further refinements have seen the increasing use of tumescent fluid to enable removal of large volumes of fat. Again this is to aid patient recovery and comfort however the use of often large volumes of fluid to improve results need to be carefully monitored in a facility with dedicated postoperative monitoring and care. Although liposuction can be performed under either local anaesthesia or general anaesthesia, postoperatively patients should be monitored closely to limit the complications resulting from fluid imbalance. Liposuction can be performed on any area of the body although for women it is most commonly performed on the abdomen and thighs and for men abdomen and flanks. Liposuction can also be performed in addition to facial surgery e.g. facelifts and neck lifts, breast surgery e.g. breast reduction / mastopexy and body rejuvenation surgery e.g. abdominoplasty and arm/thigh lift.

Liposuction remains one of the most commonly performed operations in cosmetic surgery, however it is important for patients to consult with a plastic surgeon with experience in liposuction and other body rejuvenation procedures. The pros and cons of local / general anaesthesia, types of liposuction, alternative procedures and additional non surgical / surgical treatments need to be discussed. Patients should be weight stable and at their ideal weight before considering liposuction and it should not be seen as quick fix to reduce fat. Judging the correct amount of fat to remove remains one of the most important decisions in order to limit complications.

One of the commonest errors is removal of too much fat or to perform the technique on patients with excess skin. With the right patient selection liposuction is an excellent tool to reduce unwanted fat and is best performed on isolated areas of fat and in patients with good quality skin. Choosing the right patient will help reduce the skin irregularities that occur following liposuction which remains the biggest concern long term. If liposuction is performed alone the incisions used are determined by the liposuction technique and the size of the cannula although they are usually no more than 0.5 – 1cm in length. The incisions can be well hidden and can be either sutured or left open. It is rare for patients to notice these incisions in the long term. Although non-invasive methods of liposuction exist and may be useful in certain patients the pros and cons of these techniques need to be discussed alongside the pros and cons of traditional invasive techniques. For the right patient liposuction provides excellent results and these results are often improved by the use of compression garments that help in the postoperative phases to reduce swelling and discomfort.

Further improvements in liposuction mean that patients can have the fat that has been removed injected into other areas of the body such as the breast, buttocks and face. Liposuction can thus now be seen as liposculpture and an important adjunctive tool in body rejuvenation

 

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