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.
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.
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.
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.
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
The breast has a tendency to age due to a combination of tissue changes in the skin, breast tissue, the ligaments within the breast, the position on the chest wall and the size of the nipple/areolar. Changes to these tissues occur most acutely with fluctuation in weight, and pre/post pregnancy. Mastopexy is a technique used to lift and change the tissues of the breast. Each component of the breast can be lifted and each component needs to be addressed individually. The consultation must take into account the patients ideal size and a discussion regarding previous shape and desired shape. Often breasts are slightly different both in terms of size and shape and the position of the nipples. The crucial question is whether there is enough volume of current breast tissue to provide the desired size and the position of the nipple areola complex. Where volume is deficient and the nipple areola is sitting in a reasonable position anatomically shaped implants may be able to give the perception that the nipple areola has been lifted. It may be over time that patients may require a lift subsequently but in some scenarios a good result can be obtained by breast augmentation only. Where the nipple areola is sitting low and the volume of the breast is satisfactory a mastopexy can improve the shape and position of the breast. The overall size and shape needs to be tailored to the individual using methods to minimise risk to the blood supply to the tissues. The breast mound is designed in order that the breast can be lifted into a new position. The skin is re-draped over the breast and the nipple/areolar size adjusted to the needs of the patients. Sometimes the nipples need be lifted a considerable distance in combination with the breast tissue. Often the nipples point into the armpit and these need to be relocated centrally at the same time. Contour defects as a result of stretching of the breast ligaments needs to be addressed by relocating the breast tissue higher up the muscle on the chest wall.
There are a number of different ways of performing a mastopexy and these are determined by the incisions performed. The donut or benelli mastopexy is performed through a scar placed around the areola. It may be used to increase the height of the nipple areola by 2-3 cm. It does have a tendency to form stretched scars but does not involve a vertical incision. The lollipop mastopexy is performed via a scar around the areolar and a vertical incision. It is useful in patients where there is no need to remove excess skin. The nipple areola can be lifted significantly higher than in a benelli mastopexy. Where there is significant excess skin and the breast tissue and nipple areola need to be raised significantly an anchor scar mastopexy is the proffered rejuvenation technique. The scars are place around the areola and a vertical scar that meets a horizontal scar in the crease/ fold of the breast. Where the nipple areola complex has dropped and there is also insufficient volume one should consider a combination of a mastopexy with an implant or autologous fat transfer. This can be done as a one stage procedure using the mastopexy techniques described above. Autologous fat transfer involves the removal of fat from the body and transferring it into the breast to try and give extra projection at the upper part of the breast which is the place that is usually most empty. Autologous fat transfer does allow patients the potential of an increase in volume without an implant but often patients may require more than one treatment of autologous fat transfer and the volume improvements are not as predictable as an implant. Using an implant at the same time as a mastopexy in a one stage operation is an excellent means of providing breast rejuvenation in patients who want a moderate increase in volume. For patients wishing to have a dramatic increase in size and wish to have large implants or in those who need the nipple areola lifting considerably mastopexy implant is better performed as a 2 stage operation. Patients undergoing any form of breast lift should be aware that the breast will sit high on the chest wall and will drop over time. Usually this can take 3 months. All the operations described above are usually performed under general anaesthetic. Patients are usually able to drive after a week and may start gentle exercises at this time building up to normal exercising by 4 weeks. A consultation regarding the pros and cons of mastopexy will help to clarify the expectations of patients and provide results that are achievable to meet these expectations. One should consider all the possible options, and if consulting with myself, one will be able to look at results related to all the operations above and make an informed decision
Often excess skin or fat can be a problem for patients in the thigh area and thigh rejuvenation is being more frequently requested. For patients with excessive weight loss thigh lifting can be combined with other procedures in other areas of the body.
The distribution of excess fat and skin and the quality of skin of the thighs will often determine what the best options for patients are. Surgical treatments combining skin tightening and fat removal without skin excision may offer some promise and a discussion regarding the pros and cons should be addressed in any consultation relating to thigh rejuvenation. Liposuction on its own can provide some skin tightening and the perception of skin rejuvenation, although where excess skin is present surgical excision is often the only reliable way to improve contour. If there is excess fat only liposuction can be used, although patients must be aware that excessive fat removal alone will often lead to visible skin excess that may only be correctable by surgical excision at a second stage.
There are many areas of the thighs that can be troublesome to patients but most often it is the appearance of the thighs from the front. The appearance of the thighs from behind and rejuvenation in this area only is less frequently requested although for some the appearance of the thighs all the way around the body is of concern. The most frequently requested rejuvenation procedures on the thighs are for excess skin and/or fat in the inner and/or outer thighs.
It is important for patients to discuss the various options and pros and cons of thigh lifting, liposuction, buttock lifting and total body lifting when considering surgery for thigh rejuvenation. Each of the techniques has pros and cons and help to address different areas.
Traditionally the terminology of thigh lifting has been applied to an inner thigh lift where the scars are placed in the groin crease and/or a vertical line along the inside of the leg. The extent and the position of the scar need to address the skin excess present and the needs of the patient.
If the patient has good quality skin a thigh lift using a groin incision may be sufficient in combination with liposuction to give a pleasing result. If excessive skin is present a vertical scar may be a better option. The vertical scar can be limited or extended depending on what one is trying to achieve. It is not recommended that the scar go past the knee.
Thigh lifting can also be performed from under the buttock crease or the thighs can be lifted by incisions above the buttocks. In certain circumstances a total body lift is a good option in addressing the upper thighs. In a total body lift the scars are placed all the way around the body. Where there is excessive skin excess in the upper thighs in combination with excess tissue all the way around the body a total body lift remains a good option. Often scars in the buttock crease can be become troublesome and the pros and cons of thigh lifting via this method should be discussed with the patient.
With modern surgical techniques recovery following thigh lifting is relatively short. It is uncommon to require drains and although it is recommended that thigh lifting be performed using general anaesthetic, patients are able to mobilise as soon as they have recovered from the anaesthetic.
Thigh rejuvenation may involve many different options and a consultation regarding all these different options will help you make a decision as to what the best option is for you.
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. The timing of revisionary breast augmentation must take into account the type of implants, the age of the implants, the associated changes of the implant, the capsule and the differences and changes of the breast.
Many patients will have experienced mild changes and often reassurance is all some patients require. For some patients changes to the implants may require a more immediate treatment. The majority of patients will have seen a gradual change in the aesthetics of their breast over a period of years and the timing of surgery can be based on the pros and cons of what can be achieved. Assessment of the implant for leak or rupture is imperative and may alter the timing of future surgery. It is uncommon for these complications to occur and occasionally if doubt remains and there is no immediate decision to perform surgery a diagnostic scan is warranted. It is rare for patients to have associated lymphadenopathy but again if present the pros and cons of managing this surgically need to be discussed. Often implants will develop creases or ripples and these need to be separated from the more troublesome changes mentioned above. The quality of the capsule needs to be assessed to determine whether the capsule should be removed in its entirity (en bloc resection – total capsulectomy), whether part of the capsule needs to be removed (partial capsulectomy) or whether the capsule needs to be released (capsulotomy). Capsules develop in all patients and are a protective barrier.
Over time however they can have a detrimental effect on the breast implant and can result in pain and visible changes. The visible changes are related to the squeezing of the implants in a confined space. This can compress the implants and make them feel hard and alter the position on the chest wall. Implants can move upwards creating an upper fullness or double bubble effect, downwards (bottoming out), outwards or inwards.
During surgery it may be necessary to place the implants in a different pocket ie where patients have implants above the muscle a new pocket can be made under the muscle.
Often with time the breast tissue will drop and one must determine whether a lift or mastopexy should be performed at the same time as implant replacement or whether it is advisable to perform the augmentation first and then a mastopexy at a second stage if needed. The need for mastopexy is dependent on both the quality of the skin and the breast tissue with particular importance taken to assess the height of the nipple areola complex on the breast and the breast’s position on the chest wall. Depending on the quality of the implant, the capsule, the skin and breast tissue one must consider the pros and cons of separating the removal of implant / surgery on the capsule with a second definitive operation. It is often possible to remove / replace implants at the same stage and mastopexy can often be performed at the same time. The pros and cons of each of these options needs to be addressed by a plastic surgeon with experience in revisionary breast augmentation. Patients often do not appreciate the complexity of the decision making process and what is involved in revisionary surgery. All patients should have the details of their previous implants available. From this information one can determine the width of the current pocket and adjust implant size and shape to improve any deformity that has occurred. There are pros and cons of using different implants, sizes and shapes in breast augment revisionary surgery and patients must be informed of the pros and cons of these and be part of the decision making process.
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The diagnosis of breast cancer can be devastating and decisions regarding reconstruction are often seen as a secondary consideration when dealing with so many other painful issues. However, women often feel that breast reconstruction is essential to recovering their self-confidence once the ordeal is over, and for those women there are different options available. Patients may undergo autologous reconstruction at the same time as the initial mastectomy or may choose to wait until after mastectomy and subsequent oncological treatments such as chemotherapy and radiotherapy. A careful discussion with the surgeon is imperative to guide the patient in the decision making process. This often requires multiple consultations with both the doctor and the specialist reconstructive nurse within a multidisciplinary oncological team. Breast reconstruction can be provided by either autologous or non-autologous tissue, or a combination of both techniques. Non-autologous methods of reconstruction include the use of tissue expanders and implants. Autologous reconstruction uses one’s own tissue. The advantages of this are that the tissue ages naturally and the reconstruction changes minimally with time.
Initially, an autologous reconstruction may be more time consuming in terms of surgery and recovery, however the benefits often outweigh the risks. It is important that the surgeon discusses the pros and cons of each form of reconstruction with each patient individually to determine suitability. For autologous breast reconstruction the gold standard technique is the deep inferior epigastric perforator flap (DIEP), which is a modification of the transverse rectus abdominis muscle flap (TRAM). With newer techniques to protect the muscle and its function (DIEP), tissue from the abdomen can be used to reshape the breast with minimal side effects to the abdomen. The tissue that would normally be excised during a cosmetic tummy tuck is dissected carefully with its blood supply (the diep inferior epigastric artery) to avoid damage to the tummy muscles creating a flap of tissue. Blood vessels in the chest or the armpit are also dissected free and the artery and veins of the veins in the chest and the veins in the tummy tissue are sutured together using fine suture material under a microscope. The tummy is closed in the same way as a tummy tuck or abdominoplasty and the new tummy tissue is reshaped onto the chest wall to create a new breast. The most important aspects of breast reconstruction include size, shape and symmetry. The initial operation provides the basis with which the surgeon can mould the final result. Often a second operation is required in order to achieve these goals. In order to achieve these goals.
With increasing refinements such as lipo modelling – combining liposuction (removal of fat) and autologous fat transfer (injection of fat) – the new breast can be remodelled to give an even more natural result. This can be combined with a nipple reconstruction to give a result that is similar in size, shape and symmetry The advent of microsurgery in the field of plastic, aesthetic and cosmetic practice has made the provision of this form of autologous reconstruction more widely available. Although it is not suitable for everyone and can never replace the original breast tissue, those that choose this form of surgery benefit from longer lasting breast aesthetics and abdominal contour. As with all aesthetic surgery, autologous breast reconstruction is not without its inherent risks and these need to be discussed with surgeons experienced in this highly specialised form of breast reconstruction.