Category: Press Articles & Interviews

Even a successful breast augmentation can be affected by the ravages of time. Leading plastic surgeon Mr Gary Ross explains how he deals with revision breast augmentation, an often complex and difficult operation.

Breast augmentation is one of the most common aesthetic procedures with the aim being to provide a natural long-lasting result. However, over time both the skin and breast tissue and the implant itself can change and this can affect the overall result. Although this is uncommon and occurs infrequently the change can be devastating for the patient.

There are a number of possible aesthetic changes associated with the implant and its surrounding tissues; these include migration of the implant higher in relation to the nipple/ areola/breast tissue or migration of the implant lower in relation to the nipple/areola/breast tissue and loss of integrity of the implant/its capsule leading to a change in shape.

The migration of the implant upwards can lead to the nipple / areola and breast tissue lying lower than the implant. This Even a successful breast augmentation can be affected by the ravages of time. Leading plastic surgeon Mr Gary Ross explains how he deals with revision breast augmentation, an often complex and difficult operation time and leads to an unnatural aesthetic appearance that exaggerates any natural ptosis or drooping that occurs with age. The correction of this deformity requires a manipulation or removal of the capsule that surrounds the implant. It may be necessary to move the pocket of the implant from sub glandular to sub pectoral or vice versa and to close the original pocket (see patient one in PDF).

In severe cases where there is associated capsular contracture the natural definition of the breast inframammary fold can be completely lost and redefining the fold requires recruitment of abdominal wall skin and a recreation of the fold (see patient two). There may also be a requirement to change the pocket placement and removal of the previous pocket.

Migration of the implant downwards can occur due to relaxation of the inframammary ligaments. This results in the unnatural appearance of the nipples/areola sitting too high in relation to the implant. This bottoming out effect can be corrected by manipulation of the implant pocket to raise both the fold and the implant. In cases where the skin has not been stretched excessively there is no need to remove any further skin and the original inframammary scar can be used for the procedure (patient three).

Capsular contracture is probably the most common reason for change in shape and in severe cases can be associated with intracapsular and extracapular leak with seroma formation. The aesthetic results of this are unpredictable and any revisionary surgery is extremely difficult. In almost all cases the capsule must be removed in its entirety and the pocket changed to accommodate the new implant. Due to excessive expansion of skin it may be necessary to not only remanipulate the inframammary fold but also to elevate the areola with a combination mastopexy (patient four in PDF).

The main principals of breast surgery, namely size, shape and symmetry still remain, but the techniques to achieve an improved aesthetic outcome need to be altered to meet each individual requirement.

I aim to change and improve the patient’s appearance by concentrating on these individual expectations and needs. Preoperative consultations are crucial in developing the patient/ surgeon relationship and are a means to discuss any concerns and prioritise needs and expectations.

 

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Breast uplift and breast augmentation are two very different procedures but, for some women, a combination of these two procedures is necessary to produce the best aesthetic outcome. Leading plastic surgeon Mr Gary Ross explains.

Some women require a breast augmentation and some, particularly after childbirth or weight loss, require a breast uplift or mastopexy. However, for many women a combination of these two procedures is what is required and a skilled and experienced cosmetic surgeon will be able to determine the best option for you. As you age the skin stretches and breast tissue droops, which can result in the breast tissue lying lower on the chest wall and the breasts may become asymmetric in size and shape. A mastopexy is a fantastic procedure for recreating a more youthful shape, but another side effect of the ageing process, particularly post childbirth and breast feeding or weight loss, is that there is a loss in volume. Implants are therefore essential to increase volume. Different sized implants can also be used to improve symmetry. Women with a smaller bust can end up very disappointed if they have breast implants that then exacerbate a problem with sagging skin, so it is the plastic surgeon’s job to advise them that mastopexy implant procedure might be best for them. There are a number of different types of mastopexy implant that can be performed. Following breast augmentation one can lift just the nipple and areola by using a periareolar mastopexy, where the resulting scar is positioned only around the nipple and areola. This gives a small nipple/areola lift and does not require any other scarring. A vertical scar mastopexy implant requires the positioning of the scar around the areola and a line vertically on the breast. This allows the breast tissue to be lifted and redraped over the implant as well as lifting the nipple and areola. Nipples and areolae can be lifted as high as required aesthetically and this technique provides a very flexible means of lifting the breast. Where there is significant excess skin a mastopexy implant using a vertical scar, an inframammary scar and a periareolar scar can provide an excellent means of lifting the nipple, areola and breast tissue to a new position and also allows movement of the breast tissue upwards while finally allowing direct excision of any excess skin. Although more scarring is required it is sometimes the only method of creating an aesthetic result.

With so many different options, a consultation regarding each method of mastopexy implant is important to determine what your expectations of surgery are and what is achievable. The pros and cons of each need to be discussed and an informed decision made.

 

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Leading plastic surgeon Mr Gary Ross explains the options available once gravity takes its toll.

Gravity is the enemy of us all and as well as causing the face to sag it can also have an effect on our breasts. The breasts age due to a combination of tissue changes in the skin, breast tissue, the ligaments within the breast and the position on the chest wall.

Changes to these tissues occur most acutely with fluctuation in weight and the impact that pregnancy has on the body.

Mastopexy is a technique used to lift the breast. Each component of the breast can be lifted and each component needs to be addressed individually by a surgeon experienced in this operation.

The consultation regarding vertical scar mastopexy must take into account the patient’s ideal size and a discussion needs to be had regarding previous shape and the desired outcome. Often breasts are slightly different both in terms of size and shape and the position of the nipples. Sometimes the nipples need to be lifted a considerable distance in combination with the breast tissue (patient one – see PDF).

The ideal position of the breast on the chest wall is the key and will dictate whether a small amount of tissue needs to be raised and repositioned into a new inframammary fold or in some cases removed (patient two). The overall size needs to be tailored to the individual using methods to minimise risk to the blood supply to the tissues. The breast mound is then designed in order that the breast can be lifted into a new position. Finally the skin is redraped over the breast.

A single vertical scar can be used in the majority of patients (patient three). Occasionally if there is too much skin a small inframammary scar is required alongside a vertical scar. If only a small skin lift is requested a scar around the areola can be used to give a small lift without altering the inframmary fold or lifting the breast tissue.

Finally, the vertical mastopexy technique can also be used in combination with an implant to give superior fullness to the breast.

Recovering from a mastopexy

Patients undergoing vertical scar mastopexy should be aware that the breast will sit high on the chest wall and will drop over time, which will usually take three months (patient four). It is important following surgery that a well-fitted non-wired bra is worn at all times.

Often patients can go home on the night of surgery and recovery is usually quick with the wounds healing in a week (bruising and swelling is relatively common and can take a couple of weeks to settle). In conclusion Women no longer have to accept the hand that time has dealt them and it is possible to regain the shape they have lost. 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.

In conclusion

Women no longer have to accept the hand that time has dealt them and it is possible to regain the shape they have lost. 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.

 

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Face lifts often get a bad press, but techniques have changed and these days, if you pick the right surgeon, it is possible to achieve a very natural looking result. In this article, Mr Gary Ross explains his approach to face and neck lifting.

Many non-surgical treatments and minimally invasive face and neck lifting techniques have been introduced into cosmetic practice over recent years. A consultation regarding facial rejuvenation must involve the pros and cons of these alongside the pros and cons of classic face lifting and neck lifting procedures.

The aim of facial rejuvenation is to change and improve appearance and produce a long lasting, natural looking result, with as little down time as possible. Although non-surgical treatments and minimally invasive face lifting is effective in slowing the ageing process within our formative years, as we get older classical face and neck lifting is often the only procedure that can address the ageing lower face and neck adequately.

The classic signs of jowl formation, prominence of the nasolabial angle, blunting of the jaw line and fullness under the chin are best addressed by modern face and neck lifting techniques using the classic approach.

Modern techniques in face lifting address mainly the layer underneath the skin and above the muscle, which is called the SMAS layer. Minimal skin excision is required with an emphasis on redraping of the skin following the SMAS lift.

The windswept look, with change in earlobe position and stretched scarring as a result of skin face lifts only still occurs in very rare and unfortunate cases and is easily avoidable.

The effects of ageing lead to an increase in subcutaneous fat deposition in the jowls and the nasolabial creases. These descend in a vertical fashion and for face lifting the SMAS needs to preferentially lifted in a vertical fashion.

Because we lose tissue with age, the SMAS layer should be remoulded rather than removed to improve facial contour. Autologous fat may also be required to improve the volume of the face.

The neck is one of the most difficult areas to address and must be considered in all patients consulting for facial rejuvenation, as an ageing neck can let down a youthful face. To lift the neck, one must consider not only the repositioning of the SMAS layer but also the repositioning of the platsyma layer that is a continuation of the SMAS layer in the neck.

As the platysma ages and weakens the fat under the chin becomes more prominent – often this fat needs to be removed by either an open approach or by liposuction. Where liposuction is required to reduce fat in the jowls, under the chin and on the neck, the fat can be redistributed into other areas such as the cheek, lips or chin to provide an overall rejuvenated effect.

As previously mentioned, the platysma layer is a continuation of the SMAS layer and therefore the platysma also needs to be lifted in a vertical plane via suspension methods. Finally one must also consider the chin and the angle of the jaw and where required a genioplasty, or chin augmentation, may be required.

The face/neck interface must be addressed in all consultations regarding facial rejuvenation. Although non-surgical treatments and minimal access face lifting provide a useful adjunct in the fight against the ageing process, the pros and cons of classic facelifting using modern techniques provide a long lasting result with minimal downtime and may be more likely to achieve the expectations of the patient.

 

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With the rise of the ‘mummy makeover’, post-pregnancy breast augmentations are becoming increasingly popular. Leading plastic surgeon Mr Gary Ross offers an insight into this procedure and how to make it work for you.

The effects of pregnancy and breast feeding often lead to the sagging of skin and a decrease in the amount of breast tissue. New mothers are frequently concerned about both the size and shape of their breasts and the aim of aesthetic breast surgery is to both change and improve the appearance. Personally, I aim to achieve these improvements by concentrating on the individual patient’s needs and expectations. Pre-operative consultations are an important part of my service, as they allow the development of our patient/surgeon relationship and provide a means to discuss any concerns and clarify the patient’s needs and expectations. Techniques available for post-pregnancy breast surgery include both augmentation and mastopexy (uplift) and these two techniques can be combined in one surgical procedure and tailored to the individual to provide the optimal result. The two main aspects of aesthetic breast surgery are size and shape. When the patient has sufficient size but poor shape and if there is enough remaining breast tissue, an uplift alone may be sufficient to achieve the desired result. Where the nipple height is already at an optimal level and the patient has good shape but insufficient size an augmentation alone may suffice. Often, however, there are elements of both poor size and poor shape and a combination procedure including both uplift and augmentation is required to deliver a natural, lasting result.This can be performed in one operation or as two separate procedures. Different techniques, different implants, differing scarring patterns and different positioning of the implants require detailed discussion. atients before the surgery, explaining the benefits of each option, which allows them to make an informed decision about which procedure is best for them individually. Optimising results without compromising safety is paramount.

 

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Suffering from overly large breasts? Plastic surgeon Mr Gary Ross explains how breast reduction surgery can dramatically improve your quality of life.

Aesthetic breast surgery aims to both change and improve appearance. The expectations of breast surgery are based on individual requirements. Breast reduction or reduction mammoplasty is a surgical procedure that involves the reduction of the size of the breasts.

It involves the excision of excess fat, skin and glandular tissue and the reshaping of both the remaining breast tissue and the breast skin and the repositioning of the nipples.

Worldwide, the size of the average breast is increasing and younger women are requesting breast reduction surgery, aiming towards a natural, long lasting result. Patients opting for reduction surgery complain that their breasts hinder their mobility, impair them functionally and often they experience back and neck pain.

The additional weight on the shoulders may lead to skin irritation due to the pressure of the bra straps. Patients are also frequently concerned with the shape of the breasts and an inability to find bras and clothes to fit. Sometimes the size of the breasts causes emotional as well as physical discomfort with a detrimental effect on self confidence.

Breast reduction is a surgical procedure that may be combined with other cosmetic procedures such as breast lift and liposuction. These techniques vary depending on the individual requirements of each patient. These requirements dictate the number and length of incisions. The most important aspects of breast surgery are in relation to size and shape.

I aim to change and improve appearance by concentrating on the expectations and needs of the individual patients. Preoperative consultations allow the development of the patient / surgeon relationship and are a means to discuss any concerns and prioritise your needs and expectations.

Changing techniques

Breast reduction is usually combined with lifting of the nipple to a new position (mastopexy) and often liposuction. A combination of procedures are tailored to the individual to provide the optimal result.
Providing a natural, longlasting result is paramount and the procedure involves careful consideration of the different elements of breast surgery and addressing each component individually. Excess breast tissue can be removed and the remaining tissue moulded to create an enhanced shape. The nipple is moved to a position relative to the stature and chest width of the patient and the excess skin is adjusted to redrape over the new breast in such a way that the blood supply to the nipple and the skin are not compromised. Final touches can be applied to remove fat by liposuction or place fat via a lipomodelling technique to give a symmetrical aesthetic result.

Newer techniques such as the vertical scar only technique prevent the need for a scar underneath the breast and all three examples shown have been performed using this method. Drains are not required and minimal dressings are applied immediately postoperatively. The results of surgery are therefore immediately apparent and patients are able to see the results instantaneously.

Patients can mobilise on the day of surgery and are encouraged to wear a sports bra day and night for the first four weeks following surgery. Bruising and swelling does occur although this has almost subsided by one week postoperatively when the minimal dressings are removed. All the stitches are dissolvable thus minimising discomfort and maximising outcome.

Results

The results of breast reduction are immediately apparent although it does take six weeks for all bruising and swelling to settle. Results can be dramatic with immediate relief of the pain associated with excessive breast tissue. The scarring following breast reduction can take longer to settle and scars remain pink for the first few months before usually fading into fine white lines. Change in mobility and functionality combined with the dramatic improvement aesthetically allows breast reduction patients a substantial improvement in quality of life.

Safety first

Optimising outcomes without compromising safety is paramount. By practising and operating aesthetically in one hospital I am able to provide patients with a dedicated service. Preoperative consultations and all post operative visits are with me and provision of 24-hour perioperative anaesthetic cover with dedicated intensive facilities ensures that every eventuality for all patients can be provided for on a single site.

 

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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.

 

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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.

 

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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.

 

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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.

 

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