Category: Press Articles & Interviews

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.

 

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An interview with Mr Gary Ross by the BBC Manchester.

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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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