Injustice, Body Contouring and the Postcode Lottery

A few weeks ago, a patient came to see me in my private rooms. She had lost the equivalent of a small person in weight and wanted to "feel like a woman again". Her abdominal apron hung over her pubis to mid thigh. Her waist was 34 inches, but she had to buy 48 inch trousers to fit her abdominal apron into them. Her breasts were empty and deflated, the nipple hanging at the lowest part of the breast curvature. She was in her early 30's.

She satisfied all the criteria for body contouring as laid out by the CCG covering my NHS practice so I offered her the surgery on the NHS. After all, I had performed abdominoplasty, medial thigh lift and mastopexy on a similar lady only a couple of weeks previously on the Nash. Funding for her surgery was declined. Her CCG excluded funding for any type of body contouring. Had she lived 2 miles further South, she would have had the surgery funded by our CCG. I performed fleur-de-lis abdominoplasty and mastopexy privately. It has already transformed her life completely.

How can this possibly satisfy anyone's idea of the fundamental ethical principle of Justice? Weight loss surgery itself is commissioned universally across England for patients who fulfill the criteria. We have a duty of care to these patients and this duty is not satisfied if we convert one health issue into another.

In a recent study, 147 Primary Care Trusts in England were asked for information regarding provision of funding for body contouring after massive weight loss. Of the 67 who replied, 23 excluded all forms of body contouring procedures.

Before, dear Reader, you wax lyrical about funding availability for cosmetic procedures, let's be clear about something: the primary drive of this surgery is not cosmetic. Of course, there is a cosmetic aspect to it (as there is in almost all forms of plastic and reconstructive surgery), but this is not the reason that this surgery must be offered to patients on the NHS.

Research demonstrates significant improvements in patients’ physical function, emotional wellbeing, body image satisfaction, identity shifts, sexual vitality, greater wellbeing and quality of life once they have undergone body contouring surgery following massive weight loss. The NHS has a habit of running false economies. When I was a Burns Registrar at Chelsea & Westminster Hospital in London, I remember a particular case where a patient had a burn to their foot that had been treated surgically. He was fit for discharge but required dressings as an outpatient. They could not drive and, because of the dressings, they could not go home by public transport.

"Could the hospital pay for a cab to take me home?" the patient asked (quite reasonably, I thought).

 But nothing is so simple in the NHS. Rather than pay £30 for a taxi to take this chap home, the hospital management (in their wisdom) decided that he should stay in hospital (at a cost of around £700 per night on a specialist burns unit) until such a time as he could get on a bus. Bonkers.

So let's apply this to body contouring. The cost of the body contouring procedure is understandably high. However, so is the cost of psychological counselling, treatment for recurrent skin infections, time taken off work, back pain, neck pain, joint pain, recurrent urinary tract infections etc... the list goes on and on and these are all things can be attributable to the excess skin left behind after weight loss. Equally, all of these things (that can go on causing problems for the lifespan of the patient) can be addressed with a one-hit surgery. Go figure.

If you haven't already, please read the BAPRAS guidelines. I agree whole-heartedly with what lies therein.

The sooner that these guidelines become NICE guidelines, the better. It's time that all patients received a universal standard of care in this country, regardless of where they live. That's Justice.

Could advances in fat grafting spell the end for breast implants?

Fat grafting has come a long way in the last decade or so. The techniques have been refined and remastered and, certainly as far as I am concerned, methods have changed dramatically in the last three years alone.

I remember attending a BAPRAS conference a few years ago and the Birmingham group were presenting their results for autologous breast augmentation using fat grafting techniques. The results were nice enough, but the technique illustrates how things have moved on. They described filling each breast with 250cc of fat at each sitting (most patients were needing two or three attempts to reach their desired volume) and injecting the fat in 1cc aliquots. In addition, they showed a video where they illustrated the 'correct' technique by passing the cannula (the blunt needle that injects the fat) 25 times per 1cc syringe. I put up my hand.

"Excuse me," I said. "I'm no mathematician but, if you are putting 250cc into each breast, doesn't that mean you have to pass that cannula 6,250 times through the breast tissue? Do you have some kind of relay team? Doesn't that cause scarring of the breast tissue?"

I still haven't received a satisfactory answer to my question...

These days, things are different. Using sterile collection devices (such as the Aquavage system or the Lipivage system to name but two), it is possible to remove large volumes of fat in one sitting, purify it quickly and easily, and have it ready for re-injection in a fraction of the time that the old Coleman method took. I no longer use 1cc syringes, but I use 10cc syringes and inject 1cc of fat per pass of the cannula. As you can see in the picture below, it works for me. In this way, large volumes of fat can be transferred in a single sitting and, as long as the patient has enough spare fat (you would be amazed how much spare one can find on even a thin patient) the number of procedures can be minimised.

As this technique continues to evolve, I suspect that we will see an exponential rise in autologous breast augmentation, with implants being reserved for those who do not have enough of their own fat spare to create a breast of their desired volume. I can even envisage a future where, if advances in tissue bioengineering continue at their current pace, even slim women will be able to have their fat cells cultured and re-injected to provide autologous breast augmentation.

Until then we can stick with the flawed, yet safe and predictable, technique of breast implantation. However, ask your surgeon if you are a candidate for fat grafting autologous breast augmentation - who wouldn't want a breast that looks and feels natural, grows and shrinks with the rest of your body and never needs replacing?

Right Mastopexy and Left Fat Grafting

NB The longterm safety of fat grafting is not yet known - it appears to be safe from the evidence so far, but has not been in common practice long enough for us to know for sure. Be aware, be educated, be safe.

Why are breast enlargements soaring despite PIP scandal?

This was one of the headlines in the Daily Telegraph today. This, of course, follows the news from BAAPS that breast augmentation (along with every other cosmetic surgical procedure) has seen a significant increase over the last year. And why not? It's a simple, predictable and effective procedure that is versatile enough that almost anyone can find a shape and size that is to their liking (within reason - although there are surgeons out there who, in my opinion, are unethically acting outside of the patient's best interest by putting in breast implants that are patently too big for the patient's frame...)

There is one good thing that has come out of the PIP scandal (although I concede that it is a pretty thin veneer of silver lining on a rather large and ominous black cloud) and that is the undeniable fact that patients are more aware. With awareness comes caution and with caution comes safety. Patient safety to be precise. If you haven't already, please read my previous blogs on 'What do the Letters after a Surgeon's Name Mean', 'The DOs and DON'Ts of choosing where and by whom to have plastic surgery'  - both of these are pertinent to this topic as they discuss ways and means of vetting your surgeon and hospital for markers of quality.

Breast augmentation took a dip (understandably) in the 2011/2012 period while the PIP scandal was ongoing. To use business parlance, this was an example of a decrease in consumer confidence. It's hardly surprising - the PIP scandal was fraud of epic proportions. However, just like we are now seeing the back of the Global Economic Crisis (GEC), we are now seeing the back of this hideous scandal. Unfortunately, however, the comparison does not end there. There are bankers (try saying "bankers" while pulling the corners of your mouth apart with your fingers. Much better.) in the shadow of the GEC who are behaving in exactly the same gung-ho and arrogant fashion as they were before the excrement hit the turbine. Sadly, there are still surgeons and companies (can anyone say "cosmetic chain"?) who have not learned lessons from history and so are destined to repeat it.

It is not good enough to say "oops, no one told us that these implants were rubbish and dangerous. Sure, we knew that they were unbelievably cheap and that their cost was too good to be true and that they both looked and felt of inferior quality but, hey, our bottom line was fantastic for a while and, anyway, that's behind us now and, look, we're using top quality implants now so come back to us, come back, come back..."

Poor quality implants are just a link in the chain of cause and effect. Until companies use the best quality and practice in everything that they do, patient safety will always be a concern. For example, at present there is not a single surgeon on the books of the UK's largest cosmetic chain that is a member of either BAPRAS or BAAPS - the UK professional bodies for plastic surgeons. There is not single surgeon on those same books that holds the FRCS(plast) examination - the UK exit examination in plastic surgery, widely held to be the most rigorous plastic surgery specialty examination in Europe. How can it be good practice  to meet your surgeon on the day of surgery and not before? How can it be ethical practice to have the surgery explained to you by a cosmetic sales advisor who cannot possibly answer all your questions to an appropriate standard as they cannot perform the surgery?

Until all of these quality issues are adequately addressed, I'm afraid that the next scandal is just around the corner...

NHS Funding for Breast Asymmetry

So... I've recently been in 'discussions' with our local CCG (the panel responsible for determining who gets treatment funded on the NHS) about why they have made certain decisions declining surgery to patients of mine that, in my view, are clearly deserving. I also read with interest a follow-up interview with Miles Berry in PMFA News (a new information journal for Plastic, Maxillary-Facial and Aesthetic Surgery) where he was asked to define the difference between 'cosmetic', 'aesthetic', and 'reconstructive' surgery. Personally, I think that 'aesthetic' and 'cosmetic' are interchangeable terms although I tend to agree with Miles that 'cosmetic' does invoke undertones of vanity whereas 'aesthetic' tends to imply an attempt to marry form with function.

It seems to me that pretty much all reconstructive cases are aesthetic or, at least, have a considerable aesthetic component. After all, breast reconstruction after mastectomy aims to provide a breast that looks like a breast. The functional aspects of breast reconstruction are often overlooked but involve complex psychosocial factors as well as the simpler issues such as the basic ability to buy and wear clothes that fit. More obviously functional reconstructions might include transfer of a toe to a thumb in order to improve hand function. However, every effort is made to provide a reconstruction that is as aesthetically pleasing as possible.

I have recently had patients turned down for funding who have breast asymmetry. Now, EVERY woman has breast asymmetry. It's normal. Some women, however, have a degree of asymmetry that could never be classified as 'normal' by anyone with binocular vision. Yet they are still being turned down. Why? According to the CCG, they will not fund an implant into the smaller side. They don't come right out and say it, but it's clear to me that they do not want to burden the NHS with the duty of care of replacing those implants every 10 years (or so) in a young patient. Their suggestion? To reduce the larger side to match. Actually not a bad idea... were it not for the fact that in my letter requesting funding I wrote something along the lines of 'breast reduction to the larger side would not be remotely in the patient's best interests as the smaller side is so hypoplastic (small) that to match it would mean giving her a mastectomy'. Don't get me wrong, I don't like using implants for breast asymmetry; I much prefer to use fat grafting techniques to the smaller side and I've had some staggeringly good results from that. However, the CCG don't like the idea of multiple attempts at fat grafting (in fact, they rather nonsensically deem this to be 'cosmetic', arguing that the NHS would not fund fat grafting to enlarge hypoplastic breasts - something I also believe that it should do). So after several backwards and forwards emails, I have finally found a solution: a small reduction to the larger side and a single attempt at fat grafting to the smaller side. One operation. By no means a perfect solution but one that will almost certainly leave the patient better off aesthetically. This is now my standard practice for breast asymmetry on the NHS for those patients who cannot afford to go down the private practice route and it works well. Try it out for yourself the next time you have a breast asymmetry go unfunded...

The moral of the story is this: Don't give up. Look for workable solutions - the NHS is not a bottomless pit, but while funding is still being provided for less worthy causes, I'm going to continue the good fight for my patients.

What do the letters after a surgeons name mean?

All surgeons have qualifications of one sort or another and take pride in formally listing those qualifications after their name (I am no exception!). But what do all those letters mean? This short blog attempts to explain some of the more common letters seen in association with Cosmetic Surgery:

MBBS or MBChB (Medical Bachelor and Bachelor of Surgery)

This is the basic UK medical qualification that all doctors achieve when they leave medical school

BSc (Bachelor of Science - with or without Honours)

This is a University Degree based in an area of science (in my case, neuroscience)

MA or MSc (Master of Arts or Master of Science)

This is a post-graduate Masters degree based either in Science or the Arts (in my case I hold a Masters degree in Medical Ethics). Please note that students who qualify from Oxford or Cambridge Universities are awarded an MA simply by virtue of the fact that they went to those Universities without having to do any further study! An historical hangover and a bugbear of mine...

MD or PhD (Medical Doctorate or Philosophy Doctorate)

These represent a period spent in formal research. This is usually 2 years for MD and 3 years for PhD. The qualification is awarded for successfully defending a thesis.

MRCS (Member of the Royal College of Surgeons)

This is awarded to junior trainees who have completed BASIC surgical training. It is not an indication of specialist training and one would expect an aspiring surgeon to achieve this qualification after 2 years of basic surgical training. It requires the candidate to pass a written exam, a clinical exam, and a viva voce (oral) exam. A trainee surgeon can use the title 'Mr' with this qualification, so be aware that 'Mr' does not equal 'Consultant'

FRCS(plast) (Fellow of the Royal College of Surgeons specialising in Plastic Surgery)

This is the most important qualification. It confirms that the holder has passed their exit specialty examination in Plastic Surgery to UK standards. It consists of two written examinations followed, 3 months later, by examined clinical patient encounters and viva voce (oral) examinations. If a surgeon does not hold this qualification, there is no guarantee as to the quality of their training in Plastic Surgery.

In addition to these qualifications, see my previous blog for additional information regarding the GMC Specialist Register and membership of BAPRAS or BAAPS

Be safe, be informed!

As ever, all comments welcome

The DOs and DON'Ts of choosing where and by whom to have plastic surgery

Choosing to go under the knife is a difficult decision. There is an agony of choice that goes hand in hand with any procedure: Which surgeon? Which hospital? This short blog gives my own opinion as to how to best go about making that decision a little easier:

Do:

• Your research - not all surgeons are equally qualified to do the job, and neither do all private hospitals offer the same quality of care
• Ask friends or relatives who have had surgery for some advice
• Speak to your GP - perhaps they know a reputable surgeon and hospital
• Visit the clinics and ask questions - reputable clinics have nothing to hide and will be happy to answer
• Ask your surgeon about his/her qualifications/experience/complications
• Ask about the procedure itself AND the aftercare that can be expected
• Ask how much it all costs and if there are any hidden costs
• Choose a surgeon who is on the GMC Specialist Register in Plastic Surgery
• Choose a surgeon who holds the FRCS(plast) qualification
• Choose a surgeon who is a member of BAPRAS or BAAPS
• Choose a surgeon who holds (or has held) a NHS Consultant post - these are highly competitive positions and NHS surgeons are subject to large amounts of oversight

Don't:

• Assume that a good deal is a good deal - you usually get what you pay for
• Go abroad for your surgery - it may appear cheaper, but the pieces too often get picked up back home
• Accept to talk to anyone other than your operating surgeon in your consultations
• Be fooled by 'special deals' - trying to get you through the door in that manner is unethical practice and should ring alarm bells as to the ethical standards of that clinic
• Feel pressured into having surgery EVER
• Rush your decision - a good surgeon and clinic will not operate within 2 weeks of your first consultation and will usually offer a free second consultation prior to any surgery
• Assume that big is better - larger cosmetic chains are businesses first and foremost. They look at the bottom line. You don't seriously think that the cost savings from using PIP implants was passed to patients do you?

The list is by no means exhaustive and I welcome comments and suggestions. Be safe!

CD

Cosmetic Surgery - Culture or Couture?

Contrary to popular belief, plastic surgery predates Beverly Hills. In fact, the origins of reconstructive surgery predate modern America. The term “plastic surgery” stems from the Greek word πλαστικος (plasticos), meaning “to mould” or “give form”. However, the origins of the specialty even out date this archaic linguistic root. The early Egyptians are generally credited as the pioneers of the specialty, with the Edwin Smith Papyrus describing the surgical management of facial trauma some 3000 years ago. It was not until 1818, however, that this word was applied to reconstructive surgical procedures by Von Graefe in his work Rhinoplastik. Reconstructive surgery has therefore been around for a long time, absorbing various components of related specialties along its evolutionary course to become what it is today. Towards the end of the 19^th century, Listerian principles and advances in anaesthetic technique allowed surgery to be a safe, predictable, and available undertaking. It was perhaps inevitable, therefore, that the concept would soon be entertained of performing surgery for reasons other than the reconstruction of damaged anatomy. The first documented cosmetic rhinoplasty was undertaken by John Roe (an American) in 1891. Since that time, advances in reconstructive surgery have gone hand-in-hand with similar applications to cosmetic procedures. The very fact that the Hippocratic Oath states “primum non nocere” (or “first do no harm”), has led physicians, surgeons and laymen alike to question the ethics of performing “unnecessary” surgery.

The difficulty arises when the surgeon and the patient population are faced with an ever-changing idea within a particular society as to what exactly constitutes “normality”. Body image and the concept of ideal beauty have undergone many changes in the last two centuries alone. In 18^th century Georgian England, women attended court in false teeth, false bosoms, false calves and even, with the help of belladonna (deadly nightshade), falsely enlarged pupils to increase their sex appeal. Corsetry has enjoyed a prolonged period as a favourite among women over the years as an aid to attaining the slimmer, more attractive waist. Little, however, is mentioned of the discomfort involved in such attire and the two years of regular use required before the internal organs were repositioned to the extent that the waist was the desirable hand’s width across. Acceptable body shape also differs according to geography, with social norms varying with cultural diversity. For over a thousand years, until only last century, it was considered a desirable quality in Chinese women to have dainty feet. For this purpose, the feet were cut and bound at an early age in order to encourage an organically grown heel which would cause the woman to hobble upon walking. Indeed, the woman’s value as a love object was in direct proportion to her inability to walk. When faced with such extreme measures historically undertaken to achieve the desired “look”, cosmetic surgery seems humane and civilised by comparison. What is more grotesque, the woman from Chad who stretches her lips to absurd proportions by the use of metal rings, attached since early childhood, to achieve beauty or the woman from England who attends an outpatient clinic to have an injectable synthetic material implanted into her lips to achieve voluptuousness. Many would call the latter vanity, but happily condone the former under the facile umbrella of “culture”.

The chicken-and-the-egg conundrum can be aimed towards the evolution of cosmetic surgery. Was the exponential boom in the cosmetic surgery industry in the latter part of the last century due to a change in the public perception of the specialty, or was public interest spurred in a self-perpetuating cycle by the increasing availibility of the surgery? Certainly public perception has changed. In 1923, a vaudeville actress by the name of Fanny Brice had her nose “bobbed” to reduce the size and shape of what was considered to be a sign of her Jewish heritage. Many at the time wondered, aghast, as to why she had done it. By stark contrast, a mere 40 years later, there arrived on the entertainment scene an actress and singer by the name of Barbara Streisand (who, in an ironic twist, played the part of Fanny Brice in the movie Funny Girl). This time, many wondered, aghast, why on earth she had not done it. This is testament to the rapid change in the accessibility of cosmetic surgery, especially in the United States of America. There are several reasons to account for this increasing acceptance of cosmetic surgery, not least of which takes us back to the previous paragraph on the ever-changing nature of social norms. If one considers Marilyn Monroe as the quintessential beauty icon of the 1950’s, it is no great secret that her hourglass figure was achieved by a combination of large hips, a large bust, and a relatively small waist. With the help of a corset and shaped bra, and during an era where bare flesh was rarely displayed, it was relatively easy for the average women to emulate this fashion silhouette without resorting to the surgeon’s blade. As time marched on, fashions changed, and the arrival of the “Baywatch Babe” and the “Waif” coincided with an era where nakedness was accepted and less was considered more by the underwear and swimwear fashionistas. This social pressure meant that those women not genetically suited to the trend, and who could not, or would not, undertake the torturous crash diets required to achieve this shape, were increasingly turning to cosmetic surgery as a quick means to an end. Thus it was comparatively easy to conform to the fashion and advertising fads in the former part of the last century than those inflicted on us more recently.

Quite apart from the view of society is the view of the individual. The extent of deformity is not necessarily proportional to the degree of distress it causes. A child with severe facial asymmetry due to a congenital birth defect may have grown to accept his or her face depending on their own personality characteristics and their personal support networks, such as family and friends. Equally, a child from a similar background may be suicidally depressed due to a minor disparity visible only to the trained eye (and, of course, to the patient themselves). Every reconstructive surgeon has a similar tale among his caseload. It is easy to suggest that the features with which we are born are ours to keep, and as such we should learn to live with them as testament to our strong character. However, the proponents of this particular mindset tend to be either people who are fortunate enough not to be afflicted with the feature in question, or people who are blessed with the type of personality that can take a blow from nature’s battery on the chin. Unfortunately, there is a percentage of the population who are both unhappy with their appearance and who lack the supposed moral fibre to come to terms with their condition. For these people, cosmetic surgery has become a beacon of hope. It should be stressed at this stage that professional psychological support is an essential component in the cosmetic surgeon’s multidisciplinary team. Much surgery can be avoided by concentrating on the psychology behind the patient’s desire to change themselves.

Of course, regardless of this, there will always be a cohort of people who will never look at cosmetic surgery as a worthwhile practice. Reconstructive surgery is widely considered a noble and acceptable vocation, as it attempts to restore features damaged by trauma back to a semblance of normality. In this way it can be viewed as quality-of-life-saving surgery. But there is a thin line between what could be considered cosmetic, and what could be considered reconstructive. An abdominoplasty (or ‘tummy-tuck’) is generally considered to be a cosmetic procedure. However, when performed on a striated and pendulous abdomen, secondary to multiple pregnancies, or after massive weight loss, it tends to fall more under the mantle of  reconstruction. It might be considered a genetic ‘accident’ that our features are how they are. In this way it is as much out of our control as an assault in a dark alley. Thus a man born with a large nose (by comparison to social norms) should have as much recourse to surgery as a man left with a dorsal hump to his nose following damage by a blunt object. So regardless of aetiology, it is always vanity that drives the need for surgery from a cosmetic point of view. The Oxford dictionary defines ‘vanity’ as ‘excessive pride in or admiration of one’s own appearance or achievements’. It is also defined as ‘the quality of being worthless or futile’. Both meanings stem from the same Latin word vanus, meaning ‘empty, without substance’. The common perception is that cosmetic surgery involves vanity above and beyond that of reconstructive surgery, as it is the search for perfection over normality. Again, this is not necessarily the case. Following women’s emancipation, there came a gradual acceptance in society for women to both  follow the career path of men, and to follow career paths based on the vices of men. Thus in the 1940’s, women were undergoing breast reduction surgery not only to fit into the boyish fashions of the time, but also to hide their feminine charms in order to appear more professional alongside their male colleagues. On the other side of the coin, more recently, women were seeking breast augmentation in order to get better pay as exotic dancers, glamour models, or stars in the adult film industry. Thus ambition, rather than vanity, was a driving force for these women. In the same way, the acting profession pigeon-holes actors and actresses into age groups for casting purposes. Clearly, the choicest jobs are given to those in the younger adult age group, leading many with aspirations of stardom to undergo rejuvenation surgery. Again, this is not so much a question of vanity, but the dog-eat-dog reality of Hollywood.

In the United Kingdom, this debate takes on an extra dimension, as one has to consider the impact of different surgeries on the National Health Service. Reconstructive surgery has a place in the NHS, but cosmetic surgery obviously does not. The difficulty is in separating the two. When faced with an eight year old boy with prominent ears who is getting mercilessly teased at school, even the stoniest heart would suggest that otoplasty would be a worthwhile procedure to undertake on the young man in order to bring his ears back to a less noticeable position. Let us remember that his hearing is perfect, and although his ears are prominent, they are within the normal spectrum of ears for a child his age. Without surgery, he could lead a perfectly normal life. Compare this with an eighteen year old girl who has reached sexual maturity, but whose breasts have never grown beyond the buds of pubescence. She has reached an age where body image, and especially secondary sexual characteristics, is extremely important. She, too, is getting bullied by her peers, colleagues, and co-workers. Without surgery, she could still lead a perfectly normal life. She opts for surgical breast augmentation. Suddenly, to the supporters of the young boy, we have left the world of reconstruction and entered the shadowy world of cosmetic surgery. In fact, as I have shown, the two cases are both cosmetic in the strictest sense, although because of the distress caused to the patients by their respective conditions, they might equally be labelled reconstructive. Either way, neither one is morally justified over the other.

In conclusion, there is a grey area separating cosmetic and reconstructive surgery. Although the latter generally enjoys the better reputation and its practitioners are held in higher regard by the general public, it should not be assumed that the former is merely the frivolous exploitation of technology in order to feed our immortality complex and serve our shallow vanities. There are many psychosocial factors involved in both the initial choice, and the sequelae of cosmetic surgery procedures. The quality-of-life benefit, both socially and psychologically, seen by those who choose to undergo the knife in the name of improved cosmesis is often the only justification needed for the surgeons practising this dynamic and demanding specialty.