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Tuesday, 1 April 2014

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.

Sunday, 9 February 2014

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.

Tuesday, 4 February 2014

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...

Tuesday, 28 January 2014

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.