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These pages have been compiled to inform those interested in having cosmetic surgery and to those who are simply interested in finding out more about the subject.
Every patient is unique. There are many different ways in which a patient can be concerned about their appearance and their expectations so varied that this in no way can be a substitute for a face-to-face consultation with your surgeon.
We encourage potential patients to note any queries that may arise after reading about their procedure and discuss them with the surgeon at the consultation.
Every patient should be fully aware of the nature of the operation, the possible or likely result as well as the potential risks involved.


CONTENTS

1. INTRODUCTION:
General Aims
Considerations affecting all procedures
Importance of preoperative consultation

2. COSMETIC SURGERY OF THE FACE:
Face Lift/ Rhytidectomy
Temporal Lift
Brow Lift
Liposuction Chin
Cheeks
Cheek Implants
Eyebrow Lift
The Lips

3. EYELID SURGERY:
Blepharoplasty
Correction of the Oriental Eye

4. TREATMENT OF FACIAL LINES AND WRINKLES:
Collagen
Hyaluronic Acid Gel
Fat Transfer
Artecoll
Goretex/Softform
Tretinoin/Glycolic Acid
Botulinum Toxin (Botox)
Dermabrasion
Chemical Peel
Coblation

5. LASER SKIN RESURFACING:

6. EAR RESHAPING - OTOPLASTY:

7. NOSE RESHAPING - RHINOPLASTY:

8. CHIN AUGMENTATION - MENTOPLASTY:

9. ENDOSCOPY IN COSMETIC SURGERY:

10. SURGERY OF THE BREASTS:
Breast (Augmentation) Enlargement
Breast Uplift (Mastopexy)
Breast Reduction
Male Breast Reduction (Gynaecomastia)
Correction of Inverted Nipples

11. BODY CONTOUR SURGERY:
Liposuction
Ultrasound Liposculpture

12. ABDOMINOPLASTY:

TummyTuck, Abdominal Reduction

13. PENILE ENHANCEMENT:

14. VARICOSE VEINS:
Spider or Thread veins

15. REMOVAL OF TATTOOS:

16. SCAR REVISION:

17. THE TREATMENT OF BALDNESS-HAIR TRANSPLANT:
Hair Transplantation
Scalp Reduction

18. HAIR REMOVAL (LASER):

19. CORRECTION OF BODY AND MUSCLE DEFECTS:
Calf Augmentation
Sunken Chest
Pectoral implants
Buttock Implant

20. COPYRIGHT & ACKNOWLEDGEMENTS:
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1.INTRODUCTION
Cosmetic surgery is no longer the preserve of the rich and famous. Patients come from all walks of life and are of all ages. The popularity is due to the public awareness of the benefits and the fact that such surgery is now socially acceptable. Furthermore, recent advances in the design of implants and surgical and anaesthetic techniques have greatly improved the results and shortened the time needed for recovery. Another reason for the rise in popularity of cosmetic surgery has been the increase in media coverage and publicity by well known faces.

The aim of cosmetic surgery is to improve the appearance, but it is important to stress that surgery is not an exact science and that the surgeon cannot always precisely match what a patient has in mind. Results therefore cannot be promised.


GENERAL AIMS

In surgery perfection is the aim rarely the attainment.

The aim of cosmetic surgery is to improve the appearance of a particular feature or deformity thereby bringing increased self-satisfaction and self-confidence. Those expecting a miracle can be disappointed. A surgeon cannot always match what a patient has in mind regarding the final appearance. It may be that the goal of the patient is surgically unattainable or would not suit him or her.
Success of any cosmetic surgical procedure depends primarily on the skill and experience of the surgeon and also on a number of factors outside the surgeon's direct control. For example the patient's general health, age, skin texture, bone structure, healing properties and other factors such as patient expectations will all influence the final result.
Not every patient is suitable for surgery and it is sometimes in the patient's overall interests to be refused surgery. At the consultation the surgeon will try to assess the patient psychologically as well as physically in order to decide if the result is likely to please the patient. On rare occasions a cosmetic surgeon may refer a patient for a psychiatric opinion before deciding whether to operate.
The ideal patient must be sufficiently self motivated to undergo cosmetic surgery. Cosmetic surgery is not a panacea or cure-all for all of life's problems. If the desire for cosmetic surgery has been initiated or motivated by the encouragement or persistence of a friend, relative or spouse, the end result is more likely to prove to be disappointing for patient and surgeon alike.
It is extremely unusual to encounter a patient who is not nervous or apprehensive about undergoing cosmetic surgery. Every surgical procedure, even a simple one such as a mole removal, entails some degree of risk. The risks are that there may be complications and that the results may not match expectations.



CONSIDERATIONS AFFECTING ALL PROCEDURES

Introduction
This section deals with those postoperative complications that can occur with any surgical operation.

Scars: All surgical incisions heal with a scar. To make scars less obvious the surgeon tries to place incisions where they are not easily seen such as in natural skin folds or behind the hairline. It is wrong to think that scars will be invisible or that they will fade to nothing in time. Wound healing is a complex process involving many variables and for this reason results cannot be accurately predicted.
Most scars will look worse (red and raised) for some time after the operation before they mature and become pale. In general scars take 6-18 months to mature and there will always remain a permanent mark, no matter how inconspicuous, where an incision has been made.
Scars can occasionally heal unfavourably for no apparent reason and may require further treatment at a later stage. Complications such as infection or stretching of the wound can lead to unfavourable healing. Some areas of the body and some skin types are notorious for producing worse scars than others. Taking steroids can affect scar healing adversely.

Pain and Discomfort: Surgical procedures result in discomfort for the patient. The degree and duration of this will depend on the nature of the operation and the patient's pain threshold. Tablets or injections are usually given in the immediate post operative period. Patients are discharged when they are comfortable.

Bruising and Swelling: This is the body's natural response to injury. Every surgical procedure is followed by a period of bruising and swelling, depending on the nature and extent of the surgery.

Bleeding and Haematoma: Sometimes bleeding can
continue after the end of the operation or restart after an interval. It can either track to the surface or, more commonly, collect in a space or pocket deep to the skin. Such a collection of blood is called a haematoma and if it becomes large enough it may require further treatment.

Infection: A wound can become infected for a variety of reasons. Prompt and effective treatment is necessary to prevent further complications. Infections can also occur as a result of surgery in areas quite distant from the operation such as in the chest or urinary system.

Deep Vein Thrombosis: This is the situation in which blood has clotted in the deep veins of the calf. It is rare in patients undergoing elective cosmetic surgery. The clot might become dislodged and travel to the lungs where it can have very serious consequences. Patients with a previous history of postoperative deep vein thrombosis should warn the surgeon and the anaesthetist before the operation. Oral contraceptives increase the risk of deep vein thrombosis and there is some controversy about the benefit of stopping such treatment before surgery. It is thought wise to stop oral contraceptives prior to certain operations.

Allergic Reactions to Drugs and Dressings:
Various drugs are administered during the course of an operation particularly if there is a general anaesthetic. It is important to avoid giving any drug to a patient who might be allergic to it. Any known allergy must be reported to the surgeon and the anaesthetist before the operation. Severe allergic responses have to be dealt with promptly and effectively to avoid serious consequences.

Blood Transfusion: This is seldom required in cosmetic surgery. All blood is carefully screened by the blood transfusion service for any infectious agent before it is released for use.

Drains: Sometimes small flexible tubes are used to let out collections of blood or other fluids from a wound. They are removed a day or two after the operation.

Preoperative Considerations:

1. All patients are strongly encouraged to stop smoking. Smoking is not only a recognised health hazard in its own right but is responsible for a number of postoperative problems and complications in patients who have a general anaesthetic
a. Chest: Heavy smokers are more likely to develop a chest infection postoperatively particularly after major procedures such as abdominoplasty.
b. Circulation: It is a known fact that heavy smokers are more liable to suffer the consequences of impaired circulation. This can lead to flap necrosis (loss of the skin resulting in bad scars) following a facelift or abdominoplasty.

2. Alcohol and aspirin should be avoided for two weeks before and after any significant operation. Both impair clotting and hence the patient is more likely to bleed during and after the operation.

3. Abstinence from food and drink from early morning or the previous midnight is essential depending on the time of the operation and the orders of the anaesthetist.



IMPORTANCE OF PREOPERATIVE CONSULTATION

The results of cosmetic surgery can be very gratifying to both the patient and the surgeon. Before the patient has any treatment a consultation with the surgeon should take place and there should be a full discussion without any obligation. All the patient's questions should be answered and the patient should be given time to think over what has been said and what has been proposed.
A consultation is also essential because the surgeon has to ask the patient about their past medical history and health to find out if there are any details which might influence an operation. When the surgeon knows more about the patient he is then in a better position to operate effectively and safely. The surgeon will normally communicate with the patient's GP after the consultation, as long as the patient allows him to.
At the initial consultation the surgeon has a duty to decide if the patient has a problem that can be improved by an operation. Sometimes a patient's feelings about what he or she looks like are very different from what other people can see. The best results in cosmetic surgery are obtained when the surgeon and the patient agree about the problem in the first instance. Then the surgeon has to ask himself whether there is an appropriate treatment that will improve it. It is obviously pointless to undertake a treatment that might not work or might even make things worse.
Once the surgeon has decided that there is a treatment which will work then the surgeon should fully inform the patient about the operation and the post operative course of events such as when the stitches are removed and when the patient can be seen in public again after the operation.
Cosmetic surgery is not invisible mending but by careful operative technique and the accurate positioning of the incisions the scars can be almost invisible and only show on the closest examination. Patients on their part should realise that some skin heals better than others and this of course should emerge in the initial consultation and be fully discussed. All likely complications should be discussed fully. A patient who knows more about the operation because everything has been explained to them is more likely to be pleased with the result.


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2. COSMETIC SURGERY OF THE FACE

FACELIFT/RHYTIDECTOMY

Introduction
The young individual has a firm, smooth face with only a few lines and wrinkles. The skin feels tight because it fits snugly over the fatty tissue, muscle and bones of the face.
As the individual ages, the skin loses its elasticity, the muscles of the face lose tone and stretch and the fatty tissue shrinks in volume. The eventual result of this is that lines and wrinkles begin to appear and they become more prominent due to the effects of gravity and muscular action.
The most notable changes occur under the chin and upper neck (turkey neck and double chin), outer eyebrows (crow's feet), inner cheek area (jowl lines and furrows) and skin folds at the corner of the mouth.
Independently very fine lines appear where the skin is very close to the underlying muscle e.g. upper and lower eyelids, upper lip and forehead. The nose becomes sharper and longer in relation to the other facial features.
The rate of ageing in a particular individual depends on a host of variables. Apart from inherited factors other aspects that are important to the ageing process are skin type, exposure to sunlight, diet, alcohol consumption, smoking and stress.
The purpose of a facelift operation is to raise and tighten the facial skin thereby eliminating or decreasing overhanging folds or lines and to correct the effects of ageing on the deeper structures by tightening and relocating muscles which have stretched and drooped and removing redundant deposits of fat. The standard facelift operation is effective in the neck, chin, cheeks and temporal regions i.e. the lower two thirds of the face and neck. The forehead and eyelid regions are not included in the standard operation and require separate procedures that may be combined with it.
It is not possible to eliminate every line, wrinkle or furrow in a facelift procedure. Prominent lines or wrinkles that remain will require additional treatment e.g. skin abrasion, collagen injections and fat implants. In some individuals a repeat procedure may be required within a year of the initial operation to gain maximum benefit, as some skin types particularly in elderly patients will not necessarily remain stretched after only one procedure.
Having a facelift does not affect the rate of the ageing process. The improvement gained, that is the lessening of the signs of ageing compared to before the operation, is permanent. Sooner or later, depending on the factors mentioned above, the signs of ageing will return and this can sometimes be in as short a time as several months but is usually a number of years. If the patient wishes, the operation can then be repeated to gain further benefit.

Nature of operation
The patient is admitted starved on the morning of surgery. A general or twilight anaesthetic is usually administered.

The incision begins in the temple above the hairline and proceeds downwards in front of the ear. It then continues in the fold behind the ear and finally extends horizontally inside the hairline towards the back of the head. The skin is then gently lifted from the face and neck and the excess is excised. The incisions are then sutured and the face is bandaged for 24 hours. The length of stay in hospital is generally no longer than two days and the sutures are removed at 5 to 10 days.


Postoperative events
In addition to the post operative complications mentioned previously under "Considerations affecting all Procedures", the following are specific to facelift surgery:

Numbness and tension: This is common in the neck and cheek areas as well as around the ear. The numbness usually resolves within a few weeks. Very rarely areas of numbness especially on the ear can be permanent.

Change in normal hair pattern: This occurs invariably because the facial skin has been moved to a new position as a result of stretching it. The hairline in front of and behind the ear is largely affected. In males the sideboards will be altered in position and it may be necessary to shave behind the ear.

Pigmentation: This can occur over sites of bruising and may be permanent.

Flap necrosis: This is where an area of the lifted skin dies away leaving a nasty scar. It is an extremely rare complication in experienced hands. It occurs as a result of impairment to the blood circulation in the skin once it is lifted from the deeper tissues. The cause is often unknown but it is more common in heavy smokers. In severe cases further surgery may be required to improve the scarring.

Hair loss: This can occur in the scalp near to the incision lines. The hair usually regrows but it can take many months. Sometimes the hair loss is permanent and needs further surgery to correct it.

Nerve injury: On very rare occasions a nerve that activates the muscles of the face can be damaged resulting in weakness or paralysis of one side of the face. The effect may be permanent and further surgery may be required to improve the situation.

Postoperative Management
Most patients do not find this procedure unpleasant. The commonest complaint is that of tightness of the face.
Bandages and drains are generally removed after 24 hours. The hair is washed and ointment applied to incision lines. Aspirin and alcohol are forbidden for at least two weeks pre- and post- operatively. A liquid or soft diet is recommended for about three days to ease discomfort.
Quick movements, bending, straining and lifting should be avoided initially and if possible, sneezing.
Some surgeons advocate that the hair be washed daily and antibiotic ointment applied over the incision lines three times daily. Healing behind the ear is often delayed as a result of tension in the skin.

Result
Patients who are good candidates for a facelift are likely to gain a very gratifying result. They can look years younger and this can be a great boost for their confidence, both in social situations and at work. The improvement in appearance can be dramatic and is usually even more so when combined with blepharoplasty (removal of eyebags) and resurfacing to the upper lip.


TEMPORAL LIFT

This is really the upper half of a facelift. The incision is not carried around the ear but goes up high on the temporal scalp. It effectively removes crows feet creases from the sides of the eyes and lifts the upper parts of the cheeks and outer parts of the eyebrows. It is often performed on relatively young patients who do not have any problems with the neck skin and is often combined with eyebag reduction. The complications and problems are the same as a facelift.


BROWLIFT

Introduction
The browlift operation will flatten the vertical frown lines between the eyebrows and the horizontal creases of the forehead. In addition it will lift the eyebrows to a more youthful position if they have dropped. It is often combined with upper blepharoplasty and the combination often gives a better result than either operation alone.

Nature of operation
A general or twilight anaesthetic is usually administered. The incision passes across the top of the head from ear to ear inside the hairline. The scalp is undermined from the incision to the eyebrows and bridge of the nose. The muscles that produce the frown lines are weakened with appropriately placed incisions and some muscle is removed. The redundant scalp is excised and the incision sutured. The same procedure can now be performed through five small incisions within the hairline using an endoscope.

Postoperative events
Numbness and tingling invariably occurs at the top of the head and can last for several weeks.

Hair loss around the incision can occur and this may be permanent.

Scar: The scar may stretch and require a revision procedure at a later stage.

Asymmetry can occur resulting in one side being higher than the other. A revision procedure may be necessary.

Movement:Immediately after the operation the forehead will have limited movement, but normal movement returns usually in a few weeks.

Result
A browlift can make all the difference to a sad, drawn look that is caused by deep forehead lines and low eyebrows. Results can be long lasting (several years).


LIPOSUCTION CHIN

Introduction
In some people fat is deposited at an early age to give a double chin. In most cases an excess deposit of fat under the chin is associated with ageing. In addition loose skin under the chin and neck together with vertical bands that run from the chin to the base of the neck give the "turkey neck" deformity.

Nature of operation
In young people with a double chin the excess of fat can be removed by liposuction alone. Where there is loose skin liposuction has to be supplemented with skin tightening usually achieved with a facelift.



CHEEKS

Introduction
One of the most obvious signs of ageing is the increasing hollowness of the cheeks. This is due to the gradual reduction with age of the flesh that provides the fullness, compounded by losing the teeth. The skin of the cheeks is drawn inwards and thrown into folds. The problem with losing the teeth is that the gums wither away when they are not supporting them. When dentures are fitted on these thin gums they cannot be made up to be the same height as the teeth were originally. In extreme old age the loss of tissue between the nose and the chin produces the characteristic witch-like appearance.

Nature of operation
The loss of the fullness of the cheeks can be improved by doubling over the cheek tissues under the skin, done as part of a facelift in special cases. This produces a much more attractive rounded shape to the cheek which is virtually permanent.

The same procedure can also be done over the cheekbones during a facelift, but it does not work as well as implants of foreign material in accentuating the height.

Autologous fat implants
A procedure that is rapidly becoming very popular is to inject autologous (the patient's own) fat into the hollow of the cheek to replace the lost volume due to aging. This is also effective in correcting minor discrepancies in the shape and size of the two cheeks. There are two disadvantages however.
Firstly some of the fat is absorbed very quickly, i.e. it does not "take" so that rather more fat than the volume of the defect is likely to be required and how much more is difficult to judge. Most surgeons will aim slightly on the side of caution to avoid producing an unnatural bump and be prepared to add a little more later should there be any need.
The second disadvantage is that even the fat that does take will slowly disappear so that after a few years it will need to be repeated. The procedure is easy to perform and can be effective, so having to repeat it in the future is not a great problem. There is the great advantage that there are unlikely to be any visible scars as a result.
If the fat implant is put too near the skin and in too great a quantity an uneven puckering can result so this is another reason for the surgeon not to be too ambitious with this technique.



CHEEK IMPLANTS

Introduction
The height and projection of the cheekbones can be altered by the insertion of silicone implants, collagen injections and autologous fat implants.

Cheek implants are silicone plastic shapes designed to rest on the patient's own cheekbones. These are usually inserted via a small incision in the mouth.

Commercial fillers can be used if a small increase is required. Unfortunately the body gradually absorbs the material and top up injections will be necessary at intervals.

Autologous fat implants
The patient's own fat can be used to augment the cheek. The donor fat can be taken from the abdomen, thigh, neck etc and injected through a wide bore needle into the cheek area. This procedure is not permanent but seems to last longer than collagen.

Postoperative events
Malposition: Cheek implants can move out of position to give an asymmetrical appearance to the face. This is more likely to happen during the early postoperative phase.

Infection can also occur in the postoperative period. The implant has to be removed and the infection effectively treated before re-insertion.

Results
Cheek implants can produce a dramatic improvement in suitable cases and the result is permanent. Higher cheekbones tend to make people more photogenic. Collagen injections and fat transfer produce more subtle effects that slowly change back with time.



EYEBROW LIFT

Introduction
Drooping of the eyebrows causes the upper lids to bulge and descend until they seem to lie on the eyelashes themselves.

An eyebrow lift can dramatically improve this problem and result in eyes that appear larger and more youthful. An eyebrow lift will not correct excess skin of the inner part of the upper lid or pouching caused by fat herniation at their inner corners and it will not have any effect on the lower lid condition.

Nature of operation
The patient is admitted on the morning of the operation. The procedure is usually performed under local anaesthetic. The incision is made just inside the upper extremity of the eyebrow Sutures are removed after a week. An overnight stay in the clinic may be required.

Postoperative events
Scar: It is important to realise that the resulting scar can be visible if not camouflaged by eye makeup. Makeup can be applied after one week.

Hair loss can occur from the eyebrows - but since most women pluck or shave this hair anyway it does not appear to be a problem.



THE LIPS

The lips, like the rest of the body, are affected by the process of aging. The upper lip becomes less bulky with vertical crease lines. These problems are made much worse by smoking and also by losing the teeth. The creases are very effectively treated by resurfacing or a deep chemical peel, which can be combined with a facelift. If the upper lip is long and the lips themselves are thin, a slip of skin can be removed from the lip margin. When the wound is closed it rolls the lip outwards so that the lip pouts more. This will produce a scar running along the upper border of the lip where there is a natural line and in any case can be easily disguised with lipstick. This operation can be very successful in young people who want their lips to be fuller so it is not done just for aging.
If the lips themselves are not thin but the patient wants the lip skin to be more bulky then either fat, dermal graft or collagen can be implanted along the lip margin. Collagen or Restylane injections tend not to last for very long in this site. Permanent materials such as Goretex or Softform can last forever but can also change shape with time.
Oversized, thick lips that pout too much can be reduced by taking out a substantial slip of skin and underlying tissue from the inside. This operation is usually performed on Negroes. Because the scars are inside the mouth they do not show and they are unlikely to form into unsightly lumps, which can happen, when Negroes have scars on their skin surface.
The swelling immediately after this operation can be quite dramatic but after a few weeks when the swelling has gone the lips will be much less fleshy. There is a limit to how much can be removed because if too much is taken away the lips will not close properly.
After this operation it is likely that the middle part of the lip will be numb. Care has to be taken with hot food and drinks. Sensation should return to normal within a few weeks.


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3. EYELID SURGERY
BLEPHAROPLASTY

Introduction
Early signs of ageing of the eyelids are downward shifting of the brow and fullness of the upper eyelid skin. The swelling of the eyelids increases progressively and eyeshadow makeup becomes smudged at the lid folds. The upper lid fullness may eventually result in overhanging skin folds.
In addition "eyebags" become evident in the lower eyelids and at the inner corners of the upper eyelids. Eyebags result from the protrusion of excess fat in the orbit. In some cases this fatty protrusion is inherited and becomes noticeable at a much younger age.

Nature of operation
The patient is admitted to the clinic on the morning of surgery. The procedure is usually performed under sedation and local anaesthesia although a general anaesthetic is sometimes preferred for an exceptionally nervous patient.
In the upper lid the incision is made in the lid crease. In the lower lid the incision starts at the outer side in a crow's foot and extends under the eyelashes. Some surgeons prefer to make this incision through the conjuctiva rather than in the skin. Through these incisions, excess fat, skin and if necessary muscle can be appropriately removed. Sutures are usually removed between three and five days.


Postoperative events
Swelling and bruising: around the eyes is inevitable. The bruising usually subsides within ten days. Minor degrees of swelling may persist for a few weeks afterwards. Scars can usually be camouflaged by makeup after a few days. The scars will fade in time and become perceptible only on close scrutiny.

Watery eyes: This can occur for a few days post operatively and generally subside spontaneously.

Dark skin: Preoperative pigmentation of the lower eyelid skin will not be improved following this procedure. Indeed the condition may become more pronounced.

Bleeding: Occasionally a small collection of blood may accumulate under the skin and require to be evacuated. Persistent bleeding in the deeper tissues of the orbit may temporarily increase the pressure in the orbit. This is extremely rare and may require inpatient treatment although a further operation is usually unnecessary.

Blindness: This extremely rare complication causes concern to many patients. Although this complication has been reported in the medical literature the reason for it is unclear. It has not occurred in the experience of our members.

Drooping of the upper eyelid: This rarely occurs in unnoticed accidental trauma to the muscle that elevates the eyelid. A further operation may be necessary to correct this problem.

Drooping of the lower eyelid (Ectropion): This sometimes occurs in the immediate postoperative period as a result of swelling and rectifies itself in a few days. Sometimes the condition can arise as a result of excess skin resection at operation or from contraction of the tissues during healing. Occasionally a further procedure is required to improve the situation.

Inability to close the eyes completely: This can sometimes occur in the immediate postoperative period and treatment with eye drops is all that is required before the condition rectifies itself. In the rare instance that excess tissue has been removed a further procedure may be required.

Postoperative wrinkling can occur if the bags alone have been removed and the excess skin left forms creases or wrinkles. Further surgery may be required to improve the situation.

Infection: This can occur in the outer coating of the eye (conjunctivitis), incision lines (wound infection) and eyelid margins (blepharitis). These infections will require appropriate treatment.

Loss of eyelashes is very rare. The lashes however usually regrow.

Dry eyes: Patients suffering from this rare condition called the Dry Eye Syndrome (kerato conjunctivitis sicca) should inform the surgeon as lid surgery may worsen the situation.

Asymmetry: Many patients who complain that their eyes are different from each other after the operation are noticing for the first time a situation that existed before. If the asymmetry has been caused by the operation it can usually be corrected without difficulty.

Change of shape: Sometimes eyelid surgery causes the eyes to be rounder in shape than they were before. This is most likely to happen if a considerable amount of skin is removed.

Postoperative management
Alcoholic drinks and aspirin containing drugs should be avoided for two weeks pre- and post-operatively. Quick movements should be avoided initially. Individual surgeons will have their preferences with respect to treating bruising and swelling. Cold water compresses should be applied to the eyes for five minutes every hour for the first twelve hours, thereafter three times daily for three days in order to reduce the swelling and bruising. Ointment and eyedrops can be applied at the discretion of the surgeon. Contact lenses should not be worn for at least two weeks afterwards. Normal activities can be resumed in seven to fourteen days.

Result
The result of a successful blepharoplasty can be dramatic and extremely pleasing for the patient as well as long lasting. The best result is obtained if a facelift is performed as well. Eyelids without creases and bags will look much younger and the eyes often will look larger.


CORRECTION OF THE ORIENTAL EYE

Introduction
The essential difference between a Caucasian and Oriental upper eyelid is that the former has a transverse fold or crease above the eyelashes.

Nature of operation
The operation is usually performed under sedation and local anaesthesia. Through a transverse incision in the upper lid a fold is created by suturing part of the muscle that elevates the upper eyelid into the deeper layer of the skin. Several operations have been devised to produce this effect and the techniques used vary with different surgeons.


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4. TREATMENT OF FACIAL LINES AND WRINKLES

COLLAGEN
Collagen is a natural protein found throughout the body and is the main component of skin. During life the collagen in the skin is gradually weakened or destroyed by the ageing process. As a consequence smiling, frowning, the effects of gravity and sunlight result in the formation of fine lines and wrinkles. Smoking accelerates this process.
The damaged collagen can now be replenished by injecting highly purified animal collagen, which the body accepts as its own and incorporates it into the skin filling in the wrinkles and smoothing the surface of the skin. It becomes a functioning part of the skin and even stimulates new natural collagen formation.
There are now several different types and strengths of collagen available. Each type is designed either for a specific area or for a particular kind of skin crease, wrinkle or fold.

Test Dose: Before treatment can begin a small amount of collagen is injected into the skin of the forearm as an allergy test. 97% of patients will show no reaction to the skin test and can proceed with treatment. The result of the test is assessed after four weeks. Assuming there is no reaction to the test dose, the treatment consists of a series of tiny injections into the wrinkles and is performed as an outpatient procedure.
Like the body's own collagen, the new collagen will gradually be depleted or absorbed by the body and further "top-ups" will be required at intervals. As there are many skin types and several different factors involved it is not possible to predict accurately how long the effects of each injection will last in any particular individual. In most cases "top-ups" are required every six to twelve months.

The amount of material used for these "top-ups" is much less than the original treatment but this will ensure that 100% correction of the defect is maintained.

Paris Lip: Collagen implants, as well as being used to fill out the small creases around the lips, can also be used to enhance the borders of the lips and give more definition. Younger patients may wish to have more prominent and "pouty" lips. This technique using collagen to produce this look has been named the "Paris Lip" after the French plastic surgeon who first created it.


HYALURONIC ACID GEL
Hyaluronic acid is a natural material present in all connective tissue and has been developed as a filling agent similar to collagen and used in the same way but with the ease of not needing a skin test. The commercially available products are either extracted from rooster combs or more recently as a non-animal stabilised formulation that is claimed to offer longer lasting properties.

FAT TRANSFER
A procedure that is rapidly becoming very popular is to inject autologous (the patient's own) fat into the hollow of the cheek to replace the lost volume due to aging. This is also effective in correcting minor discrepancies in the shape and size of the two cheeks. There are two disadvantages however.
Firstly some of the fat is absorbed very quickly, i.e. it does not "take" so that rather more fat than the volume of the defect is likely to be required and how much more is difficult to judge. Most surgeons will aim slightly on the side of caution to avoid producing an unnatural bump and be prepared to add a little more later should there be any need.
The second disadvantage is that even the fat that does take will slowly disappear so that after a few years it will need to be repeated. The procedure is easy to perform and can be effective, so having to repeat it in the future is not a great problem. There is the great advantage that there are unlikely to be any visible scars as a result.
If the fat implant is put too near the skin and in too great a quantity an uneven puckering can result so this is another reason for the surgeon not to be too ambitious with this technique.


MICROPARTICULAR SILICONE (ARTECOLL)
This substance was developed to act as a permanent injectable filling agent that does not migrate. It is a suspension of tiny solid silicone particles suspended in an absorbable gel. These particles are unable to migrate beyond the site of injection. The material has a very thick consistency and can therefore only be injected through a large, blunt-ended needle. This makes its application limited to injections deep in the skin, such as nose, chin, lips, cheeks, deep facial grooves and puckered scars. It is not suitable for the treatment of fine facial lines. The result is permanent although it may be possible to remove the material surgically.

Nature of operation
The area to be treated is injected with local anaesthetic. The skin is punctured with a needle and the material is injected into multiple tracks until the desired effect is achieved. The treated area is then taped for 24 hours.

Postoperative events

Swelling: The degree of swelling will depend on the area treated.

Pain and discomfort: There is usually a little discomfort for 24 hours. Postoperative pain killers are generally not necessary.

Infection: As with any implant there is a small risk of infection and if it occurs will require treatment with antibiotics.

Overcorrection and displacement:
Either may occur because the treated area has been distorted by injection of local anaesthetic and injection through a large needle is relatively imprecise. If necessary the displaced or excess material can be removed surgically.

Clumping and hardness:
This occurs where the injected material can be felt as an abnormal, hard lump. This can be caused by the material being placed too close to the surface of the skin and not having been spread around thinly enough in many tunnels. Microparticular silicone is not recommended for using in the lips.

GORETEX/SOFTFORM
Several materials have been developed to augment areas such as the folds from nose to mouth and the lips. The most prominent are non-toxic polymers derived from medical products that have been used elsewhere in the body known as PTFE (polytetrafluoroethylene). The porous nature allows the body’s tissue to grow into it and some are tubular in design for better fixation.

Nature of operation
A small incision is made at the implantation site under local anaesthetic and a small tunnel or pocket is created for the implant. The incision is often closed with a stitch that will be removed after 5 days.

Postoperative events
Swelling and some discomfort or bruising can occur for a few days.
Hardness of the material can be felt after the swelling has subsided, as it is not the same as the natural tissue of the body.
Migration of the material is rarely possible and may protrude through the skin if there is inadequate healing.

TRETINOIN is a derivative of vitamin A. Research has clearly shown that Tretinoin increases the rate of skin cell turnover, increases the thickness of the skin and increases collagen deposition. The overall effect is that the skin becomes more youthful in appearance with fine lines and wrinkles smoothed out.
In addition tretinoin hastens the clearing of pigment filled skin cells. As a result dark spots lighten and discolouration evens out. Research has also shown that tretinoin helps eradicate precancerous skin changes such as actinic keratoses.

Side effects: Tretinoin has been used by doctors for over 15 years and has proved to be a safe preparation. During the initial stages of application some patients may experience minor skin irritation, redness and a burning sensation as well as peeling of the skin. Tretinoin increases the skin's sensitivity to ultraviolet radiation and prolonged exposure to the sun should be avoided.

ALPHA HYDROXY ACID: Also known as Fruit Acids; the most well known of which is Glycolic Acid and works in the same way as tretinoin but has the advantage of being available in higher strengths or concentrations.


BOTULINUM TOXIN (BOTOX)

Introduction
Facial wrinkles and unsightly lines of facial expression are due to overactivity of the underlying facial musculature. Botulinum toxin can reversibly paralyse these muscles so that the lines are smoothened out.

Postoperative events
Swelling, skin redness and bruising can occur for about 48 hours.
Weakness of the eyebrows can occur temporarily and very rarely double vision and watering of the eyes have been seen.


DERMABRASION

Introduction
Dermabrasion or "sanding" is a procedure used in selected cases to remove irregularities in the skin surface. It is performed by employing a rotating wire brush or diamond wheel to plane down or sand the irregular area. An improved appearance is obtained by making the surface uniform.
Old acne scars and chicken pox marks can be improved as well as certain superficial skin discolourations. Dermabrasion is also used to treat fine lines and wrinkles especially those in the upper and lower lip regions. It must be emphasized that in severe acne scarring several procedures will be necessary over a period of time.

Nature of operation
The patient is admitted on the morning of surgery. Small areas can be treated under local anaesthesia. Large areas are best treated under general anaesthesia.
At the end of the procedure the face may be bandaged or left uncovered. Ointment may be applied to the abraided area once the bandages are removed. The patient is discharged home with detailed postoperative instructions the following day.
Crusting develops on the abraided area within 1 or 2 days and gradually lifts off in 7 to 10 days depending on the depth of the abrasion. A smooth, pink skin results that gradually returns to normal colour in the next 6 to 8 weeks.


Postoperative events
Swelling invariably occurs in the immediate postoperative period. Keeping the head elevated helps to reduce this problem.

Fever can occur immediately after. Medication is not often required.

Discomfort can occur and responds to medication.

Insomnia: Sleeping tablets are prescribed if this is a problem.

Milia: Tiny white firm bumps in the skin can appear from 3 to 4 weeks post operatively. They may require removal and sometimes this can be achieved with a rough flannel.

Pigment changes: Pigment alteration occurs in all patients for several weeks. Initially the abraided area will appear pink and less pigmented than the surrounding skin.lt may take up to 6 weeks to regain normal pigmentation. Final pigment adjustment may take several months.

It is important to remember that exposure to sunlight within six or eight weeks following treatment may result in unfavourable discolouration.

All patients are strongly urged to stay out of the sun for this length of time and use emollient sunblock cream if exposed to sunlight.

Excessive pigmentation is seen in about 10% of cases. It is usually temporary but can last several months. It must also be emphasized that permanent excessive or decreased pigmentation can result but this is extremely rare.

Scarring: Unfavourable healing is rare, but can occur particularly if a deep abrasion is performed. Thickened (keloid) scarring can result and mar the result. Further treatment will be necessary.

Postoperative management
Without doubt dermabrasion or chemical peeling can be extremely difficult for a patient post operatively. Most patients would wish to stay out of the limelight until healing has occurred or until such time as makeup can be applied to hide the initial effects.
It is recommended that patients sleep upright for the first few days to help reduce the swelling. All prescribed ointments should be applied meticulously as directed by the surgeon. After a few days the face can be washed three times daily with a soft cloth and lukewarm water.
The soft crusts that form will lift off in 5 to 10 days. At this stage a bland soap can be used and unmedicated makeup applied. In men shaving can restart.
It is important to avoid excessive straining, lifting, bending, intense sunlight or extremes of temperature or strong winds for six weeks. In addition it is vitally important to avoid contact with persons who have herpes simplex (fever blister or cold sores), shingles or chickenpox, impetigo or any other contagious skin disease.
Pinkness, dryness and itching can be reduced with a mild anti-inflammatory lotion or cream.

Results
The result of a successful dermabrasion can be extremely pleasing especially if the original blemish was very noticeable. Despite the horrendous initial appearance after the first 24 to 48 hours patients cope very well.



CHEMICAL PEEL

Introduction This procedure consists of applying strong chemicals (phenol, croton oil) that burn and remove the upper portion of the skin in much the same way as occurs mechanically with dermabrasion. Lesser strengths of peel are also available combined with various additives to enhance the action of the main chemical, glycolic acid.

It is most commonly used for improving fine lines around the mouth and eyes, but large areas; even the whole face can be peeled under special conditions. The upper lip and brow are often treated in this way in conjunction with a facelift.

Chemical peeling acts like dermabrasion by stimulating the patient's own collagen formation beneath the treated area. This rejuvenates the skin giving it a fresh, smooth appearance.

Additional considerations and events
Crusting, tightness and redness will last for at least 10 to 14 days. Frequently pink discolouration will last three to four weeks. Although this is not a surgical procedure it can be quite uncomfortable for several days, particularly when the entire face is treated at one time.

Temporary heart problems have been caused by the application of the stronger phenol chemical. The procedure needs to be done where treatment for this problem is available.

Herpes simplex: People who carry the herpes simplex virus (and who are susceptible to cold sores etc.) run the risk of exacerbating this condition and special precautions are necessary.

Exposure to sunlight within six to eight weeks following treatment may result in unfavourable discolouration

Increased or decreased pigmentation to the skin may occur and may be permanent. The tendency to develop increased skin pigmentation may be increased if the patient is exposed to sunlight or is taking oral contraceptives or hormone replacement therapy or becomes pregnant within six months of treatment.

Difference in texture: It is important to realise that the peeled skin will be different in colour and texture from the non-peeled areas and this effect can be permanent.


Thickened scars may occasionally occur and require further treatment.

Milia: little white lumps in the skin - can occur as with dermabrasion and are treated along similar lines.

COBLATION

The term stands for controlled ablation and works by utilising radio frequency energy to remove damaged skin and to stimulate collagen regeneration under the skin. After treatment the new skin heals in a softer, smoother and more youthful way. Resurfacing takes about one week to heal over and the new skin will be pink or red for a few weeks. Following treatment some swelling is present for a few days. This option is considered similar to Erbium laser but with a faster recovery time.


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5. LASER SKIN RESURFACING

Introduction
Dermabrasion and Chemical Peels have been overtaken by this method of treating lines and wrinkles. The removal of the upper layers of facial skin is one of the most popular rejuvenation procedures today. Since the introduction of the high energy pulsed CO2 & Erbium YAG Lasers new opportunities in cosmetic surgery have opened up. The heat of the laser vaporises old damaged skin to reveal fresh new skin. The treatment is extremely effective when used on sun-damaged skin giving a fresh smooth textured result to the treated areas. This treatment can also smooth out scars caused by acne and chicken pox and can fade age spots.

Areas and skin types suitable for this type of treatment include:
CO2 Laser: Face, eyes, mouth (Caucasian skin types only)
Erb YAG Laser: Face, eyes, mouth, (All skin types)
Hands, neck & chest

Nature of procedure

CO2 Laser: For this treatment a full general anaesthetic is required and the area would be infiltrated with local anaesthetic to reduce postoperative pain. A complete face will take approximately 90 minutes and it is recommended that two nights are spent in hospital under medical supervision.

Erbium YAG Laser: Local anaesthetic cream would be applied to the area one hour before the treatment (general anaesthetic is not required). A complete face will take approximately 40-60 minutes and the patient will be able to travel home within two hours of treatment.

Postoperative events
CO2 Laser: The immediate results are traumatic for the first 7 days. Symptoms include severe swelling, scabbing and redness. Belying the appearance there is very little pain. After 10 days the remaining redness can be camouflaged with make-up. In most cases the redness will have faded significantly after 6 weeks and disappeared completely after 4-5 months.
Erbium YAG Laser: The treated area will be slightly red for 4-7 days. There is very little discomfort and in most cases the redness will have disappeared completely within 10 days.

In both instances any untoward side effects such as scarring or pigmentary changes can be discussed with the surgeon at the initial consultation.


Postoperative management
CO2 Laser: For the first 3 days frequent use of cold water is mandatory. It is essential that the area does not dry out as this will result in thicker scabs and further discomfort. The use of liberal amounts of aqueous cream is also recommended. The head should be elevated for the first 3 days to eliminate swelling. Antibiotics and antiviral medication are usually prescribed post operatively.
Erbium YAG Laser: Keep the area cool and moist for the first 2 hours. After that the use of aqueous cream until the initial redness has died down. Usually after 3 days a good moisturiser will be all that is needed.

For lasting results exposure to sunlight should be restricted and use of a good moisturiser and sun block (factor 30) at all times.


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6. EAR RESHAPING – OTOPLASTY


Introduction

Otoplasty is the name given to the procedure used to "pin back" protruding ears. This condition is inherited and surgery can be performed as early as the fifth year of life to avoid classroom teasing. One or both of the ears may not grow into the normal shape during development and there are many descriptive terms applied to these abnormalities. In such cases surgery is often very helpful in making the ears look better although sometimes it may not be possible to achieve an entirely normal appearance, especially in the worst cases.

Nature of the operation
The patient is admitted on the morning of surgery. A general anaesthetic is given to young children whereas local anaesthesia and sedation is preferred in older children and adults.
Incisions are made in the groove behind the ear so that scars are hidden from view. At the end of the procedure a turban bandage is usually applied for a week. Thereafter a bandage is worn at nighttime until healing is complete within 6 weeks. Sutures are tidied after 1 week.

Postoperative events
Bruising and swelling of the ears is inevitable. By the time of suture removal the majority of the bruising has subsided. If blood collects under the skin (haematoma) it may have to be removed.

Pain and discomfort is variable and usually medication is only required during the first 24 to 48 hours post operatively.

Scars: Usually the incision is hidden in the fold at the back of the ear and is unlikely to be obvious but in those cases where a significant abnormality of the ear has been corrected it is sometimes necessary to place an incision, and therefore produce a scar, on the outside of the ear where it might be visible.

Infection: can sometimes occur and require antibiotic treatment. Rarely the wound may require to be resutured if this occurs.

Inadequate correction or recurrence of the problem:
Sometimes the final position of the ears may prove to be unsatisfactory to the patient and a further procedure may be required. This is particularly so in cases of severe deformity.

Asymmetry: It should be stressed that both ears are never exactly alike even in the normal state and that perfect symmetry is not a reasonable expectation.

Skin loss: On rare occasions a small area of skin covering the ear may be lost as a result of impaired circulation resulting from bruising or infection. A tidy up procedure may be occasionally necessary to achieve the best results.

Ear deformity: This is an extremely rare complication and can occur as a result of inadequate healing after the operation. A second procedure may have to be performed to improve the result.

Result
After the otoplasty the ears that used to be a source of great embarrassment should look normal. This gives the freedom of choice to choose any hairstyle and avoids the difficulty of hiding them when going swimming or on windy days. This is one of the most frequent and successful operations in cosmetic surgery. The result is permanent and if performed early in life will prevent classroom teasing which can lead to serious psychological disturbances in the child and heartache to parents.


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7. NOSE RESHAPING – RHINOPLASTY

Introduction
Corrective nasal surgery is one of the commonest cosmetic procedures performed today. The operation is performed for repair of injuries and also when the nose has become an ugly shape during growth.
Basically, the nasal contour is changed by removing, shifting or altering the underlying bony and cartilaginous structures. In some cases an implant is required to build up structures within the nose. Except in special circumstances (see later) the operation is performed from inside the nose leaving no external scars. Before the operation the shape of the new nose is carefully discussed.

Nature of operation
The patient is admitted on the morning of the operation. Preoperative photographs are taken. A general or twilight anaesthetic is given. The shape of the nose is changed along the lines agreed with the patient. This will nearly always involve fracturing the nasal bones. At the completion of the operation a plaster of Paris splint is placed on the nose and secured in position with sticky tape to the forehead and cheeks. The plaster splint is removed after 7 to 10 days.
In addition soft packaging is placed inside each nostril for 24 to 48 hours. The duration of the stay in the clinic is usually no longer than 48 hours.

Postoperative events
Bruising and swelling of the nose as well as around the eyes is the commonest postoperative feature. Most of the bruising and swelling around the eyes subsides within a week in most patients. Slight swelling in the nose which is not generally apparent to the onlooker, but which can be noticed by the patient, may take many weeks to subside.

Infection and bleeding may occur as with any operation. Fortunately these complications are uncommon and do not generally give any cause for concern.

Nasal blockage: As the tissues inside the nose are swollen afterwards it is not uncommon to experience a variable amount of blockage to breathing. This symptom however resolves itself in a short time following operation. It is extremely rare to experience permanent nasal obstruction if this was not already present before surgery.

Numbness of the tip: often occurs and may be present for weeks after the operation. It usually resolves completely.

Pain and discomfort: Despite the nature of the operation, pain and discomfort are surprisingly rare. Painkillers are given as required.

Skin type: The thicker the skin covering the nose the longer it takes for the nose to attain its final shape. Sometimes refinement is limited if the skin is too thick.

Scars: In the vast majority of cases all work is done on the inside of the nose leaving no external scars. There is one exception. If it is necessary to make the nostrils smaller an incision is made where the side of the nostril adjoins the upper lip. Because this is located in a natural body fold, the scar is practically unnoticeable to the average onlooker.

Postoperative management
After discharge from the clinic and until the plaster cast is removed patients are advised to rest as much as possible, sleep upright, sneeze through the mouth and avoid blowing the nose.
Ice packs applied to the eyes help to reduce bruising and swelling. The hair should not be washed until the plaster is removed as this may dislodge the plaster. Glasses may be worn on top of the plaster if this is possible but once the plaster is removed it is advised that glasses should not be allowed to rest on the nose for 6 weeks. Contact lenses can be inserted after a few days.
Should a significant haemorrhage occur from the nose after discharge home it is advised that ice packs are applied to the side of the bleeding. After the first 48 hours bleeding from the nose is very uncommon.
Strenuous exercise should be avoided for 4 weeks. After that time non body-contact sports are permitted. Body-contact sports are prohibited for 6 months.

Result
Most patients are delighted with the result of the operation, which is generally very successful in improving the appearance of an ugly nose.
It should be stressed that there is a limit to the corrective procedures possible or recommended. The surgical goal is improvement and not to match the ideal which might be present in the mind of the patient. Some of the limiting factors in rhinoplasty are the contour and shape of the face, the texture and thickness of the skin, the inclination of the chin, lip and forehead, the depth of the angle between the forehead and the nose, the height of the patient and the healing powers of the tissues.
Noses that have been severely injured or those which are markedly crooked are technically difficult to correct and a second procedure may be necessary.


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8. CHIN AUGMENTATION – MENTOPLASTY

Introduction
Chin enlargement is performed either for a receding or week chin or in conjunction with a nose reshape operation to achieve a better profile.

Nature of the operation
The procedure is usually performed under sedation and local anaesthesia or general anaesthesia if a rhinoplasty is performed as well. A silicone chin implant (which is available from the manufacturers in various shapes and sizes) is inserted to lie against the front surface of the original chin via an incision inside the mouth. The operation therefore leaves no external scars.

Postoperative events
Extrusion of the implant sometimes occurs, generally as a result of infection. This will probably occur soon after the operation but can sometimes happen many months afterwards. A further procedure will then be required to re-insert the implant at a later date.

Displacement of the implant can occur even if the implant was correctly inserted initially. Further surgery to put it back in the right place will be necessary.

Infection is uncommon and usually responds to antibiotic treatment. It can lead to extrusion of the implant.

Numbness of the lower lip occurs very frequently. It is usually a temporary phenomenon but on extremely rare occasions it can remain as a permanent feature.


Result
The improved shape of the chin and the balance of the face should be permanent once the wound around the implant has fully healed.

OTHER OPERATIONS
Implants can also be placed on the underside of the chin to make the lower part of the face longer but they are not very stable unless secured into position in some way and this makes the operation more complicated. They are inserted through an incision in the skin just below the jaw in the midline.
If the jaw is too long then a small amount of bone can be removed from the point of the jaw, either from the front or underneath. Unfortunately the roots of the teeth and the shape of the jaw itself often limit the amount of bone that can be removed, and therefore only fairly minor changes can be achieved by this method. The incision would be made on the underside of the jaw in the natural crease and if there is any redundant skin as a result of the bone removal then it can be easily excised leaving a single scar line.
Occasionally patients request that various alterations are made to the actual shape of the chin, such as producing a clef or making a dimple. It is possible to do this in some cases.



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9. ENDOSCOPY IN COSMETIC SURGERY

Introduction
Much interest has been generated over the last few years in magazines addressing the wonders of ‘keyhole surgery’. The term involves the use of a fine telescope to which is attached a television camera. Surgery can be carried out on the face, abdomen and breasts and the progress monitored on a television screen. In practical terms, the endoscope has been found to be useful in the tightening up of abdominal muscles where excess skin does not need to be removed and in tightening up parts of the face in relatively young patients. Their use in breast enhancement and nose surgery is so far of limited value.

Nature of the operation
In endoscopic face-lift, the endoscope is inserted into about five stab incisions within the frontal hairline and the surgeon dissects the forehead and facial tissues close to the bone. Certain facial muscles enhance the appearance of facial ageing, whereas other muscles enhance a more youthful appearance. It is the muscles that enhance ageing that are divided and the muscles that enhance youthfulness are left intact. The latter group, now acting without the effect of its antagonists, exerts an increasing rejuvenating action on the tissues of the face, and this continues in the first 6 months after surgery.

Result
Because endoscopic surgery involves much less invasive surgery, there is less disturbance to facial tissues and a more rapid recovery from surgery. The longer and more noticeable scars of traditional face-lifts are also avoided. However the technique is more suited to younger patients where there is less need to excise much skin and the permanence of the lift may be more limited.


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10. SURGERY OF THE BREASTS
BREAST AUGMENTATION (ENLARGEMENT)

Introduction
Breast enlargement is one of the commonest cosmetic procedures performed in this country today despite all the recent media publicity concerning the safety of the silicone breast implants. In 1997 at the request of the Government, the Independent Review Group (IRG) was established to investigate the possible health risks associated with silicone breast implants and to examine the issues relating to preoperative patient information. The IRG published its findings in July 1998 and these are their conclusions
1. There is no histopathological or conclusive immunological evidence for an abnormal immune response to silicone from breast implants in tissue.
2. There is no evidence for any link between silicone breast implants and any established connective tissue disease. If there is a risk of connective tissue disease, it is too small to be quantified.
3. Good evidence for the existence of undefined conditions such as ‘silicone poisoning’ is lacking. It is possible that other conditions such as low-grade chronic infection may account for some of the non specific illnesses noted in some women.
4. The overall biological response to silicone is consistent with conventional forms of response to foreign materials, rather than an unusual toxic reaction.
5. There is no evidence that children of women with breast implants are at an increased risk of connective tissue disease.
6. The IRG recognized that there were such issues such as the precise incidence of rupture where the scientific data was incomplete so that rigorous conclusions could not be drawn.


Types of implants
All breast implants currently available have an outer silicone shell, which have either a smooth or textured surface. It is the filler that differentiates the various types available.
1. Standard Silicone Gel: Has a long history of reliable use with a natural feel. Main disadvantage is the media scare mongering.
2. Firm Cohesive Silicone Gel: Made to a solid consistency that maintains its shape. Gel does not ooze if the implant ruptures. Main disadvantage are high cost, unnatural feel and asymmetry with rotation of the implant.
3. Saline: Biocompatible filler with a long history of use. Main disadvantages are unsuitable for females with little breast tissue, may not look aesthetic, more prone to wrinkling, more prone to rupture.
4. Hydrogel: Biocompatible filler made of water, salt and sugar. Main disadvantages are can change volume in situ, less natural feel, not presently available.
5. PVP: Biocompatible filler with polyvinyl pyrolidine commonly used as a plasma expander. Main disadvantages are can change volume in situ, more prone to wrinkling, less natural feel, not long on the market.
6. Vegetable oil: Biocompatible filler made of soya oil which presently has been withdrawn from use awaiting further evaluation of safety and reliability.

Nature of operation
The patient is admitted to the clinic on the morning of the operation. A general anaesthetic is used in most cases although it is possible to perform the operation under intravenous sedation and local anaesthesia. The site of the incision (usually about 3 - 4 cms in length) will be chosen by the surgeon. It is generally made in the crease underneath the breast. Some surgeons however prefer to make the incision in the armpit or around the areola. A pocket for the implant is then fashioned behind the breast. A silicone implant is then inserted into the pocket. The implant may be placed in front of or behind the muscle of the chest. The implants come in different sizes and the surgeon will choose the one that is most suitable.
Some surgeons may also insert a fine tube to drain out any fluid which that collect around the implant and this is removed the following day. The pocket and the wound in the skin are closed with sutures that do not come through the skin surface so that there are no suture marks. A bandage or very supporting bra is applied. The following day before going home, the bandage is removed and the patient is fitted with a bra that should be worn night and day for 2 weeks. The sutures may be removed after 10 days.

Postoperative events
Bleeding and haematoma: On rare occasions bleeding may occur into the pocket created for the implant resulting in a haematoma. If a significant amount of blood collects in the pocket it may have to be removed, necessitating a further procedure.

Infection: This very uncommon complication may lead to the breakdown of the incision necessitating the temporary removal of the implant. It usually occurs if it is going to, within the first ten days after the operation. After the infection has subsided the implant can safely be reinserted.

Scars: Every attempt is made to make the scars as short and as inconspicuous as possible. A sagging breast has a natural crease underneath and scars placed there will not normally be noticeable except perhaps on lying down on a topless beach. When there is little skin and breast tissue at the outset there will not be significant breast crease formation after surgery and therefore a scar placed at the lower border of the breast will not be hidden as readily.
Most patients consider a short scar that is visible a small price to pay for an otherwise pleasing result. On rare occasions scars may have to be revised if they become stretched or thickened but in most cases the patients are left with a barely perceptible thin line.

Capsule Contracture: The body’s natural response creates a layer of scar tissue around any artificial material placed in the body and this will surround the entire surface of the implant. Ideally, the scar capsule will remain thin and pliable. However, if the scar tissue shrinks and thickens (contracts), it may compress the implant, making the breast round and firm, and sometimes tender and immobile. It may occur on one side only.
Capsule contractue due to scar tissue forming around the implant was more frequent with the smooth shelled prosthesis (20-70%) used some years ago. The new textured surface type implant is believed to modify the body’s local response and markedly reduced the problem of encapsulation to less than 6%. The cause is poorly understood but what happens is that the excess scar tissue squeezes the implant and makes it feel hard under the breast tissue and may also cause pain and, in severe cases, a misshapen appearance. Calcium deposits may form in the tissues around the implant in rare cases.
Treatment of contracture may require capsulotomy where the implant is taken out and the scar tissue is cut to loosen it or it is removed (capsulectomy) and then the implant is replaced back in the new pocket.

Breast Investigations: Despite the presence of breast implants, it is still possible to perform mammography. The radiologist should be informed so that the x-rays are taken from different directions. There are other methods of investigation including ultrasound and nuclear magnetic resonance scanning for detecting and diagnosing lumps in the breast.

Breast Feeding is still possible after implantation. There is no evidence for an increase of illness in children who have been breast fed by women who have had implants at the time of feeding.

Ptosis: (drooping of the breast) can benefit from breast augmentation. However there is a limit to how much an implant can improve ptosis and augmentation can sometimes make the ptosis worse. If the nipple falls below the inframammary fold, concurrent mastopexy (uplift) is usually advisable. The risks of augmentation alone versus the scarring associated with mastopexy must be especially considered by both patient and surgeon.

Wrinkling and folds are unpredictable complications that may follow breast implantation. Factors contributing include thin breast tissue, loss of skin elasticity, very small breasts, and excessive weight loss. It is due to the rippling of the shell of the prosthesis and may become more obvious when leaning forward without a brassiere. Wrinkling can also produce little corners on the implant that can sometimes be felt if the breast tissue is too thin. Sometimes it is necessary to change and insert a different type of implant.

Shape and symmetry:It is extremely rare for two breasts to be visibly symmetrical on close scrutiny. With implantation, this asymmetry may be exaggerated further. Sometimes asymmetry may become more apparent after infection, capsular contraction or deflation of the implant.

Pain in the breasts is uncommon once the initial postoperative discomfort has subsided.

Sensory changes: Some impairment of sensation in the nipple area may occur following surgery. Usually the sensation returns to normal in a few weeks. Very rarely is sensory loss a permanent feature. Sometimes the nipple area can become extra sensitive temporarily. In addition sensation in the lower portion of the breast may be impaired until the sensory nerves have recovered. Some patients report temporary "electric shock" type sensations lasting for a few moments. These mostly settle in time.

Rejection: True rejection is extremely rare.

Rupture of the implant is extremely rare. The actual incidence is unknown and research is ongoing. Rupture can result from deterioration of the implant shell with time, undetected damage at operation, a manufacturing flaw or as a result of severe trauma to the chest. If there is internal or intracapsular rupture, there may be no dramatic change in the breast as the gel is still contained in the fibrous capsule. If there is spread of the gel through the ruptured shell beyond the fibrous capsule (extracapsular spread), the rupture will be more obvious with a change in the shape of the implant and possibly a reduction in the size due to extrusion of gel beyond the breast area. In the vast majority of extracapsular ruptures the gel is still in the region of the original pocket and can be removed with the ruptured implant. Removal may be necessary from these sites. Gel outside the capsule can cause inflammation with the development of lumps that can be felt.

Implant lifespan: It should not be considered that implants are definite lifetime devices as it is impossible to predict the state of the implant over long periods of time, especially as the new generation implants have only been recently introduced. Revision surgery, including explantation and replacement, may be indicated at any time.


Silicone migration: Concern has been raised in the media about the possibility that leakage of silicone from breast implants can cause health problems. Actually the amount of silicone that leaks through the shell of modern implants is microscopic and no health problems have ever been shown to be associated with this. It is actually quite difficult to avoid silicone in ordinary life as it is a common constituent of food packaging and is found in many cleaning agents. It is very widely used medicine in silicone tubing, artificial joints, cardiac pacemakers and the lubrication of hypodermic needles. Even over-the-counter indigestion remedies contain silicone that is absorbed by the stomach. No documented health hazards have ever been proven to result from the presence of small quantities of silicone in the body.

The risk of cancer: Unfortunately cancer of the breast is a common disease. Extensive research has been carried out to make sure that breast implants do not increase the risk. The results of this research show that there is no evidence that breast implants increase the chance future development of cancer of the breast.


Postoperative management
A properly fitted bra, of the type specified by the surgeon should be worn after the operation day and night for the first two weeks. Hereafter a bra should be worn as usual. Breasts that were droopy before the operation will droop more after the insertion of implants unless properly fitted support bra is worn.
The wound dressing should be kept dry and patients should wash themselves with a sponge, avoiding baths and showers until the incisions have properly healed.
Heavy lifting should be avoided for 2 weeks after surgery. Strenuous exercise such as aerobics should be avoided for at least 6 weeks in order to give the wounds adequate time to heal fully.

Result
Breast augmentation boosts the self-confidence of women who would otherwise feel inadequate in certain clothes, on the beach and in sexual relationships. Research has shown that there is a significant psychological benefit in that over 90% of patients have increased self esteem and feeling of self worth following the operation, due to a more balanced perception of their body image. Most patients are completely comfortable with the change to their breasts and cease to be aware of the implants after a few weeks.
With modern technology the newer breast implants now available have markedly reduced the incidence of capsule formation, which is the one major problem that could mar an otherwise perfect result.


BREAST UPLIFT - MASTOPEXY

Introduction
This operation lifts up breasts that have sagged but without making them any bigger or smaller. A droopy breast can be restored to a much more youthful shape. It is also used to improve breasts that have an unusual shape, such as those where the crease is very high so that the nipple and areola descend over it and point downwards. By lifting the nipples to a better position and changing the position of the crease underneath a mastopexy can produce a more normal appearance.
The most common reason for having the operation is where a woman has had children or lost weight and the breasts have become droopy with the nipples lying lower than the breast crease when she is standing. (If the nipple is above the crease then breast augmentation is a better operation.) After having children, often the skin of the breast seems stretched and the contents of the breast have shrunk so that the skin no longer fits nicely around the breast tissue. The aim of the operation is to reduce the amount of skin, lift the nipple and then redrape the skin so that it gives the breast a pleasing shape.
If the breasts are droopy simply because they are very bulky then a breast reduction should be performed. This combines the skin tightening and nipple raising operation with removal of breast tissue. If, on the other hand, the breasts are still going to be too small even if they are raised to a better position, then mastopexy can be combined with augmentation.
There are no exercises that are capable of shrinking stretched skin. Once a breast has drooped exercises will not help. A good supporting bra, worn routinely (especially during pregnancy) is the best prevention.

Nature of the operation
Before the operation the new nipple site is marked with the patient standing. Under general anaesthetic an incision is made around the edge of the areola and a lot of the skin on the lower part of the breast is removed, but not the breast tissue. The nipple is lifted to its new position, often a few inches higher, and the skin is brought together underneath. There are several techniques available and which one is used depends on the surgeon’s preference as well as on the particular case in question. There will always be scarring which is permanent. Usually there is a scar around the areola then a vertical part from the edge of the areola going downwards and a variable length scar in the crease underneath. After the wound is sutured a padded dressing is applied and the patient goes home the following day.


Postoperative events
Scarring is the main problem with this operation. Although the surgeon will try to make the wound look as neat as possible, it is unlikely that the scar will ever completely disappear. They may even stretch or become red and raised and require further treatment.

Infection and postoperative bleeding can occur as in any operation.

Soreness and pain is likely to be present soon after the operation but it is not usually severe.

Recurrence: In some patients there is a risk that the problem can recur, that is the breasts might become droopy again afterwards. Wearing a well-fitting support bra afterwards reduces the chance of this happening.

Sensitivity of the nipples may well be reduced or altered although in all but a tiny minority this will return to normal.

After the mastopexy operation there should be no trouble with breast-feeding. Pregnancy itself though must be avoided for some years after the operation to avoid stretching the scars and this operation is best carried out only after the family is complete.

Postoperative management
Patients are strongly advised to wear a properly fitted support bra night and day for some weeks. This supports the skin and helps the healing and gently moulds the shape of the breasts during recovery.
The dressings must be kept clean, dry and intact until they are removed at about 2 weeks.
Strenuous movements should be avoided for several weeks and driving is discouraged.
After the dressing is removed the wounds are helped by massaging them with skin cream.


Result
In carefully selected patients and with optimum healing of the scars the results of mastopexy are very pleasing. The operation is not recommended for the young woman who is likely to have more children.



BREAST REDUCTION

Introduction
Large breasts can be a source of major embarrassment. As well as the difficulty of finding clothes that fit and look elegant, they tend to interfere with active sports. Sometimes they also cause backache and their weight makes the bra straps dig in over the shoulders. There is a tendency towards skin problems in the crease below each breast. With the passage of time they will hang lower and lower and the skin can become stretch marked.
Reducing the size of the breasts is a major operation. Several different techniques are used but they all cause quite significant scarring. The most usual method leaves a scar that runs around the edge of the areola and one in the crease underneath the breast and a vertical scar linking the two. These scars do not usually show outside an ordinary bra or bikini top. Although in most patients they fade with time they should be considered to be permanent.

Nature of the operation
Before the operation the new site of the nipple is marked on each side; it is often a few inches above the original position. Under general anaesthetic an incision is made around each nipple and a shape is cut in the skin to allow the skin and breast tissues to come together again after the redundant breast tissue and skin have been removed. The nipple is inset into its new site and the remaining breast tissue and skin are brought together beneath it. In very large breasts sometimes the nipple is taken off completely and placed in its new site as a skin graft. Normally the nipple is carried on bridges of skin to its new position that helps it retain a blood and nerve supply. The skin is sutured usually with absorbable sutures and a padded dressing is applied. Most patients are fit enough to go home two days afterwards.

Postoperative events
Nipple: Partial or even total loss of the nipple or areola can occur. If this happens it will need to be reconstructed.

Swelling and bruising: The breasts will be swollen and probably quite bruised and tender for a few days and need to be supported well.

Soreness and pain is likely immediately post operatively but it is not usually severe.

Bleeding and infection can occur post operatively as in any other surgery.

Scars: may stretch and become red and raised. If the scars do not heal well they can generally be improved about a year after the original operation. Every attempt is made to make the scars as neat and inconspicuous as possible but they will always show on close examination.

Sensitivity of the nipples may well be reduced or altered.

The shape of the breasts may look quite odd initially but as time passes they will settle down to look more natural. It is unlikely that the breasts will have a perfect shape or be exactly symmetrical.

Recurrence: There have been cases where further enlargement occurred but as long as there is not excessive weight gain this is a very unlikely event.

It is unlikely that a baby could be successfully breast- fed afterwards and indeed it is very important that pregnancy itself is avoided for several years because the scars will stretch badly during pregnancy unless they are completely mature.

Postoperative management
Patients are strongly advised to wear a properly fitted support bra night and day for some weeks. This supports the skin and helps the healing and gently moulds the shape of the breasts during recovery.
The dressings must be kept clean, dry and intact until they are removed.
Strenuous movements should be avoided for several weeks and driving is discouraged.
After the dressing is removed massaging them with skin cream helps the wounds.


Result
Some surgeons have described this operation as one of the most gratifying in the whole of surgery with an extremely high success rate despite the extensive scarring. Patients say that it is like an enormous weight has been lifted. They can go on the beach without embarrassment and fit into ordinary clothes. After the operation most patients feel a tremendous sense of freedom because they can do all the things that their large breasts stopped them doing before.



GYNAECOMASTIA
MALE BREAST REDUCTION

Introduction
Gynaecomastia is an enlargement of the male breast as a result of an abnormal increase in the glandular (breast) tissue. Pseudogynaecomastia describes an enlarged male breast that is simply due to increased deposition of fatty tissue.
During adolescence it is common for the male breast to enlarge and later to decrease to normal size before the age of 21. Breast enlargement in the adult male may be due to excess fatty tissue or a combination of fatty and glandular tissue.
Gynaecomastia in the late adolescent and adult male may be associated with hormone disorders, hormone producing tumours, liver disease and other rare abnormalities. In addition various drugs if taken for long enough can give rise to this embarrassing condition. Usually though, no underlying cause is found.
Patients seek treatment because of the embarrassment they suffer. In some patients pain and discomfort are additional problems. Before surgery is considered each patient must be fully tested to exclude any sinister cause for this condition.

Nature of operation
The patient is admitted on the day of operation. A general anaesthetic is usually employed although some surgeons prefer local anaesthetic. The following procedures are usually involved: 1. Liposuction alone 2. Liposuction combined with resection of the glandular tissue. 3. Excision of glandular tissue alone.
Tiny incisions are made at the periphery of the areola and at other sites on the chest, (depending on the surgeon's preference) for the introduction of a blunt metal tube to suck out the fatty tissue. Glandular tissue cannot be treated in this way and requires excision through an incision near the areola.

Postoperative management
Patients are usually fit to be discharged home the next day and sutures are removed at 7 to 10 days. Pressure dressings if used are left on for 7 days and many surgeons advocate the patient wearing an elasticated garment for several weeks afterwards. Normal exercise can be resumed as soon as the patient feels comfortable.



Postoperative events
In addition to the possibility of swelling, bruising and infection, the following can occur:

Asymmetry: It is not possible to guarantee perfect symmetry of the breasts as most breasts are asymmetrical to begin with. Sometimes additional revision procedures may be necessary to improve the final result.

Contour: Sometimes the breast contour may be irregular and ruts and depressions can occur requiring further surgery.

Loose skin: This is particularly applicable to those cases where the breasts are large with a corresponding increase in the amount of skin. Removing a significant volume of breast tissue beneath the skin in this situation will result in loose skin. The skin will recoil to a certain extent depending on the individual, but if it remains unsightly a further procedure can be performed to tighten this loose skin. This would result in noticeable scarring.

Nipple, areola and skin loss can occur as a result of poor circulation to these areas after the operation. Fortunately this complication is rare.

Hollowing: This occurs if too much breast tissue is removed and can be unsightly. Further surgery may be required to improve the situation.

Result
This operation is permanent and should free the patient from embarrassment on the beach or in other situations where clothes cannot hide the abnormal breast development.




CORRECTION OF INVERTED NIPPLES

Introduction
In the majority of cases inverted nipples occur as a result of a defect in their development. Women who used to have normally protruding nipples but who find that they have become inverted later on in life should be fully investigated to exclude the possibility of underlying breast disease, most importantly cancer, which occurs in one in fourteen women in Great Britain.

Nature of operation
Surgery to correct inverted nipples can usually be performed under local anaesthetic on a day care basis. Occasionally an overnight stay in a clinic may be recommended. Generally a small incision is made near the base of the nipple. Several different techniques can be used depending on the exact nature of the abnormality and the preferences of the surgeon and patient. Sutures may be removed after one week.

Postoperative events
Breast-feeding may prove difficult or impossible afterwards due to the fact that the milk ducts in the nipple are often affected by the operation.

Nipple sensation: The sensation to the nipple may be permanently impaired or even lost after surgery.
Usually most patients experience some loss of sensation, which gradually returns to normal in time.

Recurrence or failure: It is still possible for the nipples to invert again after the operation, even after the most expert surgery and a further correction may be required.

Result
The usual result is entirely normal-looking nipples which react normally to temperature changes and being touched.



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11. BODY CONTOUR SURGERY: LIPOSUCTION

Introduction
Liposuction (fat suction) has revolutionized body contour surgery in recent years and is now an internationally approved and accepted method of removing unwanted fat from the body.
It must be emphasised that this procedure is not a method of reducing weight in the obese patient. It is a technique designed to resculpture parts of the body, which have unsightly stubborn areas of fat that do not respond to diet or exercise.
Liposuction can benefit many patients where previous techniques of body contouring were inadequate in achieving the desired result. It can also be combined with other standard procedures thereby producing better and longer lasting results such as in face lining or abdominal lipectomy.

This technique is now used to recontour or resculpture the following areas of the body:
1. Face and neck: In particular, the double chin and fatty neck.
2. Limbs: Thighs (riding breeches deformity), knees, calves, ankles, buttocks, fat arms and other abnormal isolated fat deposits.
3. Abdomen: Used alone in suitable cases or in conjunction with a tummy-tuck
4. Breasts: Abnormal collections of fat in male breasts (gynaecomastia) as well as in the female breast.
5. Lipomas: Large isolated collections of fat.


Nature of operation
The patient is admitted on the morning of the operation. A general anaesthetic is administered. A number of small incisions are made to allow a metal tube to be passed into the area of the unwanted fat. The fat is removed by powerful suction until a satisfactory shape is achieved. The length of the stay in the clinic is usually no longer than 2 days.


Postoperative events
Apart from the complications that are common to all surgical operations, the following are specific to liposuction procedures.

Scars are usually small and are placed in sites that are not easily conspicuous. Whereas a permanent mark will always remain it will not as a rule cause the patient any grave concerns.

Rippling and sagging of the skin: This can occur if either excessive amounts of fat have to be removed from an area or if the skin is of such a poor tone initially that removing even a small amount of fat will exacerbate this effect.
Although each case must be assessed on its own merits, as a general guide those patients who are under the age of 35 years old have a much better chance of a satisfactory result. It may be impossible to predict accurately how much the skin will recoil and take up the slack after the operation. It is important to appreciate that some patients will not accept loose skin in return for a more pleasing contour whereas others will do so quite happily.

Ruts, depressions and defects can occur as a result of too much fat having been removed from a particular area. Although this complication can occur with any operator it is much less common in experienced hands. A further procedure may be required to improve the situation.

Asymmetry: It is not possible to promise the patient perfect symmetry after the operation, as the body is asymmetrical to begin with. Where an obvious asymmetry results, further surgery may be necessary to correct it.

Skin loss:Rarely small patches of skin may die and be lost, especially near incision sites. Later scar revision will improve the situation.

Numbness or other changes in sensation can occur in the treated area due to nerve damage and may take some time to resolve completely. Various sensations have been described by patients such as stiffness, pins and needles, electric shock like sensations and persistent discomfort. Usually however these symptoms settle in time.

Blood transfusion is occasionally required. It is not usually necessary if no more than 2 litres of fat are removed at any one time.

Postoperative management
Patients are usually advised to rest for the first 24 to 48 hours. There is usually considerable stiffness and discomfort. After this time patients are encouraged to become more active. An elasticated garment is usually recommended by most surgeons and these should be worn constantly for several weeks. There is a wide variety of liposuction garments now available for all areas of the body.
Sutures are usually removed after a week after which showering and bathing are permitted.
Gentle massage of the treated areas should begin at about 10 days after the operation and some surgeons advocate ultrasound or other physiotherapy to disperse the bruising and swelling (which can be quite pronounced) more quickly.
Exercise can be resumed at about 2 weeks and some surgeons recommend bicycle riding for a few weeks afterwards.

Result
Liposuction is an extremely successful operation removing permanently unwanted pads of unsightly fat. As with any other cosmetic operation this can bring increased confidence and happiness to the patient.



ULTRASOUND LIPOSCULPTURE


Introduction
A newer technique using a specially designed machine that melts the fat and removes it from the body. All areas can be treated, even areas that previously could not be operated on with traditional methods.


Nature of operation
A special probe is inserted under the skin through a small incision. The ultrasound is then switched on to a particular frequency to target the fat cells, in the area to be removed and leave the surrounding tissue unharmed. The process turns the fat to liquid, which is then gently removed from the body. The operation can be carried out under either local or general anaesthetic.

Postoperative events
It is claimed that because ultrasound liposculpture is gentle to surrounding tissues such as nerve and blood vessels, there is less bleeding, bruising and uneven skin effects. There is stimulation of the dermis, which can create a lifting effect and improve cellulite. However there have been instances where the skin has been injured by the ultrasound being too strong for the area.


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12. ABDOMINOPLASTY - TUMMY TUCK, ABDOMINAL REDUCTION

Introduction
The tummy tuck operation eliminates excess skin and fat from the abdomen. The tummy muscles can be tightened at the same time.
Many surgeons carry out a liposuction in conjunction with the standard "tummy tuck" procedure in suitable cases as the final result is superior.
Tummy tucks are performed in those patients whose abdomens have stretched and sagged after weight loss and pregnancy. This is not a procedure designed to remove large amounts of weight from the obese patient. In fact usually there will be hardly any weight loss as a result of the operation.
Patients who have lost massive amounts of weight often have an apron of skin hanging down in front of the abdomen. They often find that they get skin problems such as chafing and rashes under this apron and these are difficult to control. Also it is difficult to find clothes that fit and those, which do, are not flattering.
Apart from improving the profile, the procedure also helps to remove stretch marks and scars from the lower part of the abdomen.

Nature of the operation
The patient is admitted on the morning of surgery. A general anaesthetic is necessary. In selected cases fat is sucked away from the abdomen first. A long horizontal incision is made in the lower abdomen inside the so called "bikini line". The skin and fat layer is lifted off the muscles of the abdomen as far upwards as the rib cage. The umbilicus (navel) is freed from its attachments to the skin and fat of the abdominal wall. The abdominal muscles are tightened if they have been stretched. The skin and fat layer is trimmed by removing the overhanging part and the wound is closed so that the tummy is as smooth as possible. The umbilicus is reimplanted so that it lies in its usual position once more.
The length of stay in the clinic is no longer than 2 days and the sutures if they are not dissolvable are removed at 14 days.

Postoperative events
Infection: Wound infection can occur resulting in delayed healing and sometimes complete wound breakdown. An unfavourable scar may need revision at a later date.

Haematoma: This is a collection of blood caused by bleeding occurring beneath the skin after the operation. It is a rare complication but may require drainage under a general anaesthetic.

Seroma: This is a collection of fluid that has accumulated under the skin in the postoperative period. It can usually be removed easily with a needle but this procedure may need to be repeated several times as it can reaccumulate.

Skin loss can occur if there is a reduction of the blood supply to the edges of the wound after the operation. This may happen if the skin has been closed under too much tension or it is sometimes a consequence of the patient's heavy smoking. If it results in wide scars they can be improved by scar revision at a later date. Fortunately this complication is unusual.

Scars may become stretched or thickened (keloid) and may require revision.

Loss of the navel is a rare complication resulting from inadequate blood supply to the navel after reimplantation. Further surgery may be required to fashion a new navel.


Malposition of the navel has been described. The new navel may be placed too high or low or not in the middle. Further surgery may be required to move it to a better position.

Abdominal asymmetry is a rare problem that occurs if more tissue has been removed from one side than the other. Further surgery may be required to correct the difference.

Loss of sensation: There will be an area above the long horizontal scar that will have a loss of sensation in all cases. This results from the unavoidable damage to the sensory nerves that supply the area. These nerves regenerate slowly and after several months sensation begins to return.


Postoperative management
Most patients feel well enough to get out of bed the day after the operation. Thereafter short walks are encouraged. However activities are limited by the discomfort that will invariably be present initially.
The healing wound must be kept clean and dry and the patient must wash carefully so that the dressing is kept dry.
Strenuous exercises should not be done for at least 6 weeks. The patient should continue to diet as weight gain defeats the whole purpose of the operation. After full recovery a regime of good diet and plenty of exercise will ensure that the result of the operation is permanent.
The skin and muscles will stretch again if the patient becomes pregnant after the operation so this is really an operation for those women who have completed their families.

Result
Abdominal lipectomy causes a permanent improvement of the shape of the tummy if it was poor before the operation. It often encourages patients to adopt a healthier regime of diet and exercise because they look so much better. They may be able to wear clothes that they could not before and feel more confident in underclothes and on the beach.


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13. PENILE ENHANCEMENT

Introduction
Penile lengthening can be promoted by releasing the ligaments under the pubic bone so allowing the shaft to protrude further forwards by up to 2 inches. Further lengthening can also be produced by reducing the fat pad by the pubic bone.
Penile girth can be increased by transferring fat harvested from liposuction to the space under the skin around the shaft. Additionally strips of processed human dermis can be implanted around the shaft to increase girth.


Postoperative events
Pain is not severe on the first postoperative day and can be controlled with oral painkillers.

Swelling will occur which should begin to subside after 2 weeks. Uncircumcised men can experience foreskin swelling for several weeks.

Bleeding or haematoma under the skin has occurred in 1 out of 100 patients and often drains away by itself.


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14. VARICOSE VEINS

Introduction
Varicose veins affect about 20% of the population in Great Britain, affecting women 4 times as often as men. There is an inherited tendency in about 40% of cases. The commonest predisposing factors are obesity and pregnancy. Varicose veins are veins that have become widened and at the same time more tortuous. The little valves in the veins become damaged causing excess pressure of blood that damages the next section of the vein so the condition slowly worsens.
Treatment will depend on the severity of each case and can only be assessed at preoperative consultation with the surgeon.
Essentially those cases that do not have a leaking valve in the vein of the groin, where the superficial varicose veins drain into the deep veins of the leg, can be treated on a day care basis.
Those cases with a leaking valve in a groin vein require more extensive surgery. The operation is usually performed under general anaesthetic and one or more night's stay in the clinic will be necessary.

Cases suitable for day care surgery: The patient is admitted to the clinic on the morning of the surgery. The veins are mapped out using a special pen. The patient is taken to theatre and sedated with an intravenous injection. The area to be operated on is then anaesthetized (frozen) with local anaesthetic.
Once the anaesthetic has taken effect, tiny stab incisions are made over the varicose veins and they are removed with special instruments. Because the incisions are tiny sutures are unnecessary.
On completion of the operation, dressings and a pressure bandage are applied for one week. The patient is usually discharged home about an hour after surgery and given postoperative instructions. Patients are forbidden to drive initially and so must arrange for suitable transport to take them home.

Cases with a leaking valve in the groin: The patient is admitted to the clinic on the morning of surgery. A general anaesthetic is administered. The varicose veins are removed as described above. In addition the valve in the groin vein is tied off via a small incision in the groin. The stay in the clinic is usually 1 or 2 days depending on the severity of the condition.

Postoperative events

Pain and discomfort: This is rare and if it occurs it only lasts for a short time. Painkillers are usually prescribed.

Scars: The tiny scars in the legs are hardly noticeable once they have matured.

Bruising and swelling occurs in varying degrees and usually resolves in a few days.

Discolouration: Very rarely the bruising does not resolve completely leaving an area or areas of purple or blue discolouration. The reasons for this are not clear but the condition can be permanent.

Spider veins: In a tiny minority of cases spider or thread veins can appear for reasons which are not understood. It is impossible to predict with any degree of accuracy which patients will develop this complication but those who already have areas of spider veins are more likely to suffer this effect.

Nerve damage: Occasionally a superficial sensory nerve can be damaged in an area operated on resulting in a decrease or loss of sensation as well as discomfort to an area. These symptoms resolve once the nerve has regenerated (healed).

Postoperative management
The leg should be elevated as much as possible for the first 24 hours. Sleeping with the leg elevated for the first night is also recommended.
Sometimes the bandage will be too tight and will need to be reapplied. Also if bleeding occurs through the bandage rest and elevation of the leg is necessary and another bandage may have to be applied.
Full mobilization is usually permitted after the first 24 to 48 hours.
Spider veins can be treated with injections.

Result
The individual veins, which bothered the patient beforehand, will be removed by the operation and they cannot return. However the tendency to develop varicose veins will still be present and further varicose veins will therefore appear in time. It is better to get these treated fairly regularly because treatment is then easier and more effective. The treatment described above gives an excellent cosmetic result and is better than injection treatment (sclerotherapy), which is uncomfortable, cumbersome and antisocial for the patient and has a high recurrence rate because the injected veins can open up again.



SPIDER OR THREAD VEINS

Introduction
Thread veins are abnormally widened (dilated) small blood vessels very close to the surface of the skin. They most commonly occur on the face and legs and are usually inherited. They become more prominent with increasing age and can occur in clusters, especially on the face, causing patchy discolouration (redness).
Thread veins are worsened by excessive exposure to the sun and wind and extremes of temperature. Alcohol makes them more prominent because it causes them to dilate more.
The exact mechanism of thread vein formation is poorly understood. In those who are predisposed to this irritating condition, it should be mentioned that any treatment of varicose veins, i.e. by injection or surgery, could exacerbate the appearance of thread veins in the legs.

Treatment
Electrolysis This method involves applying a fine needle to the skin over the thread vein and passing an electric current through it. This cauterises the vessel and prevents blood from flowing through it, making it invisible.
Electrolysis is best suited to the fine facial thread veins but not the large ones.
The main disadvantage of electrolysis is that it can produce tiny-pitted scars which are permanent. Sometimes a new crop of veins appears after a course of treatment.

Injection sclerotherapy This is more suitable for the larger thread veins in the legs. Sclerosing fluid is injected directly into the thread vein by a very fine needle. The inflammation produced causes the walls of the vessel to stick together thereby preventing blood flow through it and making it invisible. Several injections may be necessary and recurrence is common.
Localized bruising, swelling and redness is common initially and this resolves within a few days. On rare occasions a brownish discolouration may occur at the injection site and take several months to fade.
The treatment is uncomfortable, not painful. Injections are performed on a walk in walk out basis with no dressing or bandages being required. Injections are carried out at two to four weekly intervals.

Dermabrasion will remove thread veins from the face but they would need to be very marked to justify this treatment.

Laser can be effective for removing smaller veins and will become more important in the future.


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15. REMOVAL OF TATTOOS

Introduction
Tattooing is the introduction of pigment under the skin to produce a permanent mark. It may occur sometimes as a result of an accident when dark coloured material is implanted into a wound. Occasionally such traumatic tattooing can be extensive, especially after an abrasive wound and these should be treated at the time of injury by vigorous scrubbing of the abraided area.
Decorative tattoos are either self-inflicted or professionally performed. In the majority of cases young men have them put on as a result of bravado or peer pressure and later on they very much regret them especially when they realise that tattoos are not accepted in society or often by employers. It is then that requests are made to have them removed. Unfortunately it is a lot more difficult to remove a tattoo than to put it on in the first place.

Treatment

Excision: If it is small, the tattoo can be totally excised and the resulting wound closed with stitches. The resulting scar being preferable to the tattoo.

Skin shaving: where progressive layers of the skin are removed, can be successful if the depth of the injected pigment is not too deep. The surface of the skin can be removed by several methods such as dermabrasion, laser treatment or with a skin graft knife.

Excision and skin graft: If the pigment is deep in the skin the area may be excised and the defect covered with a skin graft.

Laser is emerging as an effective method of removing tattoos with minimal scarring. However different lasers targeting different colours of the pigments are required and many visits needed before a good result can be achieved.
The procedures can be performed under local or general anaesthesia depending on the size of the tattoo and the preference of the patient and surgeon.

Postoperative events
Where the tattoo has been excised and the defect sutured the resulting scar may become stretched or thickened depending on the site of excision. Where a skin graft has been used there will always be a permanent mark. The grafted area will be a different colour compared to the surrounding skin and it will be hairless. Altered pigmentation as a result of sunburn may occur and the margins of the graft may become red and raised. In addition the graft donor site may not heal perfectly though in the majority of cases it heals very well.

Result
The regretted tattoo should be removed, but only at the expense of significant scarring in some cases.


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16. SCAR REVISION

Introduction
Unsightly facial scars and blemishes can very often be improved by well-planned and carefully executed surgery.
It must be stressed again that a cosmetic surgeon cannot make invisible scars. He can only make the scars as inconspicuous as possible. The aim of scar revision is to achieve a scar which is fine, level and even with the surrounding tissue, about the same colour as the adjacent skin and which causes no pull on the surrounding structures.
The old unsightly scar has to be removed first. Any planned surgical incision heals in exactly the same manner as any other deliberate or accidental cut, i.e., it produces scar tissue which is nature's method of healing. Once an incision is made and sutured the surgeon has little control over the healing process, a fact which must be appreciated by the patient.
It is often not realized that a period of 6 to 18 months must elapse before the scar is mature, which is the stage where no further change or improvement will occur.
Initially any scar will be red and raised above the level of the surrounding skin and may often be hard in consistency. Gradually the redness and hardness lessen and resolve leaving a soft scar that is level with and somewhat paler than the adjacent skin.

For these reasons scar revision must not be undertaken too soon because adequate time must elapse to allow the healing tissues to mature.
When revising a scar on the face the surgeon attempts to get the best possible result by placing the new scars parallel to or actually in one of the normal crease lines of the face. This usually means that the direction and shape of the original scar has to be changed.
Excision of large scars or blemishes may require several operations over a period of time. It must also be mentioned that some areas of the body always produce noticeable scars e.g. nose, chin, chest, shoulders, upper back and parts of the arms and legs.
In summary therefore, the goal in scar revision is improvement and not perfection. Patients who are unable to accept this should not have treatment.

Nature of operation
The patient is admitted on the morning of surgery. Most facial scars can be revised under local anaesthesia. Extensive scarring in adults and scars in children are best treated under general anaesthetic. Most scar revision procedures can be treated on a day-care basis but some may require an overnight stay in the clinic.

Postoperative events
As mentioned previously unfavourable results will occur when a scar becomes stretched, thickened or infected.

Result
It is most unlikely that any scars can be removed completely, but the aim of the procedure is to make them less noticeable and perhaps easier to disguise with make-up.


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17. THE TREATMENT OF BALDNESS : HAIR TRANSPLANTATION

Introduction
Hair restoration has evolved tremendously since the days of the punch grafts where hair can be successfully moved from one part of the body to treat the balding scalp. Not everyone is suitable for surgery and each case must be carefully evaluated before a treatment programme is started. Both men and women can be treated successfully. Every patient who contemplates embarking on a treatment programme must ensure that he is properly advised and fully understands the nature of the treatment as well as the proper outcome.
A good experienced hair transplant surgeon has to take the following into account:
1. The age of the patient and the amount of current hair loss.
2. The probable future loss of hair.
3. The quality and quantity of donor hair available.
4. The flexibility of the scalp.
5. The patient's expectations.


Surgical procedures currently available

Hair transplantation
Under local anaesthetic on a day-care basis, a strip of hair bearing scalp is cut from the back. In common male pattern baldness, a horseshoe shaped fringe of hair persists even in the most advanced cases. Hair follicles moved from this hairy fringe to a bald area on the same patient's scalp will take root and grow. In the past the donor follicles were punched out yielding grafts that were tufted in appearance and unnatural looking. Today the donor strip is carefully cut down to give grafts containing one to three hair follicles per graft. These are transplanted into the new sites either via small holes or slits. These micro (also called follicular units) and minigrafts grow well with no significant scarring and a much more natural appearance. The grafts are also excellent for fashioning a natural hairline or for strengthening areas of thinning hair. Several repeats may be required to achieve the effect of a dense coverage. Some surgeons are using lasers to create the openings for the grafts but the results are as yet not superior to cold steel.

Scalp Reduction/Alopecia reduction
Under local anaesthetic on a day care basis, an ellipse of bald scalp is excised. The edges of the wound are undermined and sutured together so that there is a smaller bald area but displays a scar running the length of the scalp. After a few months when the scalp becomes flexible again the process is repeated giving a smaller area of baldness again. Additionally, a stretching device can be inserted under the scalp after the first reduction to internally stretch the scalp so that more bald scalp can be excised in a much shorter time. Often the bald scalp can eventually be reduced to a small size and the scar can be improved with multiple flaps or by hair transplantation.

Scalp flaps
Hair bearing scalp flaps from the sides of the scalp can be rotated to cover the bald area at the front.

Scalp lifts
This is the reverse of a facelift where the scalp is extensively freed right down to the nape of the neck so that enough bald scalp can be excised at the front.

Postoperative events
Pain is variable. It may range from simple soreness with no pain killers required to pain requiring the simple painkiller paracetamol. It rarely lasts more than a few days.

Bleeding following the procedure is extremely rare. If it does occur it responds to simple pressure.

Itching: Some itching is common and rarely troublesome.

Infection: This is a rare complication. All patients are commenced on antibiotics routinely.

Swelling can occur. It usually affects the forehead and around the eyes and may last for a few days.

Numbness: Some transient numbness may occur. Patients hardly notice it. If it occurs it usually lasts a few months.

Scabbing and scarring: After transplanting, scabs will form which fall off in one to two months. Some hairs may fall out together with the scabs but these will regrow in about three months. The scars are visible for a few weeks but will blend with the scalp with time. The donor scar is often covered by hair from above and often heals as a fine line. Occasionally the scar can stretch and become visible.

Failure of hair growth can occur as a result of poor technique or as a result of infection. On rare occasions there is no apparent cause.

Failure of flap to take can be due to poor technique or inadequate blood supply. This can result in an ugly or wide scar.


Results of hair transplantation
It is certainly true to say that a poor hair transplant looks worse to the patient than his original baldness. With proper patient selection a very pleasing result can be achieved. For others surgery should be discouraged and offered non- surgical treatments instead.
Females often have a more generalised balding pattern and can be helped by transplants but will not receive as good a result as males.
Using follicular unit grafting techniques other areas such as the beard, eyebrows, moustache, eyelash and sideburns can be successfully transplanted.



Non-Surgical Treatments

Introduction
There have been innumerable claims over the years to cure male pattern baldness and none of these lotions have been shown to be effective except for Minoxidil and Finasteride.

Minoxidil was originally used as a drug to control blood pressure and it was soon discovered that it promoted hair growth by stimulating the balding scalp when applied topically. However not every patient will respond to it. This is also the drug of choice for female baldness.

Finasteride was originally used to treat prostate enlargement by blocking the action of the male hormone but was seen at the same time to promote hair growth. The drug is taken orally and has been claimed to have a small risk of side effect of decreased libido and impotence in up to 2% of patients. As with Minoxidil, not all patients will respond. However, Finasteride has been shown to have a higher degree of response to Minoxidil.


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18. HAIR REMOVAL (LASER):

Introduction
The idea of using laser to remove hair was discovered accidentally whilst treating another condition and has since been employed successfully to remove unwanted hair. Hair that is coarser and more darkly pigmented responds best as there is more potential target for the laser to hit. Another important factor in terms of success is the percentage of unwanted hair that is actively growing. This varies from site to site; up to 65% actively growing on the upper lip compared to only 20% on the arms and legs. Laser hair removal is only effective on the actively growing hairs and therefore several treatments are necessary and more so on the areas with less actively growing hairs.

Postoperative events
Pain is not severe and much less than electrolysis so local anaesthetic is usually not necessary.

Redness of the skin and slight crusting may occur and after two or three days the skin may become flaky. Using a moisturiser will help to minimise this effect.

Pigmentary skin changes after treatment can occur especially in patients with dark coloured skin where lightening of the skin can be seen. In those who tan easily darkening of the skin can be seen and may take 4-6 months to fade. Women who have had melasma (pigmentary change on the face usually associated with pregnancy or taking the contraceptive pill) are also at risk of suffering from colour change after treatment and therefore all those seeking treatment should have