Breast enhancement
Despite a significant amount of negative press in the 1990s, breast augmentation
continues to be popular. The trend has been to opt for a more natural
look, and a C-cup bra size is now usually preferred.
The procedure is usually carried out under a light general anaesthetic
(`twilight sleep') administered by an anaesthetist in a licensed outpatient
surgical facility. The implant is inserted in a small incision, often
in the inframammary fold; other popular sites include the area around
the nipple areolar complex, the axilla or (for saline implants only) even
the transumbilical route. Recovery is in the range of one to two weeks.
All patients should be aware of the potential complications and the possibilities
of implant replacement or even removal in the future.
Plastic surgeons learnt from the 1992 silicone gel implant `crisis' and
subsequent US FDA moratorium that the media are prepared to concentrate
on the poor outcome of some patients. As a consequence, surgeons are now
much more likely to do their utmost to inform patients of the possible
sequelae of any implant, especially capsular contracture (firmness around
the implant).
Silicone gel implants
Older silicone gel implants regularly 'bled', exposing the surrounding
tissues to the gel and frequently resulting in capsular contracture, hardening
and distortion around the implant. The gel in newer silicone implants
is firmer or cohesive. These newer implants were introduced by McGhan
Medical Corporation prior to their endorsement in appropriate clinical
trials, and we do not yet know if similar sequelae will occur.
Silicone gel implants have widespread popularity in Australia, where
permission to use them is available to a surgeon only after application
to the TGA on a patient's behalf. Newer adhesive gel implants are also
quite popular in Europe, although enthusiasm for them - like all implants
- is tending to wane with time. The once popular soybean implant was recently
withdrawn from the marketplace after reported inflammatory tissue reaction
when the implants leaked.
Saline implants
The 1992 moratorium effectively forced the plastic surgical community
to use saline implants, which have the same design but different fill
compared with silicone implants. In the late 1970s, implants filled with
physiological saline had a reputation for rupture that led to dissatisfaction
by patients and surgeons alike. In thin-skinned patients who had little
tissue coverage over the implant, wrinkling, rippling and palpability
were also disturbing. Newer saline implants such as the poly implant prosthesis
(PIP implant) are prefilled without a valve or palpable seal, and are
possibly less likely to rupture or wrinkle (Figures 1a and b).
 
Figures 1a (left) and b (right). A patient
before and after breast augmentation using saline implants.
The saline implants, which are manufactured by two companies
(McGhan Medical and Mentor), are provided with a filling valve and a choice
of surface (either smooth or textured). The implants can be placed in
a subglandular or submammary pocket, or in a combined subglandular-submammary
position. The advantages of the submuscular implantation are reduced palpability
of the implant itself and a lower rate of capsular contracture. The rates
of capsular contracture around saline implants and rupture are each about
1 to 2%.
Breast reduction and breast lifting
The most exciting development in the area of breast reduction
has probably been the reduction in scarring. The traditional technique
involved a periareolar scar as well as a vertical and lower horizontal
scar (the anchor or T scar), which was highly objectionable to many patients
and detracted from the aesthetic result.
To overcome this, a vertical scar technique popularised
in Europe has been embraced by many plastic surgeons, and a periareolar
technique popular in South America has been adopted by others. These procedures
are technically more difficult - wrinkling and bunching of portions of
the skin closure occur early but tend to resolve with time. Minor scar
revisions will be required in some cases, but major anchor scarring is
avoided.
There are constraints on the amount of breast resection
that can be carried out with limited incisions - usually, removal of no
more than 1000 g is feasible using a vertical scar alone, and approximately
500 g using the periareolar approach. Small reductions (less than 1000
g) can be performed as an outpatient procedure, with drains that can be
managed by patients and usually removed in a few days in the surgeon's
office. Anchor incisions are still preferred for very large breast reductions
(see Figures 2a and b), whereas a vertical scar may be used in intermediate
cases (up to 1000 g).
 
Figures 2a (left) and b (right). A patient
before and after breast reduction with anchor incision scars
The breast reduction procedure is highly satisfactory for
most patients, alleviating back strain, postural slumping, brassiere strap
pressure and subareolar inframammary intertrigo. Private medical insurance
and Medicare partially cover the costs of these procedures for patients.
Breast lifting procedures can be performed with or without
the use of breast implants, and usually with the lesser periareolar or
vertical scar only. Relapse of breast ptosis is a problem over time, and
efforts to reduce this frustration include internal wraps of suture and
medical grade synthetic meshes similar to those used for hernial repairs.
Breast asymmetries, which occur in 6% of women, cause severe
psychological stress to patients who are in their late teenage years.
Various techniques, including breast lifting and implants, can result
in highly satisfied and better socialised young adults (Figures 3a to
c).
  
Figures 3a (top), b (middle) and c (bottom).
An 18-year-old woman with breast asymmetry that was corrected by right
breast augmentation and left breast periareolar mastopexy with no implant.
Liposuction
Liposuction was introduced 20 years ago and remains highly
popular, despite some negative press and the rare, tragic sequelae of
severe infection and death. Complications such as fluid overload or blood
loss were often associated with larger volume resections, and led to the
defined term `large volume liposuction for removal of more than 5 L of
tissue. Stricter guidelines about safe limits and regulations about where
the procedure should take place have lessened the incidence of serious
complications.
The tumescent technique, which minimises blood loss, was
introduced to aid the safe resection of tissue and was popularly adopted.
A low concentration mixture of lignocaine and adrenaline in saline solution
is infused into the tissues, usually with high pump pressure. This `wet
technique' offers the opportunity to remove fat without the need for general
anaesthesia with the additional advantage of negating the necessity for
autogenous blood transfusion by reducing blood loss associated with large
volume liposuction.
Technical advantages introduced since 1993 include ultrasonic
and power assisted (pneumatic) liposuction. The ultrasonic technique involves
literally melting the fat away; the pneumatic cannula technique involves
drilling the fat out and suctioning it away. These techniques may afford
a reduction in the surgeon's fees and reduce operating time, but there
are disadvantages, such as complications developing as a result of unfamiliarity
with the new technology, which represents a new learning curve for the
surgeon.
Figures 4a (left) and b (right). A patient
before and after
liposuction of the buttocks and hips to improve contour.
In women (particularly postpartum women), the popular areas
for reshaping include the thighs, buttocks, hips and lower abdomen (Figures
4a and b). In men, the most popular sites are the abdomen, lower back
(`love handle') and chest (Figures 5a and b). The procedures are usually
carried out under light general anaesthesia in a licensed outpatient facility.
Postoperative compression garments are usually needed, as well as ultrasound
physiotherapy and massage to assist in obtaining a smooth, even contraction
of the skin. Almost any fatty accumulation is amenable to liposuction,
including lipomas which, surprisingly, generally do not recur after the
procedure.
 
Figures 5a (left) and b (right). A patient
before and after liposculpture,
which is becoming more popular for men. An ultrasonic technique is often
used
As our population tends more and more to obesity, liposuction
continues to be popular. Its efficacy is well established for improving
body contour and reducing fatty accumulations that are resistant to a
sensible diet and exercise. Patients' satisfaction is highly dependent
on the surgeon's expertise and artistic sensibility. Inexperience and
inadequate understanding of aesthetic anatomy and figure representation
can lead to poor surgical results.
Abdominoplasty
As our bodies age, the skin becomes loose, a change that
is exaggerated after weight loss and pregnancy. The abdominoplasty (`tummy
tuck') is the mainstay of body contour resective surgery, and involves
skin resection and tightening of the abdominal musculature or diastasis
recti stretched out by pregnancy.
Although the procedure has not significantly changed since
the late 1980s, the shape of the incision used for access and skin resection
has changed. The incision is now shaped like a bicycle handle, which rises
in the lateral positions so hat it is concealed in a high-cut bathing
suit (Figures 6a and b, and Figures 7a and b).
 
Figures 6a (left) and b (right). A patient
before and after abdominoplasty.
In the earlier abdominoplasty procedure shown here, the shape of the incision
was horizontal.
Incisions can be limited by liposuction, which must be performed
judiciously to avert excessive trauma and possible wound breakdown in
the abdominoplasty flap. Small abdominoplasty procedures can be performed
as outpatient procedures, but more significant resections and repairs
(such as large incisional hernias) require hospitalisation. Deep venous
thrombosis is a possible complication, and enoxaparin (Clexane) or low
dose heparin is used to prevent thrombosis in the higher risk case.
 
Figures 7 a (left) and b (right). A patient
before and after abdominoplasty.
Although the procedure has not changed significantly since the late 1980s,
a bicycle handle-shape incision is now used which can be concealed in
a high-cut bathing suit.
Loose skin in the thighs can be dealt with by a thigh plasty.
Once again, incisions are made within the outline of a bathing costume,
and the tissues require a deep fixation of the strong fascial layers of
the thigh to prevent sagging and exposure of the scars. The long scars
up the inner thigh that were used in the 1970s are most unattractive and
must be avoided. Skin and fat should not be resected in obese individuals
with `tight skin because resection leads to totally unacceptable scars
and deformities. Scar revision and touch up liposuction are common after
abdominoplasty and thighplasty to optimise the results.
Arm plasty
Arm plasty - the removal of skin from the upper inner arms
- is probably not performed as often as it is requested because patients
have an aversion to the long incision running from the axilla to the medial
elbow. The incision in the inner aspect of the arm permits the resection
of loose `bat wing' skin that causes much angst among women who are embarrassed
about, for example, wearing sleeveless blouses (Figures 8a and b).
 
Figures 8a (left) and b (right). A patient
before and after arm plasty,
showing the horizontal incision on the inner aspect of the arm.
Body lift
The procedure known as the body lift (`ring bark') involves
a circumferential excision of loose skin from the abdomen, flank and back.
Loose thigh, buttock and abdominal skin is then tightened to improve the
overall figure.
The body lift is the most extensive body contour operation,
and patients must fully comprehend the extent of scarring involved - although
it fades with time, the scarring is considerable, often stretching and
requiring revision. However, the obviation of a massive amount of loose
skin to accompany significant weight loss or intestinal bypass surgery
can be beneficial, and an overall improvement in the shape of the thighs,
buttocks and abdomen may be achieved in one stage. The results can be
very satisfying, but appropriate selectivity of cases is essential. Unsatisfactory
scarring and contour deformity can result (Figure 9). The complications
of body contour surgery include scar thickening and widening, seroma,
poor skin healing, superficial wound infections and (occasionally) severe
necrotising fasciitis. The procedures should be performed only by experienced
plastic surgeons who are at ease with the mobilisation of large, composite
skin fascial and fat flaps.
Figure 9. A dissatisfied patient with
poor scarring and contour deformity
after an attempted body lift (the surgery had been performed elsewhere).
Body implants
Women constitute 60% of calf implant patients. When inserted,
these implants provide a smooth convexity to the upper inner calf and
tends to enhance patients' confidence for wearing skirts (Figures 10a
and b).
 
Figures 10a (left) and b (right). A patient
before and after medial calf implantation.
Calf and pectoral implants for men are becoming more popular.
These firm, solid, silicone implants are used for puny, underdeveloped
men who are embarrassed about having `bird' legs and underdeveloped chests.
For these men, implants greatly improve contour and physique and represent
an alternative to anabolic steroids (Figures 11a and b). The implants
are placed through small incisions in the axilla and popliteal fossa,
and therefore must be the appropriate size and shape to eventually achieve
the dcsired contour.
Figures 11 a (left) and b (right). A patient
before and after insertion of solid silicone pectoral implants.
Buttock, triceps, deltoid and biceps muscles have all been
augmented for a variety of post-traumatic and neurological injuries to
muscles and subsequent asymmetries and hypoplasia (Figures 12a and b).
Figures 12a (left) and b (right). A patient
before and after buttock augmentation
These implants complete a plastic surgeon's armamentarium
for body contour with techniques to reduce, augment and resect loose skin,
all of which are used to improve the figure and torso of male and female
patients.
The Marketplace for Cosmetic Surgery
With their broad reconstructive background, plastic surgeons are the
practitioners who traditionally have been the most ideally trained to
perform aesthetic surgery. However, there is an expanding demand for cosmetic
procedures, and overlap with other subspecialists has naturally occurred.
Turf battles between plastic surgeons and cosmetic surgeons have entered
the media and political arena, the outcome of which has been a set of
recommendations by the Cosmetic Surgical Inquiry of New South Wales in
1999 regarding the responsibility of surgeons to patients undergoing cosmetic
surgery.
No single group of surgeons can claim exclusivity of all cosmetic procedures.
Dermatologists, otolaryngologists, general surgeons and ophthalmologists
who subspecialise in cosmetic surgery are legitimate by their training
and practice focus. Groups of subspecialists who claim expertise can mislead
a potential patient because the skills and expertise of practitioners
within all groups vary considerably. For example, one plastic surgeon's
ability to perform hand trauma surgery competently does not necessarily
mean that he or she can successfully perform breast enhancement.
GPs who perform cosmetic surgical procedures have usually limited their
practice to laser resurfacing, injectables, hair transplantation and sclerotherapy.
More recently, some have expanded their range to cover more invasive procedures
such as liposuction, breast enhancement and blepharoplasty.
Using advertising to attract patients has resulted in a shopper mentality
and n change in the traditional referral pattern such that patients may
bypass the advice of their GP. For surgeons wishing to perform cosmetic
procedures, marketing and advertising to both referring physicians and
patients represent the reality of private practice.
Ethical guidelines should be followed to maintain professionalism and
protect the public from false and deceptive advertising. This change would
subsequently satisfy expectations and minimise the possible problems associated
with cosmetic surgery, which offers an implied warranty of happiness or
success.
Patient dissatisfaction
Many factors influence the successful outcome of cosmetic surgical procedures.
It is important to assess a patient's psychological state, preconceptions,
body image and expectations preoperatively. People with certain personality
inadequacy disorders (such as narcissism or body dysmorphophobia) are
unlikely to be contented with a successful outcome from a technically
competent procedure. The challenge is to identify these patients, and
no foolproof test is available. It is estimated that 7% of patients presenting
for cosmetic surgery have a body dysmorphophobia.
Whether or not the marketplace and advertising influence the rate of
patient dissatisfaction has not been corroborated. Most recently, more
attention has been directed to preoperative psychological assessment prior
to undergoing any surgical procedure. With expectations so high, patients
may be unable to cope with scarring, erythema or the prolonged recuperative
periods involved for many procedures, leading to distress and dissatisfaction.
Patient education by medical practitioners and the surgeon's assistants
(such as nurse specialists and paramedical staff) forms an integral part
of good practice prior to cosmetic surgery. However, a small percentage
of patients will still be dissatisfied, even if no surgical complication
occurs.
Medical malpractice
Over the last five years, all surgical subspecialists have undergone
a dramatic increase (sometimes over 400%) in insurance premiums for medical
malpractice. This increase is partly due to the changing environment of
dissatisfied patients, who increasingly seek financial restitution for
claims of surgical mishaps.
Plaintiff lawyers, just like cosmetic surgeons, vary significantly in
their training and expertise in the area of medical malpractice. Unfortunately,
the legal fees associated with plaintiff cases are reflected by the financial
payouts rather than the restitution of damage to the patient. Tort reform
is a pressing issue because of the high malpractice premiums. At present,
the medicolegal system does not well serve either the dissatisfied patient
or the cosmetic surgeon when represented legally.
The future
On the whole, patient satisfaction with cosmetic surgery is high. The
media's fascination with cosmetic surgical procedures continues to be
intent and, dovetailed with a massive beauty industry, it is unlikely
that there will be a reduction in the number of patients seeking procedures
to enhance their appearance.
The major challenge facing surgeons performing cosmetic procedures is
to keep abreast of new technology and up to-date with the changes in the
digital and information revolution that will dramatically influence their
practice. To be assured that cosmetic surgery will improve not only appearance
but also quality of life, it is important to fully screen all potential
patients both med ically and psychologically. MT
Last month, the first part of this article presented a
discussion of popular facial cosmetic procedures.
Further reading
1. Hodgkinson DJ. A place for cosmetic surgery: Part I. The face. Mod
Med Aust 1993; 36(3): 32-42.
2. Hodgkinson DJ. A place for cosmetic surgery: Part 2. Body contouring.
Mod Med Aust 1993; 36(4):66-78.
3. Health Care Complaints Commission. Cosmetic Surgical Inquiry of New
South Wales. Sydney: HCCC, 1999.
4. Haiken E. Venus envy: a history of cosmetic surgery. Baltimore: Johns
Hopkins Univ Press, 1999.
5. Cash TF, Pruzinsky T, eds. Body images: development, deviance and
change. New York: Guilford Pr, 1990. |
