The key to a good cosmetic surgical procedure is for it to appear that no procedure has been done at all. Not that the desired outcome is not achieved, but that the result is entirely natural. The decision to undertake a cosmetic surgical procedure is a very personal one. It is a decision for one's self and not infrequently relates to a physical feature the individual has been self conscious about for a long period. It is equally often a major and difficult step to seek guidance regarding its resolution.
Electing to have surgery is, rightly, a major consideration. You should feel that a thorough history and examination has been undertaken and that you have been given all relevant information both verbally and in a written form, where appropriate, with pictures and photographs. You should have the opportunity to ask any questions and feel that they have been answered to your satisfaction. Above all, you should have faith in your surgeon - faith that he acts in your best interests, faith that he has the ability, skill and experience to undertake what is proposed and faith that you will be cared for in a thorough and professional manner at all times. This is very much the philosophy of A/Prof Gianoutsos' practice.
Face lift, or meloplasty, is a procedure that can be performed in a number of ways and is frequently undertaken in combination with other facial rejuvenation procedures, such as neck lift, blepharoplasty, browlift, genioplasty or rhinoplasty.
There is a great deal of terminology relating to face lift procedures. Broadly they fall into two categories – more traditional long incision approaches, or short incision procedures, which avoid scars extending behind the ear and into the hairline, for which younger patients are generally better candidates. This is a variation of a MACS lift.
The skin is only one element of a face lift, however. The deeper layer of tissue, the SMAS (Superficial Musculo Aponeurotic System) is a vital structure, which in repositioning and resuspending, provides the platform upon which a successful face lift procedure is based. In some circumstances it is appropriate to elevate and reposition tissues at a deeper plane again. This is the subperiosteal face lift technique.
Generally, the deeper the tissues addressed and the more that is done, the more profound and long lasting the result. This is also accompanied by a longer recovery period while swelling and bruising resolve.
Loss of definition of the angle between the neck and the chin is a common complaint in those considering a face lift and the platysma muscle investing the neck is the equivalent deep tissue to the SMAS in this area. In such patients it is often in their best interest that a further small incision beneath the chin is used to access and modify this layer - a so-called platysmaplasty.
The scars following a face lift are largely concealed within the hairline and hidden around the ear and once mature, are generally inconspicuous. While the placement of these scars and the relatively little tension they are under makes them very reliable, the outcome of a particular scar in any given patient can never be guaranteed.
The key to a successful face lift is a natural and balanced result. The overdone face lift is instantly recognisable and entirely undesirable. The best procedure or combination of procedures to best suit a patient's needs and wishes needs to be individually determined by careful examination and assessment.
Rhinoplasty is an area of particular interest for A/Prof Gianoutsos. His Craniofacial practice and extensive experience in nasal reconstruction have complemented well his practice in cosmetic rhinoplasty.
Like all areas of cosmetic surgery, the key to rhinoplasty is a natural result that suits the patient's face. This requires careful examination and assessment of, not only the anatomy, but the wishes of the patient. Although the procedure can be done through a closed or intranasal incision, A/Prof Gianoutsos largely uses an open approach where a small stepped incision across the columella (the strip of skin and cartilage which joins the tip of the nose to the upper lip) joins incisions hidden within the nose to allow the cartilage, soft tissue and bone, as well as nasal septum, to be clearly viewed. This enables precise reduction, repositioning and grafting (where necessary).
As well as the aesthetic imperative of such surgery, functional considerations must also be taken into account. This often means that surgery to improve the nasal airway is performed at the same time.
Rhinoplasty must be carefully tailored to the individual patient's wishes and their overall facial form, as well as the precise anatomy of their nose. The procedure is designed to suit the individual patient's face and to avoid the ‘operated look’.
Blepharoplasty is a term used to describe the surgical correction of sagging, or baggy, eyelids.
Upper eyelid blepharoplasty
An upper eyelid blepharoplasty may be undertaken for aesthetic and/or functional concerns. Ageing and sun exposure cause a downward movement of the outer corner of the eye as well as stretching of the eyelid skin, which gives a ‘hooded’ appearance. Frequently there is a downward movement of the outer half of the eyebrow itself. At the inner corner of the eye there is frequently a prominent bulge of fat.
Most of these features can be addressed through a procedure upon the eyelid itself, in which excess skin and muscle, as well as fat, can be reduced to give a brighter, more rested appearance to the eyes. Brow frown lines may also be addressed through an upper blepharoplasty incision. It is usually performed under sedation (twilight) and local anaesthetic as a day only procedure.
In some patients, however, it is the brow that is the primary problem with the eyelid secondary. In these patients a brow lift, usually combined with a blepharoplasty, is most appropriate. Upper lid blepharoplasty may be combined with other facial rejuvenating procedures such as lower blepharoplasty, brow lift or facelift operations.
Lower eyelid blepharoplasty
Lower eyelid blepharoplasty is a more involved undertaking and is impacted upon more significantly by factors such as sun damage to skin, poor elasticity of lower eyelid structures and ageing. It enables treatment of both skin excess and fatty herniation (bags). These can be achieved by approaches from within the eyelid, or through outside of the lid near the eyelashes. Fatty bulges can be removed or redistributed to achieve a more youthful appearance to the lid. It is often done in combination with elevation and suspension of the outer corner of the eye, so called canthopexy or canthoplasty. Again, lower blepharoplasty can be done in concert with other facial rejuvenating procedures.
The upper third of the face contributes largely to its youthful appearance and the brow, in turn contributes significantly to this. Ptosis, or droop, of the brow lends a tired or harsh look, as well as contributing to apparent skin excess in the upper eyelids.
Elevation, or repositioning, of the brow can be achieved in a number of ways. These range from a more traditional open brow lift, wherein a long incision within or in front of the hairline is used to elevate the brow; to an endoscopic (keyhole) approach, or a more limited ‘lateral brow lift’, where a short incision in the temporal hairline is used. The procedure can also be used to combat frown lines. It can be done as a day stay procedure or may be combined with other surgery such as blepharoplasty or face lift.
The balance of ones face is determined by the relative size and projection of each of its parts, the upper forehead, the middle nose and upper jaw and the lower third, the lower jaw and chin. Each has a relation and effect on the others.
Where the chin is less prominent than is ideal, the rest of the face is thrown out of balance to a degree. The nose appears more prominent as does the forehead to a lesser extent. Even where the chin itself may not be recognised by a patient as ‘weak’, they may comment upon the poor definition of the jaw line, the loss of the angle between the jaw and the neck, or upon the prominence of the nose. Genioplasty involves an alteration of the shape and/or position of the chin. In experienced hands it is a procedure that is less problematic in the long term than chin implants, although these too have their place. The procedure is performed using an incision on the inside of the mouth and the bony chin is repositioned and held with small screws.
Otoplasty, or setback of the ears, is a commonly performed procedure in children, but also in adults.
It involves an incision behind the ear through which the cartilage of the ear is both repositioned and reshaped. Rarely do I incise, or cut, the cartilage, as this can give an unnaturally sharp appearance to the fold of the ear. Children most frequently have the operation done around the age of five and are most comfortable staying in hospital the night after the surgery. In adults, the operation can be done as a day only procedure.
BREAST AUGMENTATION - IMPLANTS
Breast enlargement, or augmentation, is a widely requested procedure designed to increase the size of the breasts. There are many reasons for choosing to have the procedure. Many women simply have an underdeveloped bust, others may have lost breast volume following pregnancy and breast feeding, some may have a deformity of one or both breasts (constricted or tuberous breasts), while still others may have significant asymmetry of their breasts with one being much smaller than the other.
The procedure involves the insertion of an implant beneath the breast or pectoral muscle depending upon the individual characteristics of the breast itself and the chest wall, amongst other considerations. The aim of a breast augmentation procedure is to give a woman's body better balance and proportion and improve self esteem. It aims to not only give better overall proportion to the body by enlarging the breasts, but to give a better balance and contour to the breasts themselves. It is a procedure with a very high satisfaction rate, but is one which must be carefully tailored to the individuals wishes as well as their breast and body type, skin quality and age amongst other factors.
Implants can be placed using a number of different incision sites - in the fold beneath the breast, around the areola of the nipple or via the axilla (under the arm). The pocket in which the implant sits can be beneath the breast tissue alone (subglandular), beneath the pectoral muscle (submuscular), or a combination of both (dual plane). The type of implant used can either be saline or silicone filled and may be round or tear drop shaped (biodimensional/anatomical/form stable).
The correct combination of incision site, implant pocket and type of implant needs to be carefully considered and selected for the individual patient taking into account their wishes as well as other factors including their body and breast shape, skin quality and age.
The size of the implant likewise is dependent upon a number of factors, most important of these is the patient's wishes. Again, however, the key to the procedure is to have a natural and not an ‘operated’ look. It is important to recognise that cup size is not a standardised measurement, as any woman who has purchased a bra will realise. Different manufacturers have differing sizing standards. Because of these, amongst other factors, post operative breast size is necessarily a close approximation rather than an exact prediction.
Implants should not interfere with breast feeding or pregnancy. The degree to which the presence of an implant interferes with mammographic monitoring of the breast varies and may mean that other imaging techniques are on occasion required. These include ultrasound, CT scan and, rarely, MRI scan.
Are implants safe?
Silicon medical devices have been used for many decades with great safety and efficacy. Breast implants have been the subject of a great deal of scrutiny of many different kinds - medical/scientific, legal and media. Some of this scrutiny has been accurate and reasonable, but a good deal of it has been sensationalist and inaccurate. Importantly there is no greater risk of developing a cancer of the breast if you have had a breast augmentation. Also, if you are destined to develop a breast cancer, there is good evidence that there is no delay in the detection of the cancer due to a breast implant.
Although breast implants are manufactured to very high standards, they are not entirely fail safe. They can very occasionally leak and may need to be removed and new implants replaced. Despite manufacturing and surgical improvements reducing its rate, capsular contracture or hardening of implants can occur, leading to the need for removal and replacement. Changes over time with ageing and weight fluctuations can also have implications with regard to reoperation in breast augmentation surgery.
In recent times it has been recognised that there is a possible association between breast implants and the development of a rare form of lymphoma, or tumour, called ALCL or Anaplastic Large Cell Lymphoma. Globally there have been around 300 cases of this rare breast lymphoma reported in patients with implants. Relative to the many millions of breast implants in the global community, this is very small number.
Large and heavy breasts carry with them a number of concerns relating to both physical comfort and self image. Back, neck and shoulder discomfort are common complaints. Headache and breast discomfort are also frequently reported. Having a large bust can make it difficult to buy well fitting clothes, or the type of clothing a woman would like to wear. Sporting and physical activity can be made uncomfortable and difficult, often making a woman too self conscious to participate. Frequently, in the hotter and humid summer months the skin under the breasts can be prone to rashes and irritation.
There are many different techniques of breast reduction and hence, variations in the scars and their positioning. Almost uniformly there is a scar around the nipple connecting to a scar from the lower pole of the nipple to the level of the fold under the breast. Most frequently there is a horizontal scar from the level of the vertical scar in the fold of the breast for a variable length. In general therefore, the scar represents an ‘anchor’ type shape. The procedure not only reduces the size, volume and weight of the breast, but also improves the breast shape and the position of the nipple is normalised. The aim is to tailor the breast size to the woman's body and her wishes for size.
Breast reduction is a procedure that has a very high satisfaction rate. It is also a procedure which most women have contemplated for many years, and occasionally decades, before undertaking it. Very frequently women will spontaneously comment following their procedure that they wished that they had the procedure done ‘years ago’.
There are, of course, downsides to any procedure and breast reduction is no different. There are scars on the breast, as described above, which are generally a little red and may become somewhat thickened while they are maturing. This process may go on for some months. In general, once matured, the scars are relatively inconspicuous although not invisible. They are not seen in normal clothing or swimwear.
Sensation to both the breast skin particularly in its lower portion and to the nipple itself is usually altered in the short term. That is, there is a degree of numbness. This generally returns to normal, but may take some months. Nipple hypersensitivity is much less common (5-10%), but can be uncomfortable while it persists. This usually resolves within around 12 weeks.
Further details of the appropriate procedure for any individual woman and exactly what to expect will be discussed at length at your consultation.
Mastopexy, or breast lift, is a procedure designed to rejuvenate the appearance of the breast most frequently following breast feeding. This so called ‘ptosis’ (pronounced tosus), or droop, can however occur in women who do not have children and have not breast fed.
Most often the procedure is performed in a similar manner to a breast reduction without the removal of breast tissue. The scar is most usually sited around the areola (outer part of the nipple) and in a vertical line from this to the fold under the breast. Sometimes a horizontal scar is added along the fold under the breast and occasionally the scar is around the nipple only.
There are scars on the breast, as described above, which are generally a little red and may become somewhat thickened while they are maturing. This process may go on for some months. In general, once matured, the scars are relatively inconspicuous although not invisible. They are not seen in normal clothing or swimwear.
It is unusual, although not unheard of, to have alteration of sensation in the nipple or breast in mastopexy alone. Where there has been both droop and loss of volume of the breast, the addition of a breast implant is appropriate.
Reconstruction of the female breast following mastectomy is for some patients as vital a consideration as the tumour surgery itself. Rates of breast reconstruction in Australia are low compared with other parts of the developed world. This may relate to a lack of knowledge, access or availability of plastic surgical input into the treatment of breast cancer.
Reconstruction may be undertaken as an ‘immediate’ procedure along with the mastectomy, or may be delayed until after the initial surgery and any additional treatments have been completed. Reconstruction is not for every woman, nor is every woman necessarily a good candidate for reconstructive surgery. There may be factors relating to the tumour, which make a reconstruction a less viable option.
Breast reconstruction can be largely said to take four main forms:
- As more women have been better able to quantify their breast cancer risk using genetic testing for the BRCA gene mutation, the consideration of prophylactic of risk reducing mastectomyhas become more prevalent. Where possible, the mastectomy is performed using a nipple sparing technique. In these circumstances it is often possible to perform a one stage or direct to implant type of reconstruction. In addition to placing the implant beneath the muscle, Acellular Dermal Matrix(ACDM) can be used to complete the pocket into which the implant is placed. In the larger breasted patient, the tissue ordinarily discarded in a breast reduction can often be utilised to complete the lower pocket.
- Tissue expansion and implant reconstruction: wherein an inflatable implant (expander) is placed under the muscle following a mastectomy, either immediately or as a later procedure once the mastectomy wound is healed and matured. The expander is then inflated by injection with saline usually on a weekly basis. This "tissue expansion" type of technique stretches and recruits overlying skin and tissues to allow for the secondary placement of an implant. This usually takes place around three months after the desired volume is reached.
- 'Autologous' tissue reconstruction where the new breast is entirely formed by the use of the patients own tissues, usually from the abdomen. In this type of reconstruction the tissue usually discarded in an abdominoplasty is used to form the new breast. The tissue may be moved in one of two ways, either still attached to its underlying muscle to provide a blood supply to keep it alive or with its circulation wholly separated from the body and then re-established on the chest using microsurgical techniques. Basically it is the use of excess lower abdominal tissue to make the new breast. This is a significantly bigger operation than the above.
- A hybrid of the two above techniques where an implant is used to supplement the patients own tissue reconstruction. This is where the latissimus dorsi, a large muscle from the back, is used with its overlying skin and an implant beneath to give sufficient volume
Whether to have a breast reconstruction and, if so, which technique is the best for an individual patient requires careful assessment via examination and discussion, as well as consultation with the surgeon who will perform the mastectomy.
These facilities, as well as access to a highly qualified and experienced breast care nurse, can be offered through A/Prof Gianoutsos' practice.
Persistence of the normal or physiological enlargement of male breast tissue beyond the time of puberty is the cause of a great deal of self consciousness and concern in men both young and older. There may also be a fatty component to the problem.
Gynaecomastia requires careful examination to establish the appropriate means of its surgical treatment. Surgical management may involve a surgical subcutaneous mastectomy and/or liposuction. Subcutaneous mastectomy involves an incision half way around the areola (outer part of the nipple) and removal of the abnormal breast tissue. This is often combined with liposuction to contour the final result. On occasion, liposuction alone may be appropriate.
It is important to limit vigorous physical activity for around ten days following the procedure as bleeding under the skin, or haematoma, can be a problem.
Liposuction, or liposculpture, is a very good technique used to remove excess body fat in areas where skin elasticity is sufficient. It is best for areas of abnormal distribution of fat, such as ‘saddle bag thighs’, rather than as a generalised weight loss technique.
The procedure requires careful planning at the initial consultation and immediately preoperatively via markings placed upon the skin. The tissues to be treated are then infused with a large volume of local anaesthetic fluid before the contouring process is undertaken, carefully measuring the volumes removed for symmetry. There are small incisions made to access these areas, which are closed with sutures underneath the skin before applying a garment to provide both support and some compression. This is worn for around six weeks in all.
Often, liposculpture will be combined with other procedures, such as with abdominoplasty or ‘tummy tuck’’ and beneath the chin in face lift surgery.
Abdominoplasty, or tummy tuck, is a surgical procedure designed to reduce both skin and fat excess in the lower abdomen. It improves the abdominal contour. Very often, women in particular after childbirth, have areas of excess that are resistant to all forms of exercise and muscle strengthening. Abdominoplasty addresses this problem well.
The procedure involves a long incision from hip to hip and above the pubic region. Through this incision, the tissues are elevated to the level of the rib cage. The abdominal muscles, which are very often separated as a result of pregnancies, are then reapproximated with sutures. The excess skin and tissue are then removed before the umbilicus is repositioned and the operation is closed with dissolving sutures placed underneath the skin. Liposuction is often used in conjunction with this procedure.
On occasion a lesser procedure or mini abdominoplasty is appropriate. Where there is relatively less tissue excess, an improved contour is possible via a shorter scar, a little like a caesarian scar. Most often, liposuction is used in addition.
Abdominoplasty is often a useful adjunct to other surgical procedures following massive weight loss.
In some patients, an abdominoplasty alone is insufficient to deal either with the volume of excess tissue, or its particular shape. In these patients the hip and upper outer thigh area, the buttocks, as well as the abdomen are the concern.
This technique is particularly applicable to patients following massive weight loss through dieting and exercise, or more commonly as a result of bariatric surgery - laparoscopic banding and similar procedures. A lower abdominal scar, much like that used in an abdominoplasty is connected with a scar around the upper portion of he hips meeting in the midline at the back.
This is a procedure of considerable magnitude and carries with it commensurately somewhat higher complication rates and recovery periods, but is able to address these specific concerns of contour and excess where other procedures are inadequate.
MASSIVE WEIGHT LOSS
Many patients who triumph over their obesity and its medical implications are left ‘let down’ and often times considerably demoralised by the fact that in place of their excessive weight, they are left with a great excesses of skin.
There are many areas where this excess can be manifest. The common areas are the trunk where a body lift type procedure is usually the best option, the arms can be dealt with by brachioplasty, the thighs by thigh lift, the breasts usually by mastopexy, along with implants, and the face and neck with face and neck lift surgery. Where a number of these procedures is appropriate, it is important to stage the operations so that all areas can be addressed in a safe manner. That is, it may take two or even three stages to achieve the desired improvement.
In my experience, these procedures have a great impact upon the sprits of patients who have undertaken an often long and difficult journey to achieve their desired weight, but who are often distressed by their appearance having done so.
Brachioplasty is a procedure aimed at addressing the excess of tissues in the upper arm, most evident when the patient has the arms held out at right angles from the sides, so called ‘tuck shop’ arms.
On occasion this can be dealt with surgically through liposuction alone. This relies upon good skin elasticity. Where the problem is somewhat more marked, an axillary (under arm) incision is added to the liposuction to achieve some tightening of the skin. More often the excess is beyond the scope of these techniques and a combination of liposuction ad an incision from under the arm along the inner aspect of the upper arm to near the elbow is used. This is disguised when the arm is by the side but is otherwise visible depending upon the type of clothing worn.
STRUCTURAL FAT GRAFTING
Although practiced for many years, the transferal of fat from one part of the body to another has become considerably refined in recent times.
This is achieved by harvesting relatively small volumes of fat from an appropriate part of the body, often the abdomen, using a ‘microliposuction’ technique. This tissue is then treated to obtain pure fat cells alone before being placed into areas of the body requiring structural volume augmentation. This is done by injecting the fat along micro tunnels in a layered manner thereby allowing the fat cells to be nourished by a good surrounding blood supply in order for it to remain alive.
This technique can be used in many areas of the body, but lends itself particularly well to the face. It can be used alone in specific areas such as the cheeks, lips and lower eyelids or in conjunction with other facial procedures such as face lift.
As with all procedures, there are downsides. These include swelling and bruising. Also, it is impossible to exactly predict the volume of fat that will survive. On occasion, further ‘touch up’ grafts may be required.
Known commercially as either Botox (Allergan, USA) or Dysport (Ipsen, UK), botulinum toxin is a product of the clostridium botulinum bacterium and effectively weakens muscles by disrupting the signal from the nerve cells just as they enter the muscle cells. Its effect wears off after a period of months. While used for a number of spasm, or dystonia, related conditions, its benefit in cosmetic surgery is that it weakens facial muscle activity which causes frown lines and wrinkles. It is most beneficial in the upper part of the face - brow, frown lines, laugh lines.
A synthetic substance that mimics the naturally occurring gel like material in the deeper layers of the skin - hyaluronic acid (a so called ground substance). It is injected into finer wrinkles often around the lower brow and mouth but is also used in lip enhancement. It has a life of around six months and injections usually therefore need to be repeated. There is a risk of around 1:500 of reactions to the injection.
A substance used to enhance the deeper soft tissues of the face. It is similar in its formulation to some types of dissolvable suture material. It requires two injections separated by around 5 weeks and usually lasts around 18 months. Like Restylane, there is a small risk of reaction to the injected material.