Category: Press Articles & Interviews

Liposuction is a technique that removes fat from unwanted areas. The key to liposuction is to abstract the correct amount of fat, to cause the least disturbance of neighbouring tissue, to leave the person’s fluid balance undisturbed and to cause the least discomfort to the patient. Mechanical energy has been the mainstay of liposuction for many years but modern refinements utilising ultrasound, laser and water assisted techniques have helped to improve outcomes. By using additional energy sources one is able to disturb the neighbouring tissues less and reduce the discomfort. Patients tend to experience less bruising and swelling than traditional liposuction.

Further refinements have seen the increasing use of tumescent fluid to enable removal of large volumes of fat. Again this is to aid patient recovery and comfort however the use of often large volumes of fluid to improve results need to be carefully monitored in a facility with dedicated postoperative monitoring and care. Although liposuction can be performed under either local anaesthesia or general anaesthesia, postoperatively patients should be monitored closely to limit the complications resulting from fluid imbalance. Liposuction can be performed on any area of the body although for women it is most commonly performed on the abdomen and thighs and for men abdomen and flanks. Liposuction can also be performed in addition to facial surgery e.g. facelifts and neck lifts, breast surgery e.g. breast reduction / mastopexy and body rejuvenation surgery e.g. abdominoplasty and arm/thigh lift.

Liposuction remains one of the most commonly performed operations in cosmetic surgery, however it is important for patients to consult with a plastic surgeon with experience in liposuction and other body rejuvenation procedures. The pros and cons of local / general anaesthesia, types of liposuction, alternative procedures and additional non surgical / surgical treatments need to be discussed. Patients should be weight stable and at their ideal weight before considering liposuction and it should not be seen as quick fix to reduce fat. Judging the correct amount of fat to remove remains one of the most important decisions in order to limit complications.

One of the commonest errors is removal of too much fat or to perform the technique on patients with excess skin. With the right patient selection liposuction is an excellent tool to reduce unwanted fat and is best performed on isolated areas of fat and in patients with good quality skin. Choosing the right patient will help reduce the skin irregularities that occur following liposuction which remains the biggest concern long term. If liposuction is performed alone the incisions used are determined by the liposuction technique and the size of the cannula although they are usually no more than 0.5 – 1cm in length. The incisions can be well hidden and can be either sutured or left open. It is rare for patients to notice these incisions in the long term. Although non-invasive methods of liposuction exist and may be useful in certain patients the pros and cons of these techniques need to be discussed alongside the pros and cons of traditional invasive techniques. For the right patient liposuction provides excellent results and these results are often improved by the use of compression garments that help in the postoperative phases to reduce swelling and discomfort.

Further improvements in liposuction mean that patients can have the fat that has been removed injected into other areas of the body such as the breast, buttocks and face. Liposuction can thus now be seen as liposculpture and an important adjunctive tool in body rejuvenation

 

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The breast has a tendency to age due to a combination of tissue changes in the skin, breast tissue, the ligaments within the breast, the position on the chest wall and the size of the nipple/areolar. Changes to these tissues occur most acutely with fluctuation in weight, and pre/post pregnancy. Mastopexy is a technique used to lift and change the tissues of the breast. Each component of the breast can be lifted and each component needs to be addressed individually. The consultation must take into account the patients ideal size and a discussion regarding previous shape and desired shape. Often breasts are slightly different both in terms of size and shape and the position of the nipples. The crucial question is whether there is enough volume of current breast tissue to provide the desired size and the position of the nipple areola complex. Where volume is deficient and the nipple areola is sitting in a reasonable position anatomically shaped implants may be able to give the perception that the nipple areola has been lifted. It may be over time that patients may require a lift subsequently but in some scenarios a good result can be obtained by breast augmentation only. Where the nipple areola is sitting low and the volume of the breast is satisfactory a mastopexy can improve the shape and position of the breast. The overall size and shape needs to be tailored to the individual using methods to minimise risk to the blood supply to the tissues. The breast mound is designed in order that the breast can be lifted into a new position. The skin is re-draped over the breast and the nipple/areolar size adjusted to the needs of the patients. Sometimes the nipples need be lifted a considerable distance in combination with the breast tissue. Often the nipples point into the armpit and these need to be relocated centrally at the same time. Contour defects as a result of stretching of the breast ligaments needs to be addressed by relocating the breast tissue higher up the muscle on the chest wall.

Mastopexy Methods

There are a number of different ways of performing a mastopexy and these are determined by the incisions performed. The donut or benelli mastopexy is performed through a scar placed around the areola. It may be used to increase the height of the nipple areola by 2-3 cm. It does have a tendency to form stretched scars but does not involve a vertical incision. The lollipop mastopexy is performed via a scar around the areolar and a vertical incision. It is useful in patients where there is no need to remove excess skin. The nipple areola can be lifted significantly higher than in a benelli mastopexy. Where there is significant excess skin and the breast tissue and nipple areola need to be raised significantly an anchor scar mastopexy is the proffered rejuvenation technique. The scars are place around the areola and a vertical scar that meets a horizontal scar in the crease/ fold of the breast. Where the nipple areola complex has dropped and there is also insufficient volume one should consider a combination of a mastopexy with an implant or autologous fat transfer. This can be done as a one stage procedure using the mastopexy techniques described above. Autologous fat transfer involves the removal of fat from the body and transferring it into the breast to try and give extra projection at the upper part of the breast which is the place that is usually most empty. Autologous fat transfer does allow patients the potential of an increase in volume without an implant but often patients may require more than one treatment of autologous fat transfer and the volume improvements are not as predictable as an implant. Using an implant at the same time as a mastopexy in a one stage operation is an excellent means of providing breast rejuvenation in patients who want a moderate increase in volume. For patients wishing to have a dramatic increase in size and wish to have large implants or in those who need the nipple areola lifting considerably mastopexy implant is better performed as a 2 stage operation. Patients undergoing any form of breast lift should be aware that the breast will sit high on the chest wall and will drop over time. Usually this can take 3 months. All the operations described above are usually performed under general anaesthetic. Patients are usually able to drive after a week and may start gentle exercises at this time building up to normal exercising by 4 weeks. A consultation regarding the pros and cons of mastopexy will help to clarify the expectations of patients and provide results that are achievable to meet these expectations. One should consider all the possible options, and if consulting with myself, one will be able to look at results related to all the operations above and make an informed decision

 

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Often excess skin or fat can be a problem for patients in the thigh area and thigh rejuvenation is being more frequently requested. For patients with excessive weight loss thigh lifting can be combined with other procedures in other areas of the body.

The distribution of excess fat and skin and the quality of skin of the thighs will often determine what the best options for patients are. Surgical treatments combining skin tightening and fat removal without skin excision may offer some promise and a discussion regarding the pros and cons should be addressed in any consultation relating to thigh rejuvenation. Liposuction on its own can provide some skin tightening and the perception of skin rejuvenation, although where excess skin is present surgical excision is often the only reliable way to improve contour. If there is excess fat only liposuction can be used, although patients must be aware that excessive fat removal alone will often lead to visible skin excess that may only be correctable by surgical excision at a second stage.

There are many areas of the thighs that can be troublesome to patients but most often it is the appearance of the thighs from the front. The appearance of the thighs from behind and rejuvenation in this area only is less frequently requested although for some the appearance of the thighs all the way around the body is of concern. The most frequently requested rejuvenation procedures on the thighs are for excess skin and/or fat in the inner and/or outer thighs.

It is important for patients to discuss the various options and pros and cons of thigh lifting, liposuction, buttock lifting and total body lifting when considering surgery for thigh rejuvenation. Each of the techniques has pros and cons and help to address different areas.

Traditionally the terminology of thigh lifting has been applied to an inner thigh lift where the scars are placed in the groin crease and/or a vertical line along the inside of the leg. The extent and the position of the scar need to address the skin excess present and the needs of the patient.

If the patient has good quality skin a thigh lift using a groin incision may be sufficient in combination with liposuction to give a pleasing result. If excessive skin is present a vertical scar may be a better option. The vertical scar can be limited or extended depending on what one is trying to achieve. It is not recommended that the scar go past the knee.

Thigh lifting can also be performed from under the buttock crease or the thighs can be lifted by incisions above the buttocks. In certain circumstances a total body lift is a good option in addressing the upper thighs. In a total body lift the scars are placed all the way around the body. Where there is excessive skin excess in the upper thighs in combination with excess tissue all the way around the body a total body lift remains a good option. Often scars in the buttock crease can be become troublesome and the pros and cons of thigh lifting via this method should be discussed with the patient.

With modern surgical techniques recovery following thigh lifting is relatively short. It is uncommon to require drains and although it is recommended that thigh lifting be performed using general anaesthetic, patients are able to mobilise as soon as they have recovered from the anaesthetic.

Thigh rejuvenation may involve many different options and a consultation regarding all these different options will help you make a decision as to what the best option is for you.

 

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Revisionary breast augmentation is an increasingly specialised field of breast surgery.With all breast reconstruction one must consider the patients wishes for improvement in terms of size, shape and symmetry. Both clinician and patient need to establish what can be achieved and whether all expectations can be met. The timing of revisionary breast augmentation must take into account the type of implants, the age of the implants, the associated changes of the implant, the capsule and the differences and changes of the breast.

Many patients will have experienced mild changes and often reassurance is all some patients require. For some patients changes to the implants may require a more immediate treatment. The majority of patients will have seen a gradual change in the aesthetics of their breast over a period of years and the timing of surgery can be based on the pros and cons of what can be achieved. Assessment of the implant for leak or rupture is imperative and may alter the timing of future surgery. It is uncommon for these complications to occur and occasionally if doubt remains and there is no immediate decision to perform surgery a diagnostic scan is warranted. It is rare for patients to have associated lymphadenopathy but again if present the pros and cons of managing this surgically need to be discussed. Often implants will develop creases or ripples and these need to be separated from the more troublesome changes mentioned above. The quality of the capsule needs to be assessed to determine whether the capsule should be removed in its entirity (en bloc resection – total capsulectomy), whether part of the capsule needs to be removed (partial capsulectomy) or whether the capsule needs to be released (capsulotomy). Capsules develop in all patients and are a protective barrier.

Over time however they can have a detrimental effect on the breast implant and can result in pain and visible changes. The visible changes are related to the squeezing of the implants in a confined space. This can compress the implants and make them feel hard and alter the position on the chest wall. Implants can move upwards creating an upper fullness or double bubble effect, downwards (bottoming out), outwards or inwards.

During surgery it may be necessary to place the implants in a different pocket ie where patients have implants above the muscle a new pocket can be made under the muscle.

Often with time the breast tissue will drop and one must determine whether a lift or mastopexy should be performed at the same time as implant replacement or whether it is advisable to perform the augmentation first and then a mastopexy at a second stage if needed. The need for mastopexy is dependent on both the quality of the skin and the breast tissue with particular importance taken to assess the height of the nipple areola complex on the breast and the breast’s position on the chest wall. Depending on the quality of the implant, the capsule, the skin and breast tissue one must consider the pros and cons of separating the removal of implant / surgery on the capsule with a second definitive operation. It is often possible to remove / replace implants at the same stage and mastopexy can often be performed at the same time. The pros and cons of each of these options needs to be addressed by a plastic surgeon with experience in revisionary breast augmentation. Patients often do not appreciate the complexity of the decision making process and what is involved in revisionary surgery. All patients should have the details of their previous implants available. From this information one can determine the width of the current pocket and adjust implant size and shape to improve any deformity that has occurred. There are pros and cons of using different implants, sizes and shapes in breast augment revisionary surgery and patients must be informed of the pros and cons of these and be part of the decision making process.

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The diagnosis of breast cancer can be devastating and decisions regarding reconstruction are often seen as a secondary consideration when dealing with so many other painful issues. However, women often feel that breast reconstruction is essential to recovering their self-confidence once the ordeal is over, and for those women there are different options available. Patients may undergo autologous reconstruction at the same time as the initial mastectomy or may choose to wait until after mastectomy and subsequent oncological treatments such as chemotherapy and radiotherapy. A careful discussion with the surgeon is imperative to guide the patient in the decision making process. This often requires multiple consultations with both the doctor and the specialist reconstructive nurse within a multidisciplinary oncological team. Breast reconstruction can be provided by either autologous or non-autologous tissue, or a combination of both techniques. Non-autologous methods of reconstruction include the use of tissue expanders and implants. Autologous reconstruction uses one’s own tissue. The advantages of this are that the tissue ages naturally and the reconstruction changes minimally with time.

Initially, an autologous reconstruction may be more time consuming in terms of surgery and recovery, however the benefits often outweigh the risks. It is important that the surgeon discusses the pros and cons of each form of reconstruction with each patient individually to determine suitability. For autologous breast reconstruction the gold standard technique is the deep inferior epigastric perforator flap (DIEP), which is a modification of the transverse rectus abdominis muscle flap (TRAM). With newer techniques to protect the muscle and its function (DIEP), tissue from the abdomen can be used to reshape the breast with minimal side effects to the abdomen. The tissue that would normally be excised during a cosmetic tummy tuck is dissected carefully with its blood supply (the diep inferior epigastric artery) to avoid damage to the tummy muscles creating a flap of tissue. Blood vessels in the chest or the armpit are also dissected free and the artery and veins of the veins in the chest and the veins in the tummy tissue are sutured together using fine suture material under a microscope. The tummy is closed in the same way as a tummy tuck or abdominoplasty and the new tummy tissue is reshaped onto the chest wall to create a new breast. The most important aspects of breast reconstruction include size, shape and symmetry. The initial operation provides the basis with which the surgeon can mould the final result. Often a second operation is required in order to achieve these goals. In order to achieve these goals.

With increasing refinements such as lipo modelling – combining liposuction (removal of fat) and autologous fat transfer (injection of fat) – the new breast can be remodelled to give an even more natural result. This can be combined with a nipple reconstruction to give a result that is similar in size, shape and symmetry The advent of microsurgery in the field of plastic, aesthetic and cosmetic practice has made the provision of this form of autologous reconstruction more widely available. Although it is not suitable for everyone and can never replace the original breast tissue, those that choose this form of surgery benefit from longer lasting breast aesthetics and abdominal contour. As with all aesthetic surgery, autologous breast reconstruction is not without its inherent risks and these need to be discussed with surgeons experienced in this highly specialised form of breast reconstruction.

 

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An interview with Mr Gary Ross by the BBC Manchester.

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Even a successful breast augmentation can be affected by the ravages of time. Leading plastic surgeon Mr Gary Ross explains how he deals with revision breast augmentation, an often complex and difficult operation.

Breast augmentation is one of the most common aesthetic procedures with the aim being to provide a natural long-lasting result. However, over time both the skin and breast tissue and the implant itself can change and this can affect the overall result. Although this is uncommon and occurs infrequently the change can be devastating for the patient.

There are a number of possible aesthetic changes associated with the implant and its surrounding tissues; these include migration of the implant higher in relation to the nipple/ areola/breast tissue or migration of the implant lower in relation to the nipple/areola/breast tissue and loss of integrity of the implant/its capsule leading to a change in shape.

The migration of the implant upwards can lead to the nipple / areola and breast tissue lying lower than the implant. This Even a successful breast augmentation can be affected by the ravages of time. Leading plastic surgeon Mr Gary Ross explains how he deals with revision breast augmentation, an often complex and difficult operation time and leads to an unnatural aesthetic appearance that exaggerates any natural ptosis or drooping that occurs with age. The correction of this deformity requires a manipulation or removal of the capsule that surrounds the implant. It may be necessary to move the pocket of the implant from sub glandular to sub pectoral or vice versa and to close the original pocket (see patient one in PDF).

In severe cases where there is associated capsular contracture the natural definition of the breast inframammary fold can be completely lost and redefining the fold requires recruitment of abdominal wall skin and a recreation of the fold (see patient two). There may also be a requirement to change the pocket placement and removal of the previous pocket.

Migration of the implant downwards can occur due to relaxation of the inframammary ligaments. This results in the unnatural appearance of the nipples/areola sitting too high in relation to the implant. This bottoming out effect can be corrected by manipulation of the implant pocket to raise both the fold and the implant. In cases where the skin has not been stretched excessively there is no need to remove any further skin and the original inframammary scar can be used for the procedure (patient three).

Capsular contracture is probably the most common reason for change in shape and in severe cases can be associated with intracapsular and extracapular leak with seroma formation. The aesthetic results of this are unpredictable and any revisionary surgery is extremely difficult. In almost all cases the capsule must be removed in its entirety and the pocket changed to accommodate the new implant. Due to excessive expansion of skin it may be necessary to not only remanipulate the inframammary fold but also to elevate the areola with a combination mastopexy (patient four in PDF).

The main principals of breast surgery, namely size, shape and symmetry still remain, but the techniques to achieve an improved aesthetic outcome need to be altered to meet each individual requirement.

I aim to change and improve the patient’s appearance by concentrating on these individual expectations and needs. Preoperative consultations are crucial in developing the patient/ surgeon relationship and are a means to discuss any concerns and prioritise needs and expectations.

 

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Breast uplift and breast augmentation are two very different procedures but, for some women, a combination of these two procedures is necessary to produce the best aesthetic outcome. Leading plastic surgeon Mr Gary Ross explains.

Some women require a breast augmentation and some, particularly after childbirth or weight loss, require a breast uplift or mastopexy. However, for many women a combination of these two procedures is what is required and a skilled and experienced cosmetic surgeon will be able to determine the best option for you. As you age the skin stretches and breast tissue droops, which can result in the breast tissue lying lower on the chest wall and the breasts may become asymmetric in size and shape. A mastopexy is a fantastic procedure for recreating a more youthful shape, but another side effect of the ageing process, particularly post childbirth and breast feeding or weight loss, is that there is a loss in volume. Implants are therefore essential to increase volume. Different sized implants can also be used to improve symmetry. Women with a smaller bust can end up very disappointed if they have breast implants that then exacerbate a problem with sagging skin, so it is the plastic surgeon’s job to advise them that mastopexy implant procedure might be best for them. There are a number of different types of mastopexy implant that can be performed. Following breast augmentation one can lift just the nipple and areola by using a periareolar mastopexy, where the resulting scar is positioned only around the nipple and areola. This gives a small nipple/areola lift and does not require any other scarring. A vertical scar mastopexy implant requires the positioning of the scar around the areola and a line vertically on the breast. This allows the breast tissue to be lifted and redraped over the implant as well as lifting the nipple and areola. Nipples and areolae can be lifted as high as required aesthetically and this technique provides a very flexible means of lifting the breast. Where there is significant excess skin a mastopexy implant using a vertical scar, an inframammary scar and a periareolar scar can provide an excellent means of lifting the nipple, areola and breast tissue to a new position and also allows movement of the breast tissue upwards while finally allowing direct excision of any excess skin. Although more scarring is required it is sometimes the only method of creating an aesthetic result.

With so many different options, a consultation regarding each method of mastopexy implant is important to determine what your expectations of surgery are and what is achievable. The pros and cons of each need to be discussed and an informed decision made.

 

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Leading plastic surgeon Mr Gary Ross explains the options available once gravity takes its toll.

Gravity is the enemy of us all and as well as causing the face to sag it can also have an effect on our breasts. The breasts age due to a combination of tissue changes in the skin, breast tissue, the ligaments within the breast and the position on the chest wall.

Changes to these tissues occur most acutely with fluctuation in weight and the impact that pregnancy has on the body.

Mastopexy is a technique used to lift the breast. Each component of the breast can be lifted and each component needs to be addressed individually by a surgeon experienced in this operation.

The consultation regarding vertical scar mastopexy must take into account the patient’s ideal size and a discussion needs to be had regarding previous shape and the desired outcome. Often breasts are slightly different both in terms of size and shape and the position of the nipples. Sometimes the nipples need to be lifted a considerable distance in combination with the breast tissue (patient one – see PDF).

The ideal position of the breast on the chest wall is the key and will dictate whether a small amount of tissue needs to be raised and repositioned into a new inframammary fold or in some cases removed (patient two). The overall size needs to be tailored to the individual using methods to minimise risk to the blood supply to the tissues. The breast mound is then designed in order that the breast can be lifted into a new position. Finally the skin is redraped over the breast.

A single vertical scar can be used in the majority of patients (patient three). Occasionally if there is too much skin a small inframammary scar is required alongside a vertical scar. If only a small skin lift is requested a scar around the areola can be used to give a small lift without altering the inframmary fold or lifting the breast tissue.

Finally, the vertical mastopexy technique can also be used in combination with an implant to give superior fullness to the breast.

Recovering from a mastopexy

Patients undergoing vertical scar mastopexy should be aware that the breast will sit high on the chest wall and will drop over time, which will usually take three months (patient four). It is important following surgery that a well-fitted non-wired bra is worn at all times.

Often patients can go home on the night of surgery and recovery is usually quick with the wounds healing in a week (bruising and swelling is relatively common and can take a couple of weeks to settle). In conclusion Women no longer have to accept the hand that time has dealt them and it is possible to regain the shape they have lost. A consultation regarding the pros and cons of mastopexy will help to clarify the expectations of patients and provide results that are achievable to meet these expectations.

In conclusion

Women no longer have to accept the hand that time has dealt them and it is possible to regain the shape they have lost. A consultation regarding the pros and cons of mastopexy will help to clarify the expectations of patients and provide results that are achievable to meet these expectations.

 

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Face lifts often get a bad press, but techniques have changed and these days, if you pick the right surgeon, it is possible to achieve a very natural looking result. In this article, Mr Gary Ross explains his approach to face and neck lifting.

Many non-surgical treatments and minimally invasive face and neck lifting techniques have been introduced into cosmetic practice over recent years. A consultation regarding facial rejuvenation must involve the pros and cons of these alongside the pros and cons of classic face lifting and neck lifting procedures.

The aim of facial rejuvenation is to change and improve appearance and produce a long lasting, natural looking result, with as little down time as possible. Although non-surgical treatments and minimally invasive face lifting is effective in slowing the ageing process within our formative years, as we get older classical face and neck lifting is often the only procedure that can address the ageing lower face and neck adequately.

The classic signs of jowl formation, prominence of the nasolabial angle, blunting of the jaw line and fullness under the chin are best addressed by modern face and neck lifting techniques using the classic approach.

Modern techniques in face lifting address mainly the layer underneath the skin and above the muscle, which is called the SMAS layer. Minimal skin excision is required with an emphasis on redraping of the skin following the SMAS lift.

The windswept look, with change in earlobe position and stretched scarring as a result of skin face lifts only still occurs in very rare and unfortunate cases and is easily avoidable.

The effects of ageing lead to an increase in subcutaneous fat deposition in the jowls and the nasolabial creases. These descend in a vertical fashion and for face lifting the SMAS needs to preferentially lifted in a vertical fashion.

Because we lose tissue with age, the SMAS layer should be remoulded rather than removed to improve facial contour. Autologous fat may also be required to improve the volume of the face.

The neck is one of the most difficult areas to address and must be considered in all patients consulting for facial rejuvenation, as an ageing neck can let down a youthful face. To lift the neck, one must consider not only the repositioning of the SMAS layer but also the repositioning of the platsyma layer that is a continuation of the SMAS layer in the neck.

As the platysma ages and weakens the fat under the chin becomes more prominent – often this fat needs to be removed by either an open approach or by liposuction. Where liposuction is required to reduce fat in the jowls, under the chin and on the neck, the fat can be redistributed into other areas such as the cheek, lips or chin to provide an overall rejuvenated effect.

As previously mentioned, the platysma layer is a continuation of the SMAS layer and therefore the platysma also needs to be lifted in a vertical plane via suspension methods. Finally one must also consider the chin and the angle of the jaw and where required a genioplasty, or chin augmentation, may be required.

The face/neck interface must be addressed in all consultations regarding facial rejuvenation. Although non-surgical treatments and minimal access face lifting provide a useful adjunct in the fight against the ageing process, the pros and cons of classic facelifting using modern techniques provide a long lasting result with minimal downtime and may be more likely to achieve the expectations of the patient.

 

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