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When to say no to cosmetic surgery

A definition of cosmetic surgery is the change of a normal appearance into another one that makes the quality of life better. The exact nature of normality is a complex one and the benchmarks for this are usually very personal.  Usually, the problems and anxieties raised by a cosmetic issue have been thought about and perhaps even agonised over for a long time.  Therefore, any decisions to go ahead with treatment should never be rushed and you, as a patient, should never feel pressured.

Firstly, the patient must be assessed to ensure there is a treatable problem and that the surgery is within the capabilities of the doctor.  This requires trust and respect between both the patient and surgeon. If this is lacking, for whatever reason, then no treatment should go ahead. Providing the surgeon has a website, you may be able to find information about his or her qualifications and experience online. However, it is perfectly acceptable to ask your doctor about their qualifications and background during your consultation too.

The purpose of a consultation is to define the problem and to make sure that you are medically and psychologically fit enough for the procedure. During your consultation, your surgeon should ask you a number of questions, including why you want to have cosmetic surgery as well as other medical based questions. If you feel that the surgeon does not understand you or has not asked about the whole picture, then it is likely that the intention of the surgeon may not align with yours. A good surgeon is a good doctor first and will find out the relevant facts about you to make sure the surgery is truly in your interests. There should not be a mismatch between your aims and the surgeon technical ability to fulfil them.

Cosmetic surgery should be regarded as another important form of healthcare delivery. The medical infrastructure needed to deliver this is at the same standard as for any other speciality and should be viewed the same as neurosurgery or orthopaedic surgery. If you get any other impression from your surgeon or any other medical professional– run away!

During your consultation, you’ll get the chance to ask lots of questions, not only about the surgeon but as well as the procedure ahead. The types of questions you may want to ask include:

-Where is the surgery going to take place?

-Who will be performing the surgery? (In some instances, your consultation may not be with the same consultant performing your surgery – again, if this is the case – run!)

-What is the surgeon’s experience and what qualifications do they have?

-What are the provisions for aftercare?

-What if something goes wrong after the surgery both short and long-term?

If the answers to these important queries are not satisfactory, you should say no to whatever is proposed.

Questions relating to aftercare are particularly pertinent if you are wishing to have cosmetic surgery abroad. It’s important to remember that while there may be great surgeons in other parts of the world, your treatment is about more than just surgery. Therefore, unless there is practical access for your surgeon to do a post-operative follow-up, you need to think carefully about the location of your primary treatment.

You should never be pressured into cosmetic surgery by anyone and that includes family, friends, a partner or a surgeon. I would advise staying away from offers such as ‘buy one and get one free’ or money off discounts if you book before a certain date. These types of offers are particularly popular during the Christmas period as this tends to be a slower time for cosmetic surgery. However, I would regard these as a form of coercion and I believe cosmetic surgery is not a decision that should be made lightly.

With this said, it is not unusual for a surgeon to suggest additional procedures during your consultation to alleviate your primary concerns. This may be entirely in order because a sincere and experienced surgeon may see aspects about your features that you may not have been aware of and which may be part of the problem or making your cosmetic problem worse. For example, it is not unusual for patients to complain about a large nose when their real problem may be that the chin is small. However, if at the end of the consultation, you have been persuaded to undergo additional procedures that make you feel uneasy or that you do not understand, go back for a second consultation to clarify matters. If you still do not understand, you should defer.

Finally, respect the surgeon who says no to you –  there is usually a good reason for this. A good surgeon will never agree to perform a procedure that is not right for the patient, no matter what the price tag attached to that procedure might be. Most importantly, before opting for cosmetic surgery, think long and hard about why you want it. Make sure it is for yourself and not for anyone else. If someone other than you is suggesting that you should have cosmetic surgery, you should be saying no to that person!


Cosmetic Surgery and Christmas

Christmas is Jesus’ birthday and it is a time for giving and receiving; partying and drinking; making up and breaking up and is followed very closely by New Year, which entails much of the same. Through bleary eyes and an empty wallet, the rest of the year is anticipated.  One can see the seasonal period is potentially a time for great happiness and stress, both emotionally and financially.

Christmas, unfortunately, can be a battle. It takes organisation, money, energy and commitment. To add to the growing financial and planning pressures, we now, more than ever, want to look good for the festive party season. Looks and appearances are most pertinent during Christmas and this is one of the reasons why the commercialism for Christmas now extends to certain cosmetic procedures.

We all want to look good and feel confident and there are a number of ways of achieving this. For the short-term, we can get our hair done and buy new clothes. It is also becoming increasingly more popular now to have Botox and fillers prior to Christmas, which in my opinion is fine providing the procedure is performed by a skilled and qualified practitioner. However, do not be impulsive. Make sure to do your research properly before agreeing to the procedure.

Some long-term ways to feel and look better include: losing excess weight, keeping fit, having a balanced diet, enjoying your job, getting on with your partner, strategies to cope with stress and at the bottom of this list, cosmetic surgery.

Cosmetic surgery is not just for Christmas! For cosmetic operations such as rhinoplasties (nose jobs), facelifts, lower lid blepharoplasties, tummy tucks and liposuction, the final outcome can take weeks and sometimes months to achieve. While the removal of lumps and bumps, lipofilling, breast augmentation, upper eyelid blepharoplasties, otoplasties (ear jobs), have immediate results, the healing period is crucial. Therefore, a stress-free period of rest with social support is very important, making Christmas a less than ideal time for recovery. However, if you are able to plan your recovery time over the festive season, it is not necessarily a bad time.

Finally, cosmetic procedures are often given as gifts for Christmas and this can be taken in two ways. If it is a true gift, because you have wanted and asked for this, then you have a good friend who has given you the resources to seek to advise. However, make sure that it is not a suggestion from a friend that you need cosmetic surgery.  This is a personal matter for you and no one else.

Men and Cosmetic Surgery: The Parallels with Women

Men are from Mars, Women are from Venus is a famous self-help book about the psychosocial ramifications of sexual dimorphism between men and women and, in view of this, how to improve communication between the sexes. However, there are many cosmetic issues that affect men and women equally. Feeling or looking old and tired, putting on weight or losing too much weight and losing shape; anxieties about perceived deformities and asymmetry are common for both sexes.

Also, affecting both men and women are concerns about secondary sexual characteristics such as breast size, “man boobs”, the appearance of genitalia as well as facial or nasal proportions that make an individual feel unattractive, self-conscious or too masculine or too feminine. The motivation for cosmetic improvement is also probably very similar too between the sexes.

Presently ten times as many women undergo cosmetic surgery as men. However, I believe that men throughout time have had the same level of concerns about appearance but it is only relatively recently that due to a mixture of social acceptability, technical advances and social media pressure that more men are undergoing surgery. Nationally, for both men and women, liposuction remains the most commonly performed surgical cosmetic procedure. Interestingly the cosmetic statistics diverge after this. The second and third most frequent cosmetic procedures in women are breast enlargements and tummy tucks while for men they are nasal and eyelid surgery. Number four on the list for men is the surgery for gynaecomastia (‘man boobs’) followed by facial surgery (facelift and noses).

When one looks at the age at which surgery is carried out, for both men and women, 40% of all cosmetic surgery is performed between the ages of 35 to 50. On either side of this, the numbers steadily rise from the age of 18 and then diminish significantly after the age of 65. However, I believe that the drop-in procedures for both men and women with age is not necessarily related to the notion that older people start to care less aboutappearance. Recently I was asked to see a very charming 75-year-old man who had some facial asymmetry due to a condition called neurofibromatosis. He had really wanted to look “normal” all his life but only now had the courage to ask whether it was possible!

There are of course some disparities in technique and management of cosmetic procedures between men and women because of anatomical differences such as skin thickness, fat distribution and bone structure. Certain aesthetic expectations will be dissimilar because of the different norms of standard sexual characteristics. For example, for noses there are significant differences in the proportions and landmark angles between men and women and, trans-sexual surgery aside, these benchmarks need to be considered when assessing and treating either sex.

The whole arena of penile size is certainly one of complexity ranging from true disproportion to psychological anxiety with perhaps in some cases are elements of dysmorphia. The same can be said of vaginal labiaplasty in women. So, for all sexes, accurate, experienced and honest appraisal of a cosmetic problem is critical. A broad definition of cosmetic surgery is an operation to change a ‘normal’ form into another one to improve confidence and happiness. It begs the question of what is normal? Which is still a huge area of debate in society and one that currently troubles plastic surgery.

In conclusion, more and more men are having aesthetic surgery. Cosmetic surgery for men and women has strong parallels. Of course, the technical and clinical outcomes will be different but the aims are the same. Happiness for both sexes!

The ISCFS Meeting – Cancun

As well as cosmetic surgery, part of my work involves treating facial deformity in children as and adults.  The areas I deal with usually involve the skull and the face and these are known as craniofacial deformities.

I have always believed that the management of cosmetic facial problems and the treatment of facial deformity are all part of the same spectrum.  That is why I am a member of BAAPS (British Association of Aesthetic Plastic Surgeons) and The International Society for Craniofacial Surgery (ISCFS). All the pioneer’s and active members of this society meet every two years and the seventeenth biennial meeting of the ISCFS was held in Cancun, Mexico last week.  A large band of plastic, maxillofacial surgeons, neurosurgeons and some anaesthetists and scientists all congregated for a brief period on the Yucatan peninsula.

While at the conference, I learnt about some important new techniques that can expand skulls to make more room for the brain; surgery to bring eye sockets together in patients where they are too far apart and distraction methods to elongate faces and jaws as well as results of fat grafting in the treatment of facial asymmetry.

One of the important themes at the conference was the problem of outcome-measures following surgery to the face. It is an area of concern both for deformity and cosmetic surgery.  How can one prove scientifically that our surgery has made a difference for the better? The most important outcome measure is of course what the patient thinks of it all. It is correlating this with measurable changes in form, which remains a significant problem.  What degree of movement or change in volume or shape will result in an acceptable cosmetic result?  We are a long way from truly reaching a definitive answer to this but progress is being made.

At the conference, I presented a paper dealt with only a small part of this huge area of research which is taking place all around the world.  It was called ‘CT landmarks for the morphological assessment of Unicoronal craniosynostosis’. It was a very specialised paper concerning a new way of measuring angles at the base of the skull to describe the deformity of this rare condition caused by premature fusion of the skull bones in children producing lop-sided faces.

I have come back from my travels a little wiser and more stimulated and now feeling going forward I have more knowledge on how to help and manage my patients.  The next IS

CFS meeting will be in 2 years’ time and will be held in Paris – at least it is nearer!

Volunteering with Facing Africa – Hulu and Zinash’s stories

Recently I have returned from my eighth Facing Africa surgical mission to Addis Ababa in Ethiopia. As always, I come back older, slightly wiser but also humbled by what we see and do there.

Facing Africa is a charity that deals with the treatment of a devastating disease called Noma.  It affects poorly nourished children and those who survive often have terrible facial deformities as well as difficulties eating and drinking.

The charity organises and funds all the equipment and hospital conditions needed for an experienced surgical team to treat these very challenging patients in the middle of a poor developing country.

This year we were faced with both technical and ethical dilemmas. Our mixed skill set often means that we are asked to help with non-Noma cases too. This year we were presented with a total of twenty patients, all who had facial deformities. I personally dealt with two young women called Hulu and Zinash, who were both suffering from a condition known as ossifying fibroma.

Both women’s lower jaws had been replaced by a solid, rock-hard bony tumour that had invaded the surrounding tissue. They had been suffering from this slowly growing benign tumour for several years and now the size of them was equivalent to a large melon.  Unless we could treat the women, they would die as it was becoming almost impossible to eat, drink or breathe.

It took two surgical teams ten hours respectively to remove the tumours and replace the resected lower jaws with new ones made from the skin and fibula bone taken from one of their legs. The operations had been planned weeks in advance, in the UK, to allow for the precise fit of the bone and reconstruction plates by my Maxillofacial colleague Kelvin Mizen. Microsurgical techniques were also needed to allow blood to flow to the new jaw.

Zinash recovered brilliantly and her fighting spirt was inspirational. She now has a fantastic future ahead of her and it was wonderful to see her true beauty emerge now that the mass had been removed.

Prior to her surgery Zinash’s loving and totally dedicated father had tried everything to cure his daughter. He had even sold his cattle to help fund her treatment in the past but it came to no avail. Luckily however, myself and the team at Facing Africa were able to not only save Zinash but also help to fund his cataract surgery to allow him to see properly again.

Unfortunately, the reconstruction for Hulu failed, but thankfully a salvage operation helped to ensure that she would have a functional lower jaw. Despite this however, she will still require future surgery in order to live a normal life.

While Zinash came from a very supporting home, the same could not be said for Hulu, who had been rejected by her family after her disease lead to the demise of the family laundry business (locals feared they might catch the same disease as Hulu). As a result, Hulu was left living on the streets and it’s only due to the persistence of Facing Africa front line workers, Tihitna and Kidist, that she was saved.

The sadness in Hulu’s eyes reflected the desperation to be accepted by her family again, but sadly, when her mother did eventually come to visit her in hospital Hulu received a slap instead of a hug. However, in spite of this, Hulu did eventually return to her family home but unfortunately, we have no idea how she’s now being treated or whether her family have now accepted her.


Obviously, a two-week surgical mission only allows for me to skim the surface of this vast country, but I’m so thankful to say that I could assist in saving not one but two lives. Furthermore, I am so proud of the Facing Africa team as it is rare to find total harmony between skills and aims.

A Tv documentary has been made of this mission which will be shown on Channel 5 soon, giving you the opportunity to see the journey of both of these inspiring ladies.

If you would like to find out more about Facing Africa or donate you can do so here: http://www.facingafrica.org/.

My final time on call…

A quiet suburb in Stoke was turned upside down when, in a moment of total madness and drug-fuelled insanity, a man reversed his car into a random thirteen-year-old girl at high velocity. The rear bumper smashed into her right thigh and she was thrown backwards against a low garden wall and over a hedge into the front garden of a house.

She was airlifted to Birmingham Children’s Hospital with a shattered leg, a fractured skull but she was conscious and her spinal column, chest and abdomen were uninjured.  After the primary and secondary surveys of her injuries, she is rushed to the emergency theatre.  I join the team of surgeons, anaesthetists, theatre nurses and operating assistants engaged in an intense but calm and orderly activity to treat the girl urgently.

The temporary compressive dressings are removed revealing that the front of her thigh has been blown away leaving torn and shredded muscle. The femur bone is shattered underneath and the huge wound is contaminated with bits of car, wall and dirt from the front garden.

Six hours later the complex fracture is stabilised with an amazing scaffold of external fixators or rods on the outside of the limb but there is still a large hole at the front of the thigh because of how much dead skin and muscle had to removed following the incident. To help keep the wounds clean a special vacuum dressing was applied to gently suck up any fluids. In 48 hours’ time the girl will be taken for a second look surgery, hopefully, by then the wounds will be clean enough to graft with her own skin and eventually an internal metal rod can be used to keep her leg stable.

After the operation, I look around at the scene in theatre; it is like the aftermath of a battle.  I have been a surgeon for over thirty years yet I still marvel at what we can be done as a team when we use the very utmost of our abilities, experience and the technology at hand.  It is a strange kind of privilege for all of us.

I also think about the cost to the girl and how this will change her life – the time she’ll spend in the hospital, rehabilitation process and other long-term effects that she will face because of this tragedy.

I see her the next day, she is bewildered and still in a lot of pain despite very large doses of drugs she has been given. The shock and the painkillers stop her from really expressing herself or understanding what has happened which, at this point, I feel may be a small blessing.

She has been dealt a brutal flash of indiscriminate fate and it seems so unfair that the state of one man’s troubled mind has now changed her life forever.

Understanding ‘Re-Do’ Procedures in Cosmetic Surgery

A working definition of ‘re-do’ surgery is an operation carried out in order to rectify a previous procedure that has gone wrong or has not achieved the desired outcome. There are many terms used to describe this type of surgery, such as ‘touch-up’, ‘revision’, ‘adjustment’, ‘secondary surgery’ to name a few. The semantics vary and can imply minor modifications, or more extensive corrective treatment.

Not all secondary surgery denotes failure. It is not uncommon to need to make alterations such as revising scars, removing dog-ears (following abdominoplasty surgery) or carry out further liposuction to improve results. This ‘touch-up’ surgery can reflect that the surgeon really cares and wants to achieve the very best possible result for the patient. It is not the same as a ‘re-do’.

The need for re-do surgery will be different, and will vary according to circumstance. Re-do operations happen in all surgical specialties and unfortunately it is not an infrequent occurrence in cosmetic surgery. One way to avoid this is to make sure that you are certain that cosmetic surgery is really what is needed to improve your quality of life. Of course it is important that you consult with an experienced cosmetic surgeon who can truly listen to you, understand your aims and then give an honest unbiased opinion on what is possible and what is not. The mismatch between what is possible and the patient’s expectations is probably the most common reason for many re-dos in cosmetic surgery. Unlike cardiac surgery where re-do surgery is usually to save life, the reason for re-dos in cosmetic surgery can sometimes be grey because aesthetic outcome measures are very subjective.

One procedure with a high rate of revision surgery is rhinoplasty; the reason for this is complex. The surgery is difficult and exacting so technical errors or small misjudgements during the operation can lead to a poor outcome. Also every individual heals uniquely, and this is a factor that all cosmetic surgeons will have to take into consideration. The tissues that we operate on (skin, bone and cartilage) will have a built-in unpredictability as they heal in their new position, on the surface and within the nose. The nose is such an exposed and critical aesthetic area that small residual post-operative irregularities often lead to the need for touch-ups. It is more infrequent to have to carry out a total re-do after rhinoplasty but sometimes it is essential if surgery has led to a loss of function such as nasal collapse, airway difficulties or structural deviation. The grey area occurs if, after an apparently successful rhinoplasty, the patient is still unhappy about the outcome and this is usually a result of misaligned expectations, as previous mentioned. For this reason, I spend time in my clinic ensuring I have understood what the patient is hoping to achieve, and being honest about what I think is possible. From there we will come to mutual agreement of what we are aiming for.

Facelifts too can have a high disappointment. Gravity and the ageing processes are powerful forces that work against all rejuvenating surgery of the face. The facelift reverses time but does not stop the ageing process; all patients who undergo this procedure must understand this. Stress, drugs, smoking, alcohol and illness are all factors that can accelerate ageing before and after surgery. Genetics will also play a part. Re-do surgery is an option if there has been no change, or the recurrence of facial drooping has been unacceptably fast.

It’s important to note that all re-do surgery is more difficult than the primary surgery and the decision to carry out re-do surgery requires judgement, experience and honesty to the patient. Post-surgical scarring will have damaged the surgical planes and this will affect the ease and outcome of surgery. The surgeon has to judge whether another operation will be safe and that the secondary outcome will be successful; the stakes are even higher the second time round.

All cosmetic surgery is a journey with potential hazards. It will be an informed decision and the surgeon is responsible for deciding that it is a truly safe trip and in the patient’s best interests. The patient needs to be fully aware of all the risks and benefits, prior to making a decision. The understanding and trust between patient and surgeon will never prevent secondary surgery, but will help to ensure that the decision to carry out a re-do, if required, is the correct one. In all types of surgery, the appropriate and correctly counselled patients will experience life changing and enhancing results.

Japan and Cosmetic Surgery

Last month, I had the privilege of visiting the city of Nara. Nara was previously the ancient capital of Japan and today it has elements of sublime beauty, serenity and mystery in keeping with its regal past. Nara is dotted with temples and shrines along with beautiful parks where deer are free to roam. They are sacred to the city because in ancient folklore a visiting god rode into Nara on a white deer.

I was in Japan to attend the Asian Pacific Craniofacial Association (APCA) conference. Part of my work in the UK is to deal with facial and skull deformity and the conference attracted many experts from around the Pacific Rim. The meeting took place in a state-of-the-art centre. An incredible building, which reflected the fact that the co-existence of modernity with and an ancient historic past is a recurring theme in Japan.

I attended because I always love visiting the country of my birth and I find it fascinating how the approaches to surgical problems between countries and continents can be very different. One of the reasons for this is that diseases vary geographically but also cultural differences can influence management. During the APCA conference, there were some scientific papers and lectures on cosmetic surgery of the face. The essence of what is regarded as beautiful varies between cultures although I do believe that there are universal norms of an attractive human face too. One of the most active centres of plastic surgery in the World is Seoul in Korea. There were several papers from Korea on jaw and cheek surgery carried out to diminish the horizontal width of the face. The full and soft cheeks, which can sometimes be a symbol of youth in the West is not always desired in the East. A lot of cosmetic surgery of the nose in Europe centres on making the nose smaller. The statistics are different in Japan and Asia where augmentation of the nose to enhance projection is common. Differences in the racial anatomy of the upper eyelid in the Japanese have led to a great deal of cosmetic surgery to create a subtle skin fold crease. This is lacking in over 70% of far Eastern people but almost always present in European races. The presence of the crease is felt to enhance attractiveness in the Japanese female and also in some men.

Of course, there are many similarities in cosmetic issues between the East and West. Treatment for making parts of us smaller, larger or younger is international. The need to allay our cosmetic concerns and anxieties probably has similar psychological origins throughout the world. A few days in Japan truly refreshed and stimulated me to marvel at the diversity and parallels between us all.

Happy New Year!

Hiroshi Nishikawa, January 2017

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    Hiroshi Nishikawa

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    Reconstructive, craniofacial and cosmetic consultant surgeon, my principal work is with the Birmingham Children's and Queen Elizabeth hospitals and the Westbourne Centre, a private medical centre in Edgbaston.

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