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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

Brexit Effect on Cosmetic Surgery

Should I go or should I stay?

Over the last few months we have all been inundated with claims and counter claims over the benefits of leaving or remaining in Europe. The debate will be settled by our votes. We will weigh up the conflicting arguments on the economy, immigration and the effects of European Federalism and the meaning of the nation state to each of us as individuals . How complex this all is! I promise you that this newsletter is not about persuading you either way. This whole massive “in or out debate” has made me think about the how, as individuals, we end up making complex decisions such as whether or not we should undergo cosmetic surgery and who we would trust to deliver this.

Would severing links with Europe have any effect on the regulation and practice of cosmetic surgery in the UK? The Keogh report published in 2013 in the UK, was an important recommendation document concerning how cosmetic surgery should be regulated to ensure cosmetic practitioners are skilled and responsible, the products used are safe and of high quality and that the public are properly informed about cosmetic procedures having accessible redress and resolution if things go wrong. Our government is still working out how to implement these recommendations. There are also strong links between the state of the nation and the state of our health, but I suspect that being either in or out of Europe will not have any affect on the eventual implementation of Keogh’s proposals, which any responsible cosmetic surgeon would welcome.

Regarding the decision to leave Europe or not there are some parallels with a patient looking for the correct cosmetic treatment or choosing the right surgeon. The link with the grand debate on Europe is that it takes a lot of thought and courage to make major decisions. Should I do it or should I not? Should I go with surgeon X who specialises in technique α or should I go with surgeon Y who claims that he is brilliant at operation β. They both tell me they have the correct method and have the expertise to see me through. They are both confident and sure. X warns me of dangers of operation β and Y is dubious about technique α. They reassure you that they have the solutions to your concerns and fears. They provide pamphlets, brochures and website links to give you more information to bring home the message. Do you decide by information gleaned or given, surgical charisma or your instinct?

And here the parallels of cosmetic surgery and the Brexit debate break down. The final decision may be as hard for you to reach but for cosmetic surgery there should be no deadline. You can re-visit the debate for as long as you like. You need to become as informed as possible to empower you to make the correct decision. Only when you hear or experience consensus concerning your treatment, will you be more confident in making a critical decision about surgery and the role of instinct should diminish concerning your surgeon of choice. It has to evolve into something called trust!

We may not get to that point in time on this important EU referendum debate.

The Future is Fat

The role of fat in our bodies is complex. There are several types of fat but in its various forms it acts as an energy store, a shock absorber and it is essential for many of the core metabolic pathways of life. Its anatomical distribution also has a profound impact on the way we look and feel. Certainly without fat there would be no life. The distribution and volume of fat changes in our bodies as we age or if we are stressed and also with certain diseases. Emaciation and obesity are strange cousins but we have all seen the visual effects of too much or too little fat. The amount under our skin can be a clue to our health, wealth, genetic makeup and perhaps on occasions our minds! Eating too much or too little in a world of plenty can be driven by imbalances in our psychology well being.

Sometimes the fat distribution is anatomically abnormal. Drugs such as steroids can redistribute fat in characteristic ways.

Romberg fat grafting

Patient with Romberg Syndrome Before Lipo-filling

Romberg fat grafting patient

Patient with Romberg Syndrome After Lipo-filling

The term Cushinoid refers to the physical appearance of a patient with too much steroid. In cases of extreme exposure to this drug, they develop chubby moon-type facial features with fat migrating to the back of the neck causing a “buffalo hump”. Rare conditions, such as Cherubism, mimics this in babies who are born with extremely chubby faces due to too much fat making them look abnormally round. In even rarer cases of Cherubim only one side of the face can be affected or even parts of the body.

Conversely, too much thyroid hormone burns up fat, making the face gaunt and causing abnormal fatty-type material to accumulate around the eyes, causing them to bulge. Fat wasting is also seen in the cruel and rare condition known as Romberg’s disease (see Shauna’s story). Usually starting in childhood or early adolescence, one half of the face wastes away. In severe cases the underlying facial bones are also affected accentuating the asymmetry. Patients look normal on one side but skeletal on the other. The hair of the scalp can drop out on the affected side or turn white and the same can happen to the eyelashes.

It was the treatment of this disease in children and young adults that gave me a lot of experience with lipo filling. By using fat to plump up the affected side the asymmetry can be improved. Fat can be harvested by gentle liposuction techniques and injected into areas of where tissue volume is deficient. This is known as lipofillingFat Separation

The principle is to take fat from where there is enough to spare such as the abdomen, love handles or the thighs. The harvested fat is usually briefly centrifuged so that it is possible to inject pure fat without any of the infiltration fluid or cellular debris. The actual harvesting and injection technique is very important. It is easy to damage fat. Injecting it also requires care. The area needing treatment is lipo-filled in several directions. The fat is injected in small amounts with a fine metal cannula (thin tube). The fat is gradually built up in layers as a lattice and is deposited in multiple small droplet-like globules so there is a higher chance of survival. This is because of the high volume–surface-area ratio of the deposits that aids the local blood vessels to keep the fat alive. Injection of fat in one big load or simply putting in a lump of fat by an open surgical method would be much more unpredictable and will usually not work. Fat also has some amazing intrinsic properties. It contains a significant percentage of “stem cells”. This means that injected fat can turn in to other types of cells such as blood vessels, so that it can improve the blood supply in areas where it has been inserted.

The implications for plastic reconstructive and cosmetic surgery have been immense. The applications have ranged from the treatment of volumetric asymmetry in Romberg’s disease to facial rejuvenation, correction of breast asymmetry, breast augmentation as well as soft tissue defects caused by the loss of fat from trauma. It has also has a role in revision of painful scars or certain types of damaged skin. I mentioned the shock absorbing or cushioning role of fat. Lipofilling can sometimes improve the appearance of scars. The stem cells that fat contains, increases the blood supply of the overlying skin. This can lead to better scar quality. Lipofilling has also been used to treat skin, which has been damaged by radiotherapy.

In cosmetic facial surgery fat has become the ultimate filler. For example, as we age, the fat in our face migrates as the fine ligamentous tissues that hold the fat in its place stretch due to the affects of time and gravity. A significant component of youthful beauty could be defined as the fat of the right volume in the correct place! By restoring volume to the cheeks and with careful lipofilling of creases and frown lines, re-freshening or facial rejeuvenation can be achieved without the need for extensive surgery. However these procedures are often also carried as an adjunct to facelift surgery. The purpose of the face lift is not only to pull the face in the correct vector (direction) but also to restore the cheek fat pads into the correct position. Sometimes if the fat pads have aged and shrunk, lipofilling at the time of surgery is very useful.

The use of lipofilling for breast asymmetry and augmentation has been another rapid area development. BreastsAt present I think that it is less predicable than silicone implants because a variable amount of fat will disappear. This phenomenon of fat regression unfortunately occurs for all lipofilling. This can range from 40-60% of the fat injected. Sometimes there is no regression and unfortunately, although uncommon, total regression can also occur. It is for this reason that I believe that lipofilling is an art. It does require touch and judgment as well as technique. The patient has to understand that it will take about three months before we know how much of the fat has regressed. They need to be prepared for possible further lipofilling if needed. At present, in my practice lipofilling for breast augmentation is carried out when the aim is for relatively modest or moderate increases in volume, especially in women who do not want implants or who have had a history of capsular contracture or implant failure. Several lipofilling episodes maybe needed before a large stable volume is achieved. However the beauty of lipofilling is that it is safe, usually affective but also repeatable. The recovery from lipofilling is rapid as it can almost always be carried out under local anaesthetic with or without sedation as a day case. The technique uses your own cells and so there is no chance of allergic or foreign body reactions. I believe that for many conditions, which were previously difficult to treat, lipofilling has become a first line treatment. Lipofilling techniques are also improving and for all these reasons I believe that the future is fat.

Reconstruction is the basis of Cosmetic Surgery

Last week I was involved in two paediatric cases, which reminded me of the power of plastic surgery. For the first patient, I was asked to assist a colleague at the Birmingham Children’s Hospital with a thirteen-year old girl who had facial asymmetry due to an excess amount of abnormal skin. This had resulted from a benign childhood tumour called an infantile haemangioma. Small ones are quite common; they are composed of abnormal blood vessels. The overlying skin is usually red and the past they were called strawberry naevi. Initially they appear shortly after birth and grow rapidly, often at an alarming rate. They then gradually shrink and the vast majority have disappeared by the age of ten years. However some large haemangiomas leave varying amounts of loose abnormal skin that may need surgery to improve the appearance. Large or ulcerating haemangiomas can affect the way the whole face grows.

This young girl had loose hanging folds of skin affecting her left cheek and neck. Symmetry of facial features, “normal” proportions, complexion and expression are some of the many elements that allow all of us to remain within the “herd”. For this girl self esteem and teasing were daily problems in her adolescent world. My colleague cut out the abnormal folds of skin. This left a significant defect which could only be closed by using a face lifting technique, thus allowing the remaining skin to be pulled upwards to cover the defect. The non-affected side of her face was entirely normal and beautiful. I was asked to help because of my experience in cosmetic facelifting and rejuvenation. The techniques used in cosmetic surgery have originated from the reconstruction of deformity. To treat this child, the facial tissues needed quite extensive undermining. Both the skin and parts of the deeper element of the face called the SMAS (Superficial Muscular Aponeurotic System) needed tightening. The tension of part of the SMAS layer needed to be increased to allow the skin on top of the SMAS to be repositioned in a much more favourable location so it could be closed with far less tension. A lot of cosmetic operations are in essence “anti-gravity” procedures. Surgery also manipulates tissue to oppose the long-term effect of muscular tension or the forces of developing scars. This will make the results more likely to be long lasting and allow scars to heal without stretching. The incisions used in facelifts are designed to hide in shadows, creases and crevices and run within the hairline if possible, so that they are camouflaged from human gaze. Nature herself has evolved plants and animals to mask the true nature of what they maybe under the surface! The difference in this young girl’s appearance after the operation was startling. For the first time she is happy to wear her hair up and not to hide one half of her face. Time will tell whether the teasing ceases but in my experience, when one’s inner strength is released and is plain for all to see, hostile forces move to weaker pastures and easier targets.

Another aspect of the art of reconstructive plastic surgery is to transfer the laxity of one part of the body to another area which needs reconstruction and where there is no local laxity for direct closure. In general, the main laxity of the face with ageing is actually in the lower half. Surgery transposes this laxity to the upper half so that tension forces are redistributed. The same principles apply to abdominoplasty (tummy tucks). Laxity in the upper part of the abdomen is mobilised and this allows the resection of excess skin in the lower half of the tummy.

The second case last week followed these principles of transferring the laxity from one part of the body to an area of a major defect needing reconstruction. I was asked to help one of my neurosurgical colleagues to operate on a baby born only the day before with a meningomyelocele. This is a congenital central defect on the back. The meningomyelocele arises because there has been a failure of fusion of elements of the spinal cord and the overlying skin. Often there is also blockage of the cerebrospinal fluid circulation in the brain, so that the baby develops hydrocephalus (enlarged cerebrospinal fluid spaces). This has to be treated first by the neurosurgeon with a special shunt in the brain and then the meningomyelocele itself has to be repaired. After this the skin can be directly closed, but sometimes the defect is so large that a flap repair has to be carried out. A ‘flap’ in plastic surgery is defined as skin with varying amounts of subcutaneous tissue, which has been elevated from its bed and rotated, advanced or transposed to an area requiring reconstruction. In this case the laxity present in the newborn in the upper lateral trunk near the arms was used as the basis of two large skin rotation flaps (one from each side of the body). They were used to cover the upper half of the back defect where there is very little laxity. For the remaining defect, two further flaps were rotated using flaps raised from each buttock. This in turn left defects now on both flanks of the baby and these were closed by further mobilisation of the skin at the sides and around to the tummy, so that everything could be closed directly.

The surgery required close teamwork between two major surgical specialties, as well as highly skilled anaesthetic support. Some surgical problems are so complex it requires expertise of many disciplines. However this is only a small part of this baby’s treatment. The future remains uncertain. We do not know yet whether the baby will be able to walk or have control of its bowls and bladder, or even have normal brain function. Although these uncertainties generate many ethical dilemmas, I believe it was the right thing to do to give life a chance. If you are lucky enough to hold a newborn baby, you will be able to feel where the loose skin is distributed and you may start to understand the principles and art of plastic surgery I have been trying to explain.

Fig 1. Illustration of the Menigomyelocele on the baby's back. The green dotted lines are the incision markings which are in essence four rotation flaps

Fig 1. Illustration of the Menigomyelocele on the baby’s back. The green dotted lines are the incision markings which are in essence four rotation flaps

Fig 2. The red dotted lines illustrate the suture lines of all four flaps rotated into position to cover the defect.

Fig 2. The red dotted lines illustrate the suture lines of all four flaps rotated into position to cover the defect.

Fig 3. These schematic diagrams illustrate the triangulation of a circular defect so that a rotation flap can be planned. The meningomyelocele was in fact so large that four triangles and four rotation had to be planned.

Fig 3. These schematic diagrams illustrate the triangulation of a circular defect so that a rotation flap can be planned. The meningomyelocele was in fact so large that four triangles and four rotation had to be planned.

Ear Reconstruction from a Rib

Making a new ear out of a person’s rib (bone, cartilage and skin) is called autologous ear reconstruction. This service has recently been set up in the Birmingham Children’s Hospital (BCH) in order to treat a condition called Microtia. Children suffering from this condition are born with either one or both ears missing, and sometimes this can be associated with other conditions.

I have experience in the cosmetic surgery of the ears, and because of this I have been asked to help Mr Mark Lloyd, a newly appointed consultant plastic surgeon at BCH, who has expertise in this area.

It has been a great privilege for me to help him harvest the rib grafts and to assist him as he sculpts a new ear out of this cartilage. It is truly an art form and much judgement is needed because the new cartilage skeleton of the ear has to be made as perfectly as possible. Templates made as a mirror image from the ear that is present are used to help design the framework.

The framework then has to be placed within a pocket of skin, and again, careful dissection has to be carried out to make sure this flap of skin is thin enough to conform to the framework, and also robust enough to be viable as permanent skin cover.

At the second stage, about 6 months later, more cartilage is harvested from the ribs to elevate, or protrude, the ear making it look more natural. These complex operations can only be carried out after the child is at least 10 years of age, when the ribs have grown big enough for use. And only on patients who do not want, or cannot tolerate, artificial or prosthetic ears.

These prosthetic ears are a true art form, and are made in Birmingham bespoke for each patient.

These two alternatives are discussed in special microclinics at Birmingham Children’s Hospital, which means consultants from multiple disciplines get together to discuss the specifics of each case.

This experience has helped me appreciate cosmetic problems patients have better, such as over-protruding ears (over protrusion) low deformities, asymmetry – which are the common reasons why people ask for cosmetic advice about ears.

 

**Image credit Stanford Medicine, Stanford Ear Institute

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