Issue #1 summary

The truth about implants
Every year about 8,000 British women spend around £3,000 to £4,000 on breast implants. One-third do so as part of a breast reconstruction operation following a mastectomy. But most women choose to simply because they are unhappy with the size of their breasts.
   In the US the Food and Drug Administration estimate more than two million American women have had breast implants. In a recent US telephone survey, 19.4% of women respondents said, if they were to alter their appearance, their breast size would come first. Most respondents (17%) were aged 25-34; the other age groups most desiring breast augmentation were 18-34 (14.1%) and 35-44 (12.9%). Yet, many men and women are indifferent to breast size. Fewer than half of the respondents answering a reader's survey in one men's magazine say they make a "significant difference" in attracting them to women.
   As for women's views on other women having breast implants, those with "normal" cleavage appear to take it for granted, not appreciating the inadequate self-image that can accompany smaller breasts. Generally, women want larger breasts to feel sexier or more feminine. Some even desire them to help fill out their clothes. "My dresses just did not fit right before my implants - they had a fold above my bust," says Christine Elder, a 27-year-old advertising executive. "Now they seem to hang much better." Dr Judy Evans, a consultant plastic surgeon in Plymouth, England, regularly holds seminars to explain the procedure, safety, types of implants and to answer questions. "Some women suffer from a major loss of confidence, which can put them off going for an interview, pursuing a career, undressing in front of other women or even wearing a swimsuit. Others want reassurance." Whatever the reasons for considering breast enlargements, expectations must be realistic. Results depend on many individual factors such as overall health, chest structure and body shape. Looking at "before and after" pictures of women with implants gives a good indication of what can be achieved. There is, of course, no guarantee that the results a surgeon obtain with one woman will be the same with another. The most common complaint with breast enlargement is that the end result is not as large as envisaged. But big implants pose their own problems. Dr John Di Saia, a cosmetic surgeon based in southern California, says saline-filled implants are particularly prone to wrinkling. "The relative thinness of water compared with silicone gel can sometimes be seen at the surface of the skin where muscular coverage is thin or absent. To fix this once it has appeared is not easy . The surgery has to be individualised for the patient's particular problem. Suffice it to say that it is better to work to prevent this outcome than to have to deal with it later."

History of plastic surgery
History dates plastic surgery – albeit a crude forebear of modern techniques – from an early practitioner named Sushruta. In about 600BC he performed operations in ancient India using forehead skin to reconstruct noses of criminals that had been amputated as punishment. The same procedure was used in India to reconstruct the noses of women who had been mutilated by their jealous husbands. Other primitive plastic surgery is documented in world medical history, but a modern starting point is renaissance Italy. In 1597 surgeon Gaspare Tagliacozzi wrote what is considered the first textbook of plastic surgery.
    It was not until the First World War that plastic surgery developments really gathered steam. "Plastic surgery units" were set up to treat soldiers with facial gunshot wounds and burns. A French army surgeon, Morestin, established a treatment centre in France. Morestin was one of the first surgeons to show that skin and underlying tissue could be undermined and advanced without being subject to necrosis. Harold Gillies, an English ear, nose and throat specialist, visited Morestin and became fascinated by his work. Later he established a unit in the Aldershot Military Hospital, the first organised centre of facial plastic surgery. Gillies was a pioneer specialist of plastic and reconstructive surgery who frequently gave demonstrations to curious doctors. A number of textbooks were written just after the First World War. The first American plastic surgery textbook, Plastic Surgery: its Principles and Practice, was published in 1919, and in 1920 Gillies' Plastic Surgery of the Face.
    In the 1920s there was a move towards "improving facial features rather than contending with deformities. This was seen the start with the "bobbing" of the nose of American actress Fanny Brice. In Venus Envy: A History of Cosmetic Surgery, its author Elizabeth Haiken contrasts modern societal views towards cosmetic surgery was they were in the 1920s. "In 1923 Americans clamoured for an explanation of why Fanny Brice, beloved vaudeville actress, successful comedienne and star of Flornz Ziegfeld's new Follie, had bobbed her nose. Forty years later when Barbara Streisand appeared on the scene. Americans had wanted to know why she had not." Although Haiken's book is an imbalanced polemic – a one-sided argument that vilifies the practice of cosmetic surgery – it nevertheless has intriguing passages. Haiken refers to the influence of psychology on plastic surgery in the 1920s, in particular, Viennese psychologist Alfred Adler's theory of the inferiority complex. Haiken says the damage an inadequate self image could cause was so widely accepted that, in 1927, it was not considered unusual for prisoners at San Quentin to have cosmetic surgery to help with their rehabilitation. "Surgeons laid claim to the whole body and mind of healthy individuals by linking physical abnormalities to psychological problems for which cosmetic surgery intervention was the prescribed cure," writes Haiken.

Varicose veins
Varicose veins almost always occur in the leg as a result of faulty one-way flap valves that help blood flow upward on its return to the heart. When one malfunctions ("leaks") some of the blood flows back down into the leg and tends to overfill and distend branches of superficial veins under the skin. Over time the additional blood pressure causes the veins to stretch, bulge and become visible. Most varicose veins are caused by faulty valves in the groin or behind the knee.    At both sides superficial veins flow into the major deep veins of the leg. When functioning correctly at these junctions, the valves control the flow of blood in one direction. Tiny capillary branches of the veins can also overfill with blood, producing multiple "spider" veins (telangiesctasia) and pure discoloration. Spider veins, which are less than 2mm in diameter, are most common in the thighs, ankles and feet but can also appear on the face. Apart from their appearance, sufferers' biggest complaint is a burning problem over the vein. This is especially common in larger spider veins around the feet and ankles. Laser treatments are often used with sclerotherapy for treating larger spider veins in the lower extremities. A solution is injected into the spider veins to make them collapse and the smaller surrounding veins are zapped with a laser. Some people inherit weak valves. Obesity and pregnancy may also cause valves to stretch and consequently leak.. A simple clinical examination can establish the cause and appropriate treatment. Most surgeons supplement the examination with a handheld ultrasound probe – a quick method of identifying sites of faulty venous valves.

Self-image
Each of us has a "self-image" a perception of how we believe we look to others. People who are happy with their self-image are more likely to be self-confident, effective in work and social situations, and comfortable in their relationships. Those who are dissatisfied tend to be self-conscious, inhibited and less effective either at work or socially. Dr Robert Yoho, a surgeon based in Pasadena, California, says his goal is to enable patients to use their personal powers to the full. "A larger pair of breasts does not guarantee that a woman will attract the man of her dreams. A new head of hair does not guarantee that a man will be the centre of attention at a party. But the combination of better looks and a positive response from other people can produce more personal confidence and effectiveness."
    Generally, three kinds of patients make especially good candidates for surgery. The first are those with a strong self-image who are bothered by a physical characteristic that they would like to change. After surgery, these patients feel good about the results and maintain a positive image about themselves. The second category comprises patients with a physical defect or cosmetic flaw that has affected their self-esteem. These patients may adjust rather slowly after surgery, as rebuilding confidence takes time. But as they adjust their self-image is strengthened, sometimes significantly. The third category consists of patients with medical conditions that have caused deformities of the face or body. Their motivation is particularly striking – they simply want to get on without having to contend with the awkward response that their appearance can create. Poor candidates for cosmetic surgery are those with unrealistic expectations – people who wish to be restored to how they looked before a severe accident or a serious illness, older patients wishing to turn the clock back decades, people obsessed with a minor "defect" to the point that, when "fixed", believe they will lead a perfect life.

Penile servitude
A study of the artefacts of ancient civilisations reveals a phenomenon as meaningful in the 20th century as it was in those distant times. Just as breasts symbolised the concept of female fertility, the penis represented the worship of male potency. The human psyche of the 20th century is still haunted by the primitive fears of antiquity: infertility, impotence and inadequacy.    It is not surprising that a number of modern men desire a larger penis – particularly if they believe their own doesn't measure up. Psychologically – both short and long term – a small penis can cause as much mental damage as a wayward mother or brutish father. Toronto-based surgeon Dr Robert H Stubbs, discussing his two-year study in which he operated on 300 men from all racial groups who desired a larger penis, said: "The anxiety expressed from all cultural and socio-economic groups was real. Insecurity about their penis size had haunted them since puberty, and the possibility of alleviating that anxiety surgically was an option many wanted.    Operative discomfort was much less of a concern than the psychological pain that they had endured." The average age of Dr Stubb's patients was 37 and ranged from 18–74 years old. Thirty-eight per cent were or had been married; 41% had fathered at least one child; and 5% were homosexual. "Many expressed anxiety about being undressed in front of other men. Others, especially athletes and body builders, were unhappy with their penis size relative to their body proportion. A significant number (27%) had been criticised about their penis size by female sexual partners. Most felt that their self-esteem would improve with a larger phallus."

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