Issue #20 summary - GO BACK TO ARCHIVE

Sizing up breast implants
Breast enlargement is the most popular cosmetic surgery procedure in the UK. The increasing popularity and accessibility of cosmetic surgery has seen a significantly increased demand. Yet, few patients truly understand the risks, limitations and long-term effects. Although the past few years have seen much media hype associated with the good effects of breast augmentation, most information is less than satisfactory.
   An even more disturbing fact is that, due to lack of proper training, few surgeons beginning their practice really understand the factors and variables paramount in achieving a good, long-term result. Everyone knows that a breast augmentation involves adding an implant onto a pre-existing breast. However, relatively few surgeons and hardly any patients grasp the relationship of patient desire, expectations and the physical aspects of volume enlargement.
   Cosmetic surgery is unique in that, unlike other surgical specialties, it is performed in a five dimensional framework. To undertake any successful cosmetic surgery operation, an understanding of this framework is a basic requisite. Breast enlargement is no exception.
By ‘five dimensional’ I mean the three-dimensional framework of the (physical) body and accounting for the fourth dimension of time. A cosmetic surgeon has to look into the future to visualise the desired final result after the healing process is complete, taking into account the physical characteristics unique to each individual.
   Even more importantly, a cosmetic surgeon has to delve into the patient’s mind to ascertain what the patient dreams of, wants, desires and expects. Understanding this is fundamental to a successful cosmetic surgery operation.
Most patients try to describe their desired result in vaguely defined concepts and unquantifiable terms. In my experience, many female patients are even unaware of what a breast cup size means and how cup sizes are measured. Without this basic understanding, achieving patient expectations may be impossible.

Laser-assisted liposculpture
Laser-assisted liposuction is a technique that uses a pulsed Nd:YAG. The light energy is conveyed by a thin quartz fibre without any power loss. The distal part of the fibre is protected by a 1mm stainless steel cannula for insertion into the sub-dermal tissue.
   The interaction between the laser energy and the adipocytes causes lysis of membranes of the fat cells, resulting in a leakage of their contents then dispersal into the interstitial tissue. The laser reduces bleeding and its effect on collagen fibrils promotes collagen retraction and skin shrinkage.
   At one time, fatty tissue was extracted in lumps by means of large cutaneous incisions, which produced extensive scarring. In the 1970s, Italian and a French surgeons experimented independently on a new method for removing excess fat. Their efforts led to a procedure named liposuction, lipoaspiration or liposculpture.
   The greatest innovation was the use of cannulas for removing large quantities of fat through smaller incisions which reduced scarring. An American surgeon introduced an upgrading of the liposuction technique in 1987, which came to be known as tumescent liposuction. In this procedure, large quantities (several litres) of an adrenalin and anaesthetic solution are infiltrated into the areas of the fat to be aspirated. In the 1990s an ultrasonic vibrating cannula was introduced that allowed for increasing the volume of removable fat.
   All these techniques have one big disadvantage: limitatiions in modelling of the areas treated—the passage of the cannula creates subcutaneous hollows that are difficult to fill. Another disadvantage is the rupturing of the veins in the fat tissue with considerable blood loss and subsequent haematomas, requiring long-term bandaging. In laser-assisted liposuction, anaesthesia may be local, peridural, or general. We prefer to use this technique only with local anaesthesia for sessions limited to one to one and a half hours. A small incision of 2mm is made, where the cannula is introduced. The cannula has 1mm diameter with an optical fibre inside. This fibre must be outside the cannula (maximum 2mm). To our knowledge, there are no reports of fibre breaks during procedures.

Too few nurses to fill positions
The lack of accreditation makes it difficult for surgeons to track down trained nurses other than by word of mouth, or by poaching them. In contrast with countries such as the US, few UK surgeons sponsor nurse training. It’s more common for US surgeons to train nurses and then obligate them contractually to repay costs or to stay at their clinic for an agreed period.
   Bryan Mayhou, a BAAPS member who has seen his supply of trained nurses slowly dry up, says: “There is a severe shortage of nurses in reconstructive and cosmetic surgery. I’m used to having nurses who stay around a long time, but when they go it can be quite difficult to find replacements. There’s not a recognised programme that I can simply approach for staff, so it’s more a case of finding someone who knows someone.
   “Then there’s the issue of training. You need to find someone with an interest and train them up, or poach them from elsewhere—which admittedly is a rather more straightforward sounding option,” says Mr Bayhou.
   “It can take around a year to train some, or possibly even longer. There was a reliance in the past on nurses who were NHS-trained. There’s just not as many coming through now because the NHS isn’t doing so much training.”
   Hopeful cosmetic surgery nurses are very much left to their own devices. But the UK is waking up to the need for accredited courses, and this year the first cohort of the cosmetic surgery care programme begin training at Anglia Ruskin University. The course is the only one of its kind offering full postgraduate accreditation.

Laryngeal disorders
Patients with an acute onset of vocal cord palsy may be troubled by hoarseness—breathy voice with shortened speaking times due to excessive air escape during phonation. An additional symptom may be problems with swallowing and associated aspiration because of incomplete laryngeal closure during swallowing. The patient may present with an obvious cause for the vocal cord paralysis, such as surgery with recurrent laryngeal nerve transaction or bruising (neuropraxia). There are, however, a variety of causes, ranging from viral infection, neurovascular injury and idiopathic.
   The patients may find the symptoms improve spontaneously during a period of compensation—the vocal cord palsy can get better on its own or with the help of mechanisms such as the other vocal cord working harder to make the voice stronger. Or improvements can be hastened by instituting speech and language therapy regimes. The vocal cord paralysis may improve as the nerve recovers. This may take as little as a few weeks to as long as one to two years.
   To avoid a permanent medialisation of the vocal cord, a simple and reversible technique is ideal. This should enable an immediate improvement in the voice and swallowing but without a permanent and irreversible alteration in the position of the vocal cord.

Study confirms threads’ efficacy
As the face ages, atrophy of fat occurs under the skin, a loss of overall volume and wrinkles start appearing as the skin starts to sag. Happy Lift threads are designed to reposition sagging skin tissue by hooking it up and internally re-draping it to its original position. This is all done internally­—the threads are implanted deep under the skin but above the muscle layers of the face. In some cases, it may go under the muscles, but this is dependent on the surgeon and the exact procedure required.
   Happy Lift’s chemical formula makes the thread dissolve after 8–12 months by hydrolysis. Made in caprolattone (a special L-lattide co-polymer), the thread is surrounded by cogs all around the axes (Fibonacci’s spiral). To avoid the shifting of the thread because of the tissue’s weight, the cogs are directed in opposition to the middle point, whichever length is available (7cm, 12cm, 23cm and 30cm).
   My long experience in conventional permanent threadlift implants made me confident that, by increasing the number of cogs inserted in a specific volume of tissue, it is possible to improve the size, quality and longevity of the fibrosis.
   The thread improves fibrosis by scarring the tissue surrounding it, preventing the ageing ptosis and avoiding the need for permanent threads. The resulting scar around the implanted thread firms up sustains tissues and adds volume to the face.
   The cogs’ number per unit of length is responsible for the stimulation and better revitalisation of the tissues. We cannot ignore the improvement of this because, by increasing the anchoring capacity, it is possible to hold and sustain a higher weight.

Treating the ageing male
In September 2001 the international society for the study of the ageing male (ISSAM) produced a document on the ageing male and androgen replacement therapy in ageing males with secondary hypogonadism. The term Padam has been accepted as an appropriate term to describe partial androgen deficiency in ageing males. There is a slow decline in gonadal function in men from the age of 50 years onwards, and it is a slow progressive part of normal ageing. Other terminologies have been suggested for this phenomenon such as the male menopause, male climacteric or andropause.
   The syndrome known as Padam has six easily recognisable symptoms, low sex drive and reduced erectile quality, particularly nocturnal erections; mood changes, irritability, fatigue and depression; decrease in lean body mass with associated diminution in muscle volume and strength; decrease in body hair and skin alterations; decreased bone mineral density resulting in osteopenia and osteoporosis; and increase in visceral fat.
   All of these manifestations of the syndrome do not have to be present at the same time to make a diagnosis of Padam or male secondary hypogonadism. Other common symptoms are an increase in sweating and hot flushes, aches and pains in joints, difficulties in gaining and sustaining an erection, diminished volume of ejaculate, and decreased sensitivity of the penis. Because some of these symptoms may very well be associated with other conditions, it is vitally important to complete a lifestyle history including nutritional diary, exercise, sleeping pattern, relationship problems and stress at work.
   The mean serum testosterone levels in men decline after the age of 50 at approximately 1% per year. Although it is not always a constant phenomenon, biochemical hypogonadism is detected in about 7% of the age group below 60 years of age but increases to 20% in those over 60. Associated also with advancing age is an increase in the levels of sex hormone binding globulin (SHBG), which translates into a further decrease in bio-available testosterone (free plus albumin-bound fractions). It is, therefore, important to follow up the symptomatology checklist with a biochemical analysis of total and free testosterone as well as other endocrinological biomarkers, such as luteinising hormone (LH), follicle-stimulating hormone (FSH), prolactin, dehydroepiandroterone (DHEA) Sulphate, 17-beta oestradiol and prostate specific antigen (PSA).

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