Issue #9 summary - GO BACK TO ARCHIVE

Improving Standards
Cosmetic surgery continues to make headlines. On 31 January the media reported the case of a surgeon struck off by the GMC following “two botched penis enlargement operations”. In June 2002, former Scotland football captain and Bolton Wanderers player Colin Hendry announced his plans to sue a private hospital and a surgeon for a tummy tuck operation that nearly had fatal consequences for his wife Denise after septicaemia set in.
   In October last year the Consumers’ Association published a report for Health Which? after sending two under cover actors to 21 appointments at private clinics. The report suggested clinics were falling short in pre-operative counselling and consultation. Numerous “patient co-ordinators” were not qualified to perform consultations. Staggeringly, there was evidence that discounts were available if patients agreed to more than one procedure. An obvious concern was that the prime motivator was sales rather than treatment.
   The report further criticised the rather foggy descriptions given of the individual surgeon’s expertise. While to practise cosmetic surgery a surgeon must be on the GMC’s specialist register, he or she need not be a specialist cosmetic surgeon. Indeed, it is not uncommon for doctors to dabble in cosmetic surgery at the periphery of their normal specialty. ENT doctors may be involved in rhinoplasty, general surgeons in breast enhancements and dermatologists in liposuction.

Rejuvenate - not change
The worst comment to be heard at my office during a post-op consultation is: “But doctor, it’s not me anymore. I do not feel myself now. I do not recognize myself in the mirror!”
   It has been 15 years since I first heard that after performing a “mask lift”—that is to say, a real change in a patient who asked me to do just that. I did canthopexies and bone grafts of the orbital roof to correct the sunken eyes that she inhereited from her father, which were producing a sad and ageing look. This patient was extremely difficult to counsel for one year after surgery. Eventually she accepted her new face and new look, which were technically well done.
I vowed I would avoid putting myself in this situation again and be much more careful with my choice of rejuvenative surgery projects. The lesson I took from this is that it is not only technical expertise that characterizes a good surgeon but also the ability to analyze a patient’s expectations. Surgeons must be very careful and moderate in determining what we call the “indications”.
   When women ask for rejuvenation of the face, we should do only what they ask for—that is to say, help them to return to their past with a real, natural-looking rejuvenation. In my conversations with my patients, the question always raised is: “Will I be changed? I do not want a fixed face without any movement, like some old movie actresses. I do not want to lose my smile. Doctor, just get rid of the creases on my neck and my wrinkles, clean up my face, but I want to stay myself, please!”

Breast reduction and augmentation
Women with breast hypertrophy, with or without ptosis, invariably complain of physical discomfort—especially of the skeletal system. Psychological evaluation typically reveals a state of unhappiness and self-consciousness. The effect on a woman’s self-image generally results in difficult social adaptation, embarrassment in intimate relationships and avoidance of physical activities.
   In warm climates, such as Brazil’s, people perform outdoor activities and sports year round. The use of lighter and more revealing attire is almost mandatory, which the media help to promote. These combined factors help to explain why reduction mammaplasty is by far the most common contour deformity presented for surgical correction.
   In more than 40 years, Ivo Pitanguy’s service has an accumulated experience in reduction mammaplasty of 3,381 personal cases (at the Ivo Pitanguy Clinic) and 4,372 cases at the 38th Ward, Santa Casa General Hospital—this is a charity institution where the residency program is held. The feasibility of the techniques is emphasized by the ease with which the techniques are taught to the younger surgeon (see table 1).
   Our personal modification of Arié’s technique was presented in 1959 and published the following year. As well as point A—the projection of the submammary sulcus along the mid-clavicular line—the vertical incision was extended above the nipple-areolar complex, with more satisfactory and longer lasting results.

Breast implants are not all equal
Silicone is an excellent and proven bio-material, essentially inert and highly compatible with human tissue. Nevertheless, it is a “foreign body” and will evoke a tissue response when introduced into the human body.
   Natural physiological defences respond to foreign bodies in one of three ways—destruction, rejection or isolation. In the case of a large mass such as a breast implant, isolation from adjacent tissue is achieved by surrounding the implant in a capsule of scar tissue. As no known implant can prevent the formation of a natural capsule during the initial post-operative period, the challenge in breast implant surgery is the development of a capsule that is thin and pliable, rather than thick, fibrous and potentially contractile.
   The natural capsule forms as collagen accumulates on the implant surface, becoming thicker and fibrous over time. If sufficiently developed, and with parallel axes of orientation, the capsule can exert contractile forces and will shrink and tighten around the implant, distorting the shape until no further compression of the gel or saline content is possible.

Wound closure
Whether you use a suture material or a glue, obtaining the best result with optimum healing is ultimately the end goal
   The choice of wound closure materials pivots on enabling a wound to be strong enough to withstand daily tensile forces and to help healing. Wound strength gradually increases during the healing process. According to wound healing experts, after two weeks, a wound has less than 10% of its final healed strength. By this time, most superficial or percutaneous closure materials are removed, and the resulting weak wound has little to rely on for strength unless additional support is available. Wound strength increases to 20% by three weeks and 50% by four weeks. At three to six months, a wound achieves its maximum strength, which is only 70-80% of its original strength.
   The choice of a suture material is based on the patient, the wound, the tissue characteristics and the anatomic location. A surgeon’s selection may not be specifically based on scientific data, but rather, on the preferences that he or she learned from mentors or during training.
Understanding the characteristics of suture materials is important to make an educated selection. No one suture possesses all desirable characteristics.
   The optimal suture is easy to handle and has high tensile strength and knot security. Any tissue reaction should be minimal, and the material should resist infection and have good elasticity and plasticity to accommodate wound swelling. Although some of the newer materials possess many of these properties, no one material is ideal, and compromises must be made.

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