History of Cosmetic Surgery in the UK

If we define cosmetic surgery as surgery that alters physical appearance, then nearly all human cultures from the Stone Age onwards seem to have adopted practices that altered the appearance of members of the tribe. In Kenya, marks on the face were made by cutting the skin and then rubbing in earth so that the resulting scar was wide and visible. The idea was that a member of any particular tribe was instantly recognisable. Many tribesmen and women had bones or other objects forced through noses and earlobes. They did this, or had this done to them, for the age-old reason that they wanted to fit in and look like other members of their society. This is pretty much the same reason why the majority of cosmetic-surgery patients today seek surgery.

Although it is true to say that cosmetic surgery is still a relatively new speciality in the UK„ it dates back for centuries. The beginnings of eyelid surgery can be traced back to the 10^thcentury in Arabia. The first record of a facelift was in the early 1900s, although it is not known who attempted the very first one.

As early as 600 BC, the first evidence of nose reconstruction (rhinoplasty) was recorded. By the end of the 1^st century, rhinoplasty was common as a result of the uncivilised practice of cutting off the noses and lips of one’s enemies. By the 16^th century, noses were reconstructed after being severed in duels by using flaps of upper arm skin: necessity was the mother of invention!

Otoplasty (correction of protruding ears) was described in the 1850s, although there is some evidence to show that it was performed much earlier. The first breast reduction can be traced back to the 15^th century, while the first silicone implant for breast augmentation was performed in 1963. Prior to that, breasts were enlarged using dermal (deep layer of skin) grafts and even injecting liquid silicone, a practice that was short lived because of the disastrous consequences. The injection of liquid paraffin was also tried at various times since 1889, but the results were poor and the complications horrendous.

The most modern revolutionary cosmetic surgical procedure dates back to the early 1970s when surgeons in Switzerland described for the first time a technique for sucking out fat. The initial trials were not a total success because of the frequency of postoperative complications, notably seromas (large accumulations of fluid under the skin), which took a long time to absorb, and skin depressions. In 1977, a French surgeon, Gerard Motu, perfected the technique by using a blunt cannula (surgical tube) connected to a high negative pressure vacuum pump.

In most countries of the world, when a doctor qualifies as a specialist he sets about establishing a practice. There are various professional ways to do this. The usual way is to inform all of his colleagues that he is available to receive referrals relevant to his speciality, and he also sets about telling as many people as possible what he does and how to find him. Hopefully, sooner or later his reputation grows and his practice increases. Some specialists buy into already established practices as a junior partner and in many countries it is possible to buy a practice from someone who is retiring.

After the inception of the NHS in Great Britain in 1948, the system became quite different. It was only possible to set up as a specialist once one had been appointed a consultant. The supply of consultant posts was wry restricted, so a doctor only became a consultant when a post became vacant. There were always very many more trained doctors than there were posts available.

Doctors who became consultants under this system claim that only the best were chosen, but this was not always the case, as many doctors became disillusioned and either gave up hospital medicine or emigrated. It also meant that, in Britain many fully trained doctors could not get consultant posts and remained so-called junior doctors well into their 40s. This led to the concept that doctors who trained in the NHS needed 14 years or so after qualification to become adept in their speciality. The rest of the world did not believe this and overseas specialists became fully qualified at a much younger age.

The reason for the late appointment of consultants in the NHS was the bottleneck created by the lack of posts available. The training of junior doctors was generally on-the-job training, in an ad hoc fashion, more like an apprenticeship. Often there was no formal training; a junior doctor had to serve his time and hope that a consultant post became available when he was sufficiently senior.

In the NHS in the 1970s there was no formal training in cosmetic surgery. There still isn’t really, because very few purely cosmetic operations are performed in NHS hospitals. Nearly all cosmetic surgery is done in the private sector. Both the authors left the NHS and gained their training by following senior surgeons who had busy private practices.

Plastic surgery was established as a speciality only relatively recently, after the Second World War. Plastic surgeons claimed cosmetic surgery as part of their speciality, but in reality many different types of surgeon have been performing cosmetic surgery for over 150 years. It is not true that plastic surgeons are the only ones who are fully qualified, as they claim, to carry it out. Their own training programme has only recently embraced cosmetic procedures. They spend most of their time carrying out operations on burns, malformations and injuries and their training reflects this. It is quite common even today for a plastic surgeon to become a fully qualified specialist with virtually no experience in cosmetic surgery.

There is little common ground between the usual NHS plastic-surgery patient and those seeking a cosmetic operation. Cosmetic patients are generally much more exacting in their expectations than those who need cancer surgery or skin grafting for burns.

There used to be a total prohibition on any form of advertising by doctors. This was designed to protect vulnerable patients from blandishments from unscrupulous doctors. In reality, it protected and controlled the referral system of private patients by GPs to hospital consultants. Up until the 1970s it was never imagined that this ‘in-house’ system could or would be challenged by anyone. But challenged it was, by a group of entrepreneurs who took advantage of a legal loophole that allowed non-medical people to set up independent private medical services, which then employed surgeons and anaesthetists.

These entrepreneurs had only one thought in mind; medical ethics were certainly not high on the agenda. They were not regulated by any ethical body, and were therefore allowed to publicly promote and advertise medical services in the media. As a result private medical services began to be established offering abortions, medical screening and cosmetic surgery.

Some unscrupulous individuals saw this as a passport to making easy money and established some of the first cosmetic surgery clinics in the 1970s. Many employed hard-sell tactics and adopted the attitude that they were beyond reproach as any mishap could easily be blamed on the doctor. Therefore, they would refuse to take any responsibility in the event of a problem. These individuals quickly gained control of the cosmetic-surgery industry.

Unfortunately, many doctors did not approve of cosmetic surgery in any form and refused to refer their patients. This meant that many patients had no way of finding a surgeon who performed cosmetic surgery unless they contacted one of these clinics. Since that time the number of these clinics and establishments in the UK has grown enormously, particularly since 2001. Every major town and city has several different providers in competition with one another.

As a result of the activities of commercial clinics, the rules on medical advertising have now been very considerably relaxed and numbers of doctors appear in the media hawking their skills. Often they are the same doctors who only a few years ago accused surgeons who worked for commercial clinics of being unethical.

Advertising is still generally disapproved of by most of the profession. However, in Britain today, the majority of cosmetic operations are performed by doctors working for commercial clinics. These clinics have a financial imperative to carry out as many operations as possible and, certainly in the past, dubious methods were used to get patients to sign up. It is however commercial suicide to run an unethical clinic and most, but by no means all, clinics these days treat their patients with consideration and skill. There is still a risk, however, that a vulnerable patient may meet a salesman or woman paid on commission who will say virtually anything in order to get them to undergo treatment.

Whatever the criticism of cosmetic surgery in the past, one thing is patently obvious: in expert hands it is extremely successful and has transformed the lives of many people for the better. It is here to stay and is growing very quickly.

Cosmetic Surgery: General Considerations

General Considerations

Cosmetic surgery can be defined as ‘that branch of surgery whose primary aim is the enhancement of the non-pathological external appearance of a patient’.

In cosmetic surgery perfection is the aim, rarely the achievement. What may be deemed an acceptable result by one patient may be totally unacceptable to another. The realistic aim of cosmetic surgery therefore is to improve the appearance of a particular feature or deformity with the intention of achieving increased self-satisfaction and self-confidence.

Those expecting a miracle or a result that is outside the realms of surgical possibility will doubtless be disappointed. A particular surgeon may be unable to match what a patient has in mind regarding the final appearance. On occasions it may transpire that the goal of the patient would not actually suit him or her, or prove to be disappointing, even if attained.

The successful result of any cosmetic surgical procedure thus depends not only on the skill and experience of the surgeon, but also on a number of factors outside the surgeon’s direct control. These factors include the patient’s general health, age, skin texture, bone structure, healing properties, and the expectations of the patient. These can all influence the final result.

It is possible for complications to occur that in the short term can spoil a result. Complications occur in all branches of medicine and surgery, and are often outside the control of the medical practitioner. Occasionally, a patient may be directly responsible for causing a complication either through carelessness or not following postoperative instructions.

The success or failure of any cosmetic surgical procedure therefore is measured by one factor and one factor only, namely: ‘Is the patient happy with the result?’ Independent opinions count for nothing if the patient is dissatisfied.

Although a trained and experienced cosmetic surgeon is a highly qualified medical practitioner, he is not a magician, and is limited by the materials at his disposal. A person who is of moderate attractiveness cannot be turned into a ravishing supermodel by a nose-reshape operation, for example!

Not every prospective patient will be accepted for surgery. Sometimes it is in the patient’s best interests to be refused surgery, especially if the result could turn out to be less than satisfactory or, worse still, turn out to be worse than the previous situation. This can occasionally occur.

At the consultation a good surgeon will attempt to assess the patient psychologically as well as physically. This is to help him or her decide if the expected or usual result of the procedure is likely to please the patient. On rare occasions a cosmetic surgeon may refer a patient for a psychiatric opinion before deciding whether to operate. Cosmetic surgery is not a panacea or cure-all for all of life’s problems.

The ideal patient must be sufficiently self-motivated to undergo cosmetic surgery. If the desire for cosmetic surgery has been initiated by the ‘encouragement’ or persistence of a friend, relative or spouse, the end result is more likely to be a disappointment for patient and surgeon alike. It is difficult enough to satisfy and please one patient, let alone their partner and friends as well.

It is extremely unusual to encounter a patient who is not nervous or apprehensive about undergoing cosmetic surgery. This is only natural. Every surgical procedure, even a simple one such as a tooth extraction, entails some degree of risk. There may be complications, and the results may not match expectations.

The Need for Cosmetic Surgery

We have learned from experience that even stunningly attractive people find fault in their appearance, often exaggerating their problem when it may seem negligible to the average onlooker. It is difficult to explain the reasons for this, but it is possible that this particular group of people set themselves very high standards from an early age and are so preoccupied with their appearance that, the moment they perceive a deterioration, they immediately seek help.

Learned psychologists will attempt to explain this phenomenon as a personality flaw. Many psychologists still denigrate cosmetic surgery as unnecessary and attempt to explain any strong reaction to a blemish as a deep-rooted mental aberration. But, despite all the complex jargon and scientific research conducted in an attempt to explain it, they are unable to offer a simple treatment or cure that will satisfy those afflicted with an abnormal obsessional disorder pertaining to their physical appearance. In our experience, attempting to convince a patient that her nose is pretty when she is convinced it is not, simply does not work.

Most people we meet in our practice every day are perfectly normal individuals who simply dislike a particular part of their anatomy, and would like it improved. In the vast majority of cases, the results of surgery are very successful and the patient resumes a normal lifestyle with renewed confidence.

There is no doubt that there are those who will never be happy with their appearance no matter what. These people can usually, but not always, be spotted by the experienced surgeon, and the only ethical response is to refuse them treatment. The surgeon may then refer the patient for counselling, really the only alternative when surgery will undoubtedly prove unsatisfactory.

How successful counselling may eventually prove will depend on the expertise of the counsellor and the seriousness of the person’s condition. One thing is certain – no amount of counselling can remove a physical blemish! As to whether someone can be persuaded that they do not really have a problem, when for years they have despaired of their particular blemish, is a matter for debate. We have certainly not encountered a case where this has happened. Conversely, however, we have both seen patients who have been cured of psychiatric problems by having successful cosmetic surgery.

It is hard not to feel pressure to look one’s best. Media coverage constantly exposes women to pictures of beautiful women, and advertising for beauty-enhancement products. Add to this any active criticism of a blemish an individual may have received from those around them, and a person can feel surrounded by reminders of their physical imperfections. Realistically, adults are no different from children in this respect. We have even encountered patients who were not ridiculed as children, but only when they became adults. All this leads to an ever-increasing sense of self-deprecation.


Early Childhood

Problems can start early in life if classroom bullying and teasing is rife. A common example is the child with protruding ears. Such teasing can lead to serious consequences for both child and parents. The child will detest going to school, become withdrawn, unhappy and depressed. His or her early developmental progress at school may be seriously compromised. The parents will suffer likewise, very often at a loss as to how to solve the problem.

Ears are fully developed by the age of five and a simple operation, at that stage can alleviate a lot of potential psychological damage in the future.


Adolescence

The next stage is the adolescent going through puberty. This is the time when many teenagers experience the onset of acne, which may be quite disfiguring. Other problems that occur at this time include problems with the development of secondary sexual characteristics e.g. breast-development in girls. This is often a time of turmoil for many teenagers who constantly strive to look their best and comply with the latest fashion trends in order not to be the odd one out.

We are now operating on more younger people than before. Schoolgirls will seek breast enlargement to avoid ridicule by their peers. Some will refuse to attend sports activities because it means undressing in front of classmates and changing into sports kit. Nose reshaping is also becoming more frequent in teenagers, as is liposuction. However, we do not feel that cosmetic surgery should generally be offered to teenagers unless the problem is particularly severe.


Early Adulthood

At the age of 18, most females have reached full physical maturity. They stop growing and have fully developed sexual characteristics, facial features and body shape. This is the time when a general overhaul of aesthetic appearance takes serious priority.

In the majority, if adolescence precluded seeking or establishing a relationship with the opposite sex because of the usual restrictions, early adulthood, with its new freedoms, can make up for the shortfall At this time most will be seeking to look their best in order to attract a partner.

Cosmetic surgeons will see patients in their young adulthood who will request nearly all the commonly available procedures, apart from those specific to reversing the aging process.


Middle Age

This is the next category of self-referral for cosmetic surgery. By this time most women will have had children. The early signs of facial aging will also be taking their toll.

A woman might complain of smaller, drooping breasts; a loose, flabby abdomen, and varicose or thread veins as a result of childbearing. The more children she has had, the more pronounced the problem. In addition she will probably have put on weight and be concerned about her facial appearance, particularly if she has been a heavy smoker for many years. She may therefore be seeking facial fillers and Botox®, as well as surgery.

Over the years, we have observed that many women request a facelift at the age of 50 and satisfy themselves that by doing this at that age it will last them until old age when they will not be concerned about their appearance. Many do not realise that they will still strive to look their best even at 70 because mentally they will probably feel the same as they did at 50. We often see women coming back ten years later for a repeat procedure.


Old Age

The majority of patients at this age are women who are mostly concerned with facial and eyelid aging. In addition many will request facial fillers and Botox® even though at that age fillers and Botox® will have very limited beneficial effect By this stage many will not be physically fit for surgery or not even be particularly concerned about their appearance, electing instead to grow old gracefully. Only those who are in good health will be operated on.


Conclusion

Although the concept of beauty is difficult to define precisely, one thing is for certain: with ever-improving and developing technologies, most women can rest assured that a great deal can be achieved to enhance their aesthetic appearance and thereby bring increased self satisfaction and self confidence.

The perception of beauty is ultimately a matter of personal taste and opinion. One thing is for certain — if we all had the identical concept of beauty all men would be attracted to the same women and vice versa, leaving many disappointed individuals overlooked. It is patently obvious that we have been designed to hold diverse views and opinions on what we find beautiful so that the human race can continue to procreate and survive.

Are You Considering Cosmetic Surgery?

Cosmetic surgery can achieve almost unbelievable results. It has never been so popular and accessible, and celebrity endorsement has made it top of the wish list for not just the rich and famous, but for ordinary people as well.

But whether you are contemplating a simple Botox treatment to iron out your wrinkles, liposuction for troublesome areas of flab, or a more major procedure on our breast or face, it should never be undertaken lightly.

When a patient's expectations are unrealistically high or when inexperienced surgeons, employed by less reputable clinics, are let loose on an unsuspecting public, disappointment or even disaster can ensue.

It is always vital that the right surgery is done for the right reason, on the right patient, by the right surgeon. It is also imperative that sufficient time is devoted to preoperative counselling, so that informed consent can be given and the patient is fully aware of what to expect.

We live in a world where most media coverage of the subject is either journalistic hype, corporate advertorial or blatant scaremongering. It is difficult to know what to believe.

What is a Surgical Operation?

A surgical operation is a controlled injury and the body reacts to it like it does to any injury. Cosmetic surgery is not just about undergoing a surgical procedure, however. Before any patient is subjected to the physical injury of an operation, many other factors have to be considered. Indeed, we are firmly of the opinion that the preoperative considerations and preparatory events leading up to the big day when the surgeon makes the first incision, are equally if not more important, than the actual operative procedure.

Many people who undergo cosmetic surgery have never been in hospital before and are understandably frightened by the prospect. Some are more afraid of having a general anaesthetic than undergoing the operation itself. Fear of the unknown is natural and forever present in the field of surgery.

A fully informed patient is far more likely to be less apprehensive about undergoing surgery, be less nervous on the day of surgery and more likely to accept and come to terms with the possible, common postoperative events that are likely to be encountered. A fully informed patient is forewarned and therefore forearmed to face any possible eventuality. This can only be of benefit to the patient (as well as the surgeon and his staff).

Cosmetic Surgery: The Concept of Beauty

Beauty is in the Eye of the Beholder

Since the dawn of history, men and women have attempted to modify their appearance to comply with the cultural standards of the era.

There are many philosophical theories to explain this concept but it doesn’t take a genius to work out that a physically attractive man and woman are more likely to get married or find a partner (as they are more sought after by the opposite sex), get better jobs and generally be more confident and successful.

Although it is not possible to define beauty easily — it varies with different cultures and is dependent on the eye of the beholder — there are certain physical characteristics that are significant for the overall ideal concept of beauty.

It is commonly said that the ‘ideal woman’ has a small chin, delicate jaw, large lips, small nose, prominent cheekbones, large and widely spaced eyes and a waist-to-hip ratio of 0.7. The ‘ideal man’ is tall, has rugged macho features — rectangular face and chin, deep-set eyes, heavy brow, large straight nose in proportion to the size of the face — and a waist-to-hip ratio of 0.9.

It is common for men and women to try to accentuate the differences between them. For instance, women are generally less hairy than men, so go to a lot of trouble to make sure that they are even less so. They also have softer skin than men and there is a huge industry devoted to selling women’s products that will soften the skin and protect it from becoming weather beaten and therefore more ‘masculine’.

Interestingly, sexual attractiveness and the concept of beauty are not necessarily the same thing. Attractiveness for a woman usually means that she looks healthy and is of a fertile age. When a man says a woman is attractive and ‘sexy’ he is observing the signs of possible fertility. Every ‘Miss World’ who has ever won the contest has had the waist-to-hip ratio of 0.7. Research has shown that women who have this ratio are more fertile than those that don’t.

When a woman finds a young man attractive she is often seeing the signs caused by testosterone, the hormone that makes a man masculine (and more fertile). If she finds an older man attractive, she is (possibly subconsciously) seeing a man who may be able to provide for her and any children she might have.

Detailed and accurate measurements of facial features and angles have tried to add a more scientific element to the concept of beauty. When these measurements are analysed and applied to different ethnic groups, those considered to be good looking or beautiful comply with universal scientific concepts of beauty. Thus, in the main, a particular ethnic beauty will still be considered attractive by the majority of any other ethnic group.

Many studies have stressed the importance of facial symmetry. No human face is exactly symmetrical, but marked asymmetry – beyond what is considered normal – is not usually considered to be beautiful. This is probably because of the association of good symmetry with good health.

Asymmetry is sometimes caused by sleeping on one side more than the other. Most people prefer to sleep on one particular side, a pattern that is established early in life. Babies tend to sleep a lot and grow while they are asleep; the side that is on the pillow doesn’t grow as much as the uppermost side. This means that, when an adult has one side of their face that is smaller than the other, it is possible to guess on which side they prefer to sleep.

At the same time it must be stressed that although facial appearance is a very important parameter when considering the concept of beauty, other bodily features are also important. These will include height, shape, amount of fat distribution on the body, breast size and shape, skin quality and so forth. A man or woman may not be particularly facially attractive but have a near perfect figure, and vice versa.

Of course, you have to add a person’s personality, or ‘inner beauty’ into the equation. Plenty of beautiful people get married, only to separate soon after. Physical attractiveness does not necessarily guarantee a long-term relationship, and in some ways can even detract from it.

Whatever may be analysed by philosophers and experts regarding the concept of beauty – and much has been said and written on the subject - the truth remains that many people are never satisfied with what Nature gave them in terms of their physical appearance.

Cosmetic Surgery: Pre-Operative Considerations

In order to get the best possible result for a particular patient it is extremely important to strive to attain the best possible conditions in which to operate. It is our opinion that the pre-operative consultation is the most important part of the entire cosmetic procedure, and has been discussed in more detail in the previous section. This section deals with the physical and medical aspects of the fitness of a patient for surgery.

Because cosmetic surgery is entirely elective, it is of paramount importance for the surgeon to ensure that you are physically fit to withstand the operation safely and without undue risk. It would be extremely foolhardy for a surgeon to operate on any patient who has an increased risk of a serious medical complication following a procedure, which may endanger her well-being.

A carefully devised pre-consultation questionnaire is a useful tool to screen a patient from a purely medical perspective. This will usually give the surgeon all the information he requires in order to ascertain if you are physically fit for surgery, or if there are any factors that may preclude proceeding. Any grey areas can then be investigated in more detail.

In addition, the surgeon will go through his own, thorough screening routine to ensure that it is safe to operate on you. Some of the more important points to consider are as follows.

Your Current General Health

Any significant history of current problems with medical fitness will immediately alert the surgeon to take appropriate action and make an informed decision regarding proceeding with surgery. You should report any recently encountered symptoms, eg. excessive thirst, frequency of passing urine, unexplained weight loss, as these may signify the onset of an illness that has previously been undiagnosed, such as diabetes.

Past Medical History

A detailed past medical history should help uncover any contraindications to proceeding with surgery or alert the surgeon to any possible post-operative problems eg. previous post-operative deep vein thrombosis, or a history of heart or chest problems.

You should declare any past psychiatric history, with accurate details of any hospital admissions and medications prescribed. A past history of depression or anxiety can be very relevant to how you react to the stress of having an operation.

Family Medical History

And you most Any significant family history of illness should be declared, especially a family history of anaesthetic problems. A condition known as Malignant Hyperthermia is a familial disorder, whereby the sufferer's metabolic rate is grossly enhanced when under a general anaesthetic leading to a grossly exaggerated and rapid rise in body temperature, which, if not promptly and expertly treated, can lead to the rapid demise of the patient. Thankfully, this condition is extremely rare.

In fact, you should declare any disease or illness that you know runs in your family, no matter how insignificant you think it to be.

Allergies

By the time a person reaches puberty, she should be aware of any allergies she may be suffering from, especially to conventional drugs. The commonest, most important and pertinent allergen in surgery is Penicillin. Obviously an allergy to any other drug or medication is also important, especially to a particular anaesthetic agent or post anaesthetic drug, but this is less common. All allergies should therefore be declared prior to surgery.

Current Medications

It is important to inform your surgeon of any oral medications you may be taking, in case they are likely to react with any medication likely to be given during an anaesthetic or at any time in hospital. Of particular importance is the oral contraceptive pill and hormone-replacement therapy, as in some situations it will be necessary to take extra steps to protect the patient against the possibility of post-operative deep vein thrombosis.

You should also declare any homeopathic, alternative or other medicines or preparations to the surgeon and anaesthetist before surgery. These too can interact with conventional medicines, especially anaesthetic drugs, which could have disastrous consequences.

Abnormal Healing/Scarring

A history of abnormal scarring or healing should prepare you and your surgeon for the possibility of an unfavourable result. Everything possible should be done in an attempt to minimise this complication eg. your strict adherence to post-operative instructions, and measures for the prevention of infection.

Vitamins

The taking of vitamins is encouraged in order to enhance healing. The homeopathic preparation arnica is recommended by many surgeons as an aid to healing, although some scientific reports have cast doubt over its effectiveness.

Bleeding/Clotting Disorders

Any bleeding tendency or abnormal clotting disorder in you or your family must be fully investigated before surgery. Prior to surgery, many patients complain of 'bruising easily'. This is usually a harmless disorder, often referred to as 'devil's pinch', and is not significant.

If you or your relatives have previously experienced deep vein thrombosis following surgery, you should be treated with the utmost care and given prophylactic preventative therapy prior to surgery.

An increasing number of patients are travelling long distances by air to undergo cosmetic surgery. There is an increasing number of fatalities from pulmonary embolus in patients who have recently stepped off a plane and gone straight into an operating theatre for surgery. Extreme caution should always be exercised in these circumstances.

Excessive Alcohol Intake

Excessive alcohol intake will impair liver function and therefore the production of the essential clotting factors in the blood. This can sometimes cause a problem if the clotting time is increased after the operation. This can in turn lead to excessive post-operative bleeding with the increased likelihood of developing a post-operative haematoma.

Aspirin, a common drug taken for a variety of reasons, has a similar effect on bleeding, and should be avoided for two weeks prior to elective surgery if at all possible.

Smoking

All patients are strongly encouraged to stop smoking. Smoking is not only a recognised health hazard in its own right, but is responsible for a number of post-operative problems and complications in patients who have a general anaesthetic for elective cosmetic surgery.

1. Impaired circulation

It is a known fact that heavy smokers are more liable to suffer the consequences of impaired circulation. This can lead to flap necrosis (loss of the skin resulting in noticeable scars) eg. following a facelift or abdominoplasty. The rate of healing will also be affected. In addition, a smokers cough immediately following facelift surgery can easily precipitate a haemorrhage and an expanding haematoma.

2. Chest infections

Heavy smokers are more likely to develop a chest infection post-operatively, particularly after major procedures such as abdominoplasty.

Anaesthetic Reactions

This has already been mentioned above. Individual patients react differently to a general anaesthetic. Some suffer excessive vomiting, some find it difficult to wake up afterwards, some wake up very tearful, but luckily most get no side effects at all.

In many cases you will be aware of a particular reaction you have to an anaesthetic agent from previous experience. Any untoward reaction to an anaesthetic agent must be dealt with promptly and, thankfully, serious complications are rare. Any known anaesthetic reaction must therefore be declared prior to surgery.

Most local anaesthetics contain adrenaline. The function of the adrenaline is to cause vasoconstriction (narrowing of the local blood vessels) thereby reducing bleeding at the operation site. This makes it a lot easier for the surgeon to operate.

In the main, allergies to local anaesthetics are extremely rare. However, some people can occasionally develop an unpleasant feeling immediately following the injection of a local anaesthetic, which is attributable to the adrenaline. This reaction is usually short lived.

Urinary Problems

Urinary tract infections are a common post-operative complication, especially in patients who are prone to them.

Abstinence from Food and Drink

Every patient undergoing a general anaesthetic must abstain from food and drink for several hours beforehand. This is to ensure that the stomach is empty in order to prevent the inhalation of vomit during the administration and duration of the anaesthetic. Each patient will be advised accordingly.

Employment and Social History

One of the commonest questions patients ask after surgery is, 'When can I go back to work?' The surgeon will need to know what your work commitments and circumstances entail in order to answer this question accurately. Depending on the scale of the procedure you are considering, you may need to arrange to have some considerable time off work. Only you will know if this is feasible. Your relationship with your work colleagues — whether you get on well with them or not, whether they know about and are sympathetic towards your having surgery — can also have an important bearing on how successfully you view the result.

Ideally you will have a loyal and supportive partner or close friend who will help you through the inevitable stress of having surgery and coping with the immediate effects. Often the result of surgery initially is quite disappointing. At first the patient just sees the effect of an injury: bruising, swelling, scars and stitches. It is only later that the beneficial effects of the operation become apparent. It is very helpful to have personal support through these early stages after an operation.

The second best situation is to be left alone to recover quietly without having to look after anyone else except yourself. The worst situation is to live with a partner who is antagonistic to the whole idea of the operation. Every little bruise could be the focus of an 'I told you so' type of remark, and an operation that would have been a success with a supportive partner can be turned into a failure.

It is a good idea for a husband and wife to attend the pre-operative consultation together if possible, so that the events in the post-operative phase and all the complications and risks can be explained to them both at the same time. This is particularly pertinent to breast surgery and skin resurfacing procedures of the face.

Your Hopes and Expectations

One of the most important questions the surgeon should ask you is, 'What are you trying to achieve?' He then has to compare your answer to what you are actually likely to get. If you are hoping for rather more than the procedure is generally capable of achieving, then disappointment is very likely.

The ideal patients for cosmetic surgery are physically healthy, emotionally sound and want what the operation can usually provide. A supportive home and work environment also make a big difference.

Risks of Cosmetic Surgery Procedures

Here, we deal with those post-operative complications that can occasionally occur with any surgical procedure. Complications, which are peculiar, specific or unique to a particular procedure, are discussed in more detail within the relevant entry.

The human body is a very complex entity. Despite our current knowledge, we are still only scratching the surface with our understanding of the many intricate mechanisms of its functions and behaviour. We have limited understanding and therefore limited control over the complicated healing process that starts once we down tools.

We rely on the intricate biological, physiological and immunological systems to interact in a controlled and synchronised manner to heal the tissues and give a pleasing cosmetic result with the minimum of scarring or tell-tale signs of surgery. We expect our bodies to do all this despite the magnitude of the physical assault inflicted by the surgery.

The complex mechanism of the healing process is usually the patient's best friend. If all goes according to plan, an area that has been operated on will heal quickly with the minimum of bruising and swelling, leaving a thin scar, barely visible to the naked eye.

On the other hand, the opposite can occur, through no fault of the surgeon, and the operated area may become excessively bruised with permanent pigmentation, persistent swelling or thickening of tissues and a very visible disfiguring scar. At worst, the post-operative appearance may be more disliked by the patient than the pre-operative: Revision surgery may be required in an attempt to improve the final result. Thankfully this doesn't happen very often in experienced hands but, when it does, it understandably causes the patient and surgeon concern.

Every surgical procedure carries a risk, even if performed by the world's best surgeon. It is therefore important for everyone who is contemplating cosmetic surgery to be fully aware of the possible complications that may occasionally occur. This will lessen the psychological trauma and disappointment should anything go wrong.

Nervous patients may be unhappy to take the risk of surgery once they have been informed of all the possible consequences. Bolder ones may be perfectly happy to proceed. In either case it is the patient's decision, and an ethical surgeon has a duty to give a balanced account of all the risks. In conventional surgery, a surgeon may well try to persuade a patient to have an operation because he believes it is in their medical interests to go ahead. The benefits to their physical health may well outweigh any risks. This is never the case in cosmetic surgery. By definition, it is not medically essential. Thus the patient alone must choose whether they wish to expose themselves to the risks of their procedure. Some patients find it difficult to translate numerical probabilities into factors that affect their decisions on a daily basis. For example, people who truly appreciate the chances of winning the lottery don't waste their money on a ticket!

Most of the complications that are described here only happen to a very few, unlucky patients. Indeed, cosmetic surgery is safer and more predictable than conventional surgery, mainly because the patients are healthy — or should be — before the operation. Serious post-operative complications are rare and, if they do occur, further surgery will often rectify or improve the result.

In order to appreciate why complications are unpredictable or indeed occur at all, we must appreciate that every human being has a unique genetic profile. Our genetic profile ultimately controls our health and the way we react to a given set of outside influences or stimuli. It also controls the way our healing process reacts and behaves. Flaws can sometimes occur in the healing process and can predispose to a poor result.

Scars

All surgical incisions heal by producing a scar. To make scars less obvious the surgeon tries to make any necessary incisions where they will not easily be seen, such as in natural skin folds or inside the hairline. It is wrong to think that scars will be invisible or that they will completely fade to nothing in time. The term 'invisible scar' should never be used. Wound healing is an extremely complex, biochemical process involving many variables. For this reason the final results of healing cannot be accurately predicted.

Once an incision is made and sutured (stitched) the surgeon has little control over the healing process.

Most scars will look worse (red and raised) for some time after the operation before they mature and become pale and level with the surrounding skin. In general, scars take six to 18 months to mature (in some cases, they can take longer). There will always remain a permanent mark, no matter how inconspicuous, where an incision has been made.

In some situations scars can heal unfavourably in certain people. Scars may become infected, stretched or thickened (hypertrophic or keloid) and may necessitate further treatment eg. steroid injections or scar revision to improve the Final cosmetic appearance. Even in someone who has never had a history of unfavourable scarring, the unexpected can occasionally happen and mar an otherwise good result.

Some areas of the body and some skin types are notorious for producing worse scars than others eg. over the breastbone. Where an incision is sutured under tension there is a good chance that the scar will stretch, for example, in abdominoplasty.

If a ten-centimetre incision is made on the forearms of 100 individuals and sutured in exactly the same manner, the final outcome after two years would give a variety of results. At one end of the scale the scar would be almost invisible. At the other, a thickened, raised and red hypertrophic or keloid scar would result This simple example also applies to more complex procedures; unfortunate healing such as this can thus give an unfavourable result to a procedure that has been otherwise expertly performed.

Infection

Infection can occur after any surgical procedure. Most commonly the wound (incision site) is affected. If the infection progresses, the adjacent and surrounding tissues can become affected. This condition is known as cellulitis. Further progression of the infection may lead to formation of a localised deep pocket of pus or abscess formation.

Fortunately, infection in cosmetic surgery is not common and is easily treatable, usually with antibiotics, rest and local hygiene measures. Abscess formation must be more vigorously treated, often necessitating further surgical intervention in the form of a drainage procedure. Abscess formation is extremely rare but can occur following some cosmetic procedures, such as breast surgery, abdominoplasty and liposuction.

Sometimes chest infections occur after surgery, especially in smokers and patients with previous chest or breathing problems.

Finally it must be mentioned that MRSA (methicillin resistant staphylococcus aureus or 'superbug' as it is labelled by the press) is increasingly becoming the scourge of our hospitals. If an MRSA infection is diagnosed, it can be extremely difficult to treat. It is rare in previously healthy patients who only spend a short time in hospital, which is the usual situation in cosmetic surgery.

Bruising and Swelling

This is the body's natural response to injury. Every surgical procedure is followed by a period of bruising and swelling, depending on the nature and extent of the surgery.

In general, the more expert and adept a surgeon is, the less post-operative bruising and swelling will result. This is because an experienced and slick surgeon will perform an operation or procedure with the least amount of imparted trauma to the tissues.

The patient's response to trauma is also an important part of the equation. Some people bruise more easily than others and this can be caused by variations in the fragility of their blood vessels and the levels of blood coagulation (clotting) factors. Most elderly people have more fragile blood vessels than the young. Low levels of blood coagulation factors can run in families, even without obviously diagnosable bleeding disorders.

Although there has been much controversy about its effectiveness, many surgeons recommend a course of arnica tablets both before and after surgery to help reduce bruising and swelling and to enhance the healing process.

Pain and Discomfort

Following any surgical procedure the patient will experience a degree of pain and discomfort. Although research has given us an increased understanding of the mechanisms of pain and its perception by the human body, the best we can still do is to give appropriate medication in an attempt to alleviate or reduce pain, especially in the immediate post-operative period.

The degree and duration of post-operative pain will depend on the nature of the operation and the patient's pain threshold. Little can be done at present to alter an individual's pain threshold. The standard painkilling injections and tablets usually suffice to alleviate this unpleasant sensation to a tolerable degree.

It is therefore extremely difficult if not impossible to describe accurately to patients beforehand the degree and duration of their post-operative pain.

Deep Vein Thrombosis

This complication is rare in patients undergoing elective cosmetic surgery. Deep vein thrombosis (DVT) results when a blood clot develops in one or more deep veins in the calf. It is possible for the clot to become dislodged from its origin in the calf and be transported by the bloodstream to the lungs (pulmonary embolus) where it can have very serious consequences. Patients with a previous history of post-operative deep vein thrombosis should warn the surgeon and the anaesthetist before the operation.

Women taking oral contraceptives may run a slightly increased risk of developing a deep vein thrombosis after some operations. There is some controversy about the benefit of stopping oral contraceptives before surgery. Many medical practitioners hold the view that an equal or even greater risk is incurred from the possible complications of an unwanted pregnancy upon cessation of the pill. Nevertheless, it is thought wise to stop oral contraceptives prior to certain operations. Every patient is assessed on merit before surgery and the surgeon should advise each patient accordingly.

Nowadays the best equipped hospitals and clinics have equipment that massages the calves while the patient is under general anaesthetic. In addition, it is now standard practice for all patients to wear anti-embolism stockings during and after the operation.

The incidence of DVT is very much reduced if patients resume gentle activity soon after the operation. It is not a good idea to spend several days in bed after surgery if it is possible to get up and move about. This is not to say that patients should strenuously exercise soon after surgery, as this is likely to have a very deleterious effect.

Allergic Reactions to Drugs and Dressings

Various drugs are given during a hospital stay in the ward or injected during the course of a general anaesthetic. It is important to avoid being given any drug to which you might be allergic. You must report any known allergy especially to drugs, dressings and foods to the nursing staff on admission to hospital. Severe allergic responses have to be dealt with promptly and effectively to avoid serious consequences.

Bleeding and Haematoma

Sometimes bleeding can continue after the end of the operation or restart again several hours after completion of the operation. It can either track to the surface and manifest itself as localised bruising or collect in a space or pocket deep in the skin. Such a collection of blood is called a haematoma and if it becomes large enough (expanding haematoma) it will be necessary to remove or evacuate it through a further procedure.

In certain cosmetic procedures an expanding haematoma constitutes a surgical emergency in that, if it is not treated promptly, irreversible damage to the surrounding tissue can occur. The best example of this is an expanding haematoma developing under the skin flap following facelift surgery resulting in 'flap necrosis' or death of the skin.

Drains

Sometimes small flexible tubes are used to enable collections of blood or other fluids to drain out from a wound. This reduces bruising and speeds recovery. They are removed a day or two after the operation. Modern drains are made of pliable plastic and remove easily without causing discomfort.

Problems with Urination or Urinary Tract Infection

Patients who are prone to urinary or kidney infections have an increased risk of this happening after surgery. This may be due to lying in one position for a prolonged period during the operation and its recovery, and also because drinking a lot of water is discouraged immediately before surgery.

Blood Transfusion

Blood transfusion is seldom required in cosmetic surgery. All blood is carefully screened by the blood transfusion service for any infectious agent before it is released for use.

Cosmetic Surgery and the Media

When cosmetic surgery first started to become popular in the UK in the early 1980s it attracted very limited media coverage. Articles in magazines and newspapers were based on information from the USA and would only appear every few months. In total contrast, in the last few years a day doesn’t go by without some mention of cosmetic surgery in the media. Without doubt this surgical speciality attracts more media coverage than any other type of surgery.

Significant amounts of cosmetic surgery were done in the past, but patients tended to be quite secretive about having had it done and tried to avoid publicity. Also, there were very severe restrictions placed on doctors regarding advertising. If any doctor allowed his name to appear in print he risked being struck off and losing his livelihood. This has all changed now. Many doctors advertise openly, and some blatantly seek any publicity in order to increase their practices.

A word must also be said about the volume of advertising and advertisements in the media concerning clinics. Many clinics spend a lot of money with public relations (PR) companies to promote their services in the media. The more successful PR companies have a direct working relationship with editors of popular magazines and newspapers and can arrange for favourable articles to be published about their particular establishment. Quite often, media articles featuring wildly ecstatic patients are simply advertisements for the clinics concerned. We urge caution in believing everything you read, as there are some establishments that are extremely ruthless in the way they conduct themselves, and in our opinion they give cosmetic surgery a bad name.

It is easy to understand why the media publishes so many articles on the subject. The idea of anyone subjecting their body to physical assault in pursuit of enhancing their appearance attracts much criticism and controversy but, above all, the huge curiosity of the general public.

Nowadays, the back pages of both women’s and men’s magazines are full of advertisements for cosmetic surgery. In addition, television programmes on enhancing appearance by cosmetic surgery regularly appear on our screens.

From the point of view of the cosmetic surgeon, this media coverage is a double-edged sword. On the one hand, it increases the number of people seeking surgery, but on the other, the editorialising of many of these programmes can often lead to false hopes and ideas, making this a potential banana-skin situation for the surgeon. For this reason, most cosmetic surgeons who have been practising this speciality for many years will agree that patient expectations today are far higher than ever before.

Not all media reports about cosmetic surgery are favourable. Very often stories are incorrectly reported or overly dramatised to make them appear more unfavourable than they really are. The reason is simple. The more dramatic, controversial and unfavourable the report is, the more attention it will attract. Serious adverse incidents are, actually, very rare.

Government guidelines are now in place with respect to all medical specialities in an attempt to keep adverse incidents to a minimum. In addition, more stringent controls are being exercised regarding the suitability and qualifications of practitioners who perform these procedures. It is undoubtedly true to say that the vast majority of cosmetic operations and procedures are very successful and prospective patients should not be unduly apprehensive.