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Tuesday 18th October 2005, 9.00-9.30pm
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Programme 7. - Cosmetic Surgery


THURSDAY 18/10/05 2100-2130













Hello. Would you ever consider going under the knife to improve your looks? Has gravity taken too much of a toll on your eyelids, jaw line or breasts? Do the bags under your eyes mean people are always commenting on how tired you look?

Ok, so maybe not surgery, but what about something less invasive like Botox or lasers?

Have decades of smiling and grimacing left you with an unsightly frown mark, or one too many crow's feet? Or would you simply like a healthier, glowing complexion?

It happens to us all - no one can defy the effects of age and gravity forever. And despite the stereotypical images conjured up by cosmetic surgery, footballers' wives and ageing Hollywood stars aren't the only people giving it a go. Everyone's at it.

There is no such thing as an average patient. I had this image of people, typically sort of in their 30s and 40s who were now looking to go back to their 20s, if you like. Unfortunately it hasn't worked that way, we have age ranges from 18 to 80.

Cosmetic surgery is big business. British women spent an estimated £225 million pounds on improving their looks and figures last year - twice as much as they were spending just five years ago. And, as we'll be discovering later, an increasing number of men are trying it too.

I was always a quite confident person anyway but it just made me feel physically more confident. As I say I'm six foot two, I'm quite a good build now and I feel proud of myself and I can walk with my head held high and it feels very good. I've got to say when I first had it done I went through a bit of a guilt saga because obviously I spent the money and it was quite a lot of money and I was a little bit guilty afterwards but now I feel great about it.

My guest today is Mr Simon Withey, a consultant plastic surgeon at the Royal Free and UCH.

Simon, I want to start by examining those current trends. Why has it suddenly become so much more popular do you think?

I think there are number of things. I think the non-invasive, non-surgical products have changed people's perception of plastic surgery. They visit a plastic surgeon very much earlier in life and as a result feel much more comfortable when they go to see them about something slightly more serious.

And the non-invasive techniques you're talking about - the Botox and the fillers and the collagen

Exactly, the sort of things which people get - they describe as lunchtime plastic surgery, something to improve frown lines, improve creases and things like that and wrinkles. I suppose people have a lot more money, people have a lot more time to look after themselves than they may have done 15 or 20 years ago. Techniques have certainly become more sophisticated, so we can now sort of - we're slightly better at predicting what the results will be like. There's probably less sort of bruising and swelling with many of the techniques than there will have been beforehand and the complications are lower than they were beforehand. So I think...

Do you think there's stigma attached to having had plastic surgery?

Undoubtedly. I mean 20 years ago people wouldn't want to talk about it, now everyone talks about it. And if you go to a dinner party it's the main topic of conversation. They might not want to talk about their own but they're certainly very happy to talk about surgery generally.

Because America's always been ahead of us in the field of cosmetic surgery, in terms of numbers and acceptance over there and it's really taking off there, we're lagging behind aren't we here?

I mean America I think is probably an extreme example and South America's even worse. In America, you were mentioning your figures earlier, I mean it's supposedly since - in the last 10 years in the States there's been a 1600% increase in plastic surgery. Now that really is extraordinary compared to - compared to what's going on here. And South America's very similar, I mean there are an urban myth in Brazil that there's so much social cache from having a face lift that there are surgeons who are prepared to give you the scars of a face lift without having the full one, if you can't pay for the whole lot.

Is this increasing popularity accompanied, do you think, by raised and perhaps sometimes unrealistic expectations?

Yeah, that's something we've been seeing recently, I think particularly with the media exposure from aesthetic surgery programmes, I think people are coming in expecting that you can have a face lift and you can go back to work a couple of days later, that you're not going to have any bruising, that there are no complications, that you can walk in, have your operation and things will be absolutely fine. And I think they also think that they can change whatever they want into whatever they want. So those things like the celebrity makeover has sort of really distorted people's view about what surgery can achieve.

Do you actually turn people away and why?

Frequently. Some people come in with no physical deformity saying I want my nose changed and you look at their nose and it's absolutely perfect. And you have to gently say that it's really not going to be in your best interests to have it done. There are patients who have body dysmorphic disorders, so patients who again have very minor degrees of deformity and yet an exaggerated view of what the deformity is to them. And clearly they're people who are never going to be satisfied with surgery. And when you hear of patients who've had four nasal operations, two eyelid operations, a couple of breast operations this rings quite significant warning bells and they're patients who you very often ask a psychologist to see and the vast majority will be turned away.

Well one of the most significant recent developments has been the explosion in the availability of non-surgical cosmetic techniques like Botox, fillers, chemical peels and light based treatments.

Botox contains a potent toxin derived from the bacterium responsible for botulism - a potentially fatal form of food poisoning. It blocks the transmission of electrical impulses from the nerves to muscles resulting in paralysis that lasts around four months. When used in tiny amounts, and in the right place, this paralysing effect can be put to good use to smooth out wrinkles and creases caused by contracture of the underlying facial muscles - like forehead lines and crow's feet.

Manu Mehera is a cosmetic physician specialising in non-surgical treatments.

When they first come in obviously we explain the treatment to them properly, tell them a little bit about the Botox itself. We would then take photographs of them doing the expressions that concern them and then ask them well what is it that you're actually looking to do. And there must be agreement between what I feel is achievable and what they want to achieve because otherwise you'll end up in a situation where people can want some pretty unnatural things done. Following that it's a matter of actually preparing them for the treatment, explaining to them what we're going to do, it usually involves a very, very fine needle, it isn't as painful as it's perceived to be. It's often been compared to having acupuncture. Sometimes you'll have patients who will ask you - have you started yet - and well you've finished by then. I've had a wonderful patient - 27 year old girl - where she actually worked as a lawyer, you know she was told by somebody at work to say look you know people are actually getting a little bit - well I suppose the common thing that you seem to be a little bit angry all the time and she wasn't, she was just one of those people that when she expresses herself she just has a deep frown. And so it needed a little bit of gentle correction and she's very happy with the results and yes she's had a positive comments since.

Mr Alex Karidis is a consultant plastic surgeon at the St John's and St Elizabeth Hospital in North London.

The other thing that's quite commonly used are injectable fillers. Now fillers are basically a way to plump up any depressed or wrinkled area of skin on the face. And it's very, very effective. The only other non-surgical treatments that we can use to improve texture of the skin are chemical peels. In addition to that you can also have I suppose laser resurfacing to improve very, very sun damaged skin but that does require a little bit more recovery.

But even non-surgical procedures can go wrong, though the effects tend not to be as dramatic as with surgery and may be fully reversible with time. After all Botox does eventually wear off. But a disgruntled patient doesn't always mean the procedure's gone wrong. Manu Mehera again.

Was it the patient's expectations or was it genuinely somebody who perhaps didn't treat them as well as they could have been treated? And it is a very careful process in which you must find out exactly what went wrong and what correction they're looking for and what expectations they have. And sometimes it's a matter of reassuring somebody that no you didn't really have bad treatment, this is all that can be done for you. Or this is a recognised problem with whatever therapy you might have had and if need be we can effect a correction.

But, as with surgical techniques, the results depend very much on the skill and experience of the person doing the procedure. Yet fully qualified cosmetic surgeons often charge no more for non-invasive procedures than most walk-in high street clinics.

You know at the end of the day we live in a competitive world and I don't think that you can suddenly hike up your prices just because you're a respectable establishment, I don't think that's fair and right. Because I think the way I look at it is that certainly the non-surgical treatments are treatments that need to be maintained, they're not a one-off, by and large you have to repeat them every three to four months or sometimes six months. And so if you're going to be charging huge premiums it doesn't make it possible for people to undertake these treatments through the fact that they're expensive.

Surgeon Alex Karidis.

You're listening to Case Notes, I'm Dr Mark Porter and I am discussing cosmetic procedures with my guest plastic surgeon Simon Withey.

Simon, what do we know about the safety of these non-invasive procedures? Let's have a look first in the sort of medium term, what can go wrong?

Well in the medium term most of them will disappear, so whatever effects you create if you don't like them are likely to improve. However, with some of the fillers you will get some scarring and sometimes you do find scarring will persist for extremely long periods of time and you may find that it never disappears completely. In terms of sort of immediate problems, particularly with Botox, you can get asymmetry, which is correctable by putting some more Botox the other side but it may not be a look you particularly want. The most worrying one is clearly ptosis of the upper lid where Botox sort seeps in to the area around the muscles which lift up the lid and that gives you a very visible degree of ...

Look like you're half asleep.

They droop, yeah. And the trouble is it's one-sided as well, so it's even more obvious.

Nothing you can do until the Botox wears off.

Well the lid is - there are various muscles which lift the lid up and you can give something which stimulates the lid, one of the other muscles in the lid, to lift up which can make a bit of a difference but very often people are stuck with a little bit of asymmetry. It happens very rarely, I mean these things are on the whole very safe and straightforward.

That's - your biggest risk probably is you're not going to end up with the cosmetic result you quite wanted from having these procedures and that's why it presumably pays to choose someone who's extremely experienced at it because anyone can do these can't they?

Anyone seems to be doing it at the moment, there's certainly a lot of people who don't seem to be fully aware of where the muscles are and the potential ...

And you put it another way so you're not being nasty to anybody, I mean I, as a GP, could go on a Botox training course, which might only consist of a morning and then set myself up as a cosmetic physician without any trouble at all. But I mean I have no idea about the facial muscles of the face, I'm embarrassed to say.

Yeah, no I think that's very true and I think - I think you do have to choose as carefully when you're looking for someone to do these treatments as someone doing more major surgery because the complications in the immediate term are as significant in many ways.

The vast majority of cosmetic procedures may be performed on women at the moment but a growing number of men are considering them too, as Claudia Hammond discovered.

So John what I'm going to do now is just clean your forehead, okay? So just close your eyes. Okay, so give me a frown John, look angry, yeah I can see your muscles tightened up, just relax. John, just relax your frown. Okay, little injection coming up, just now ...

John is only 25, he's come to see consultant plastic and cosmetic surgeon Adrian Richards to have his first Botox treatment. He's hoping to rid himself of his frown before it sets in for good.

Just above my brow line just to stop me from frowning so much.

But you haven't got a line there.

Not yet no, I'm a bit of a worrier sometimes and when I'm concentrating, I'm biting my lips and frowning a lot and I just thought about for a little while because I tend to get a few headaches and I'd spoken to Mr Richards about it, I've known him for nearly about a year now, and I've spoken to some of his patients as well who'd had the procedure and the sort of outcome looks fantastic, so thought I'd give it a go, see how it goes and if I like it I might keep going with it.

I mean John would be on the relatively early spectrum of treatment because he hasn't really developed any frown lines at the moment. But if you see him frowning here ...

Yes, there are two lines.

And what will happen is in his 30s those lines which aren't apparent now will start to actually etch into the skin and then by late 30s, 40s they actually become ingrained. The important thing about men's muscles are they're bigger, particularly the frown muscles are approximately twice the volume of a woman's muscle. So you need roughly twice the amount of Botox.

At private hospitals like this one - the Shelburne in High Wycombe in Berkshire [sic] - cosmetic surgeons are seeing more and more men who want to look better.

Men are very straightforward about their faces, they almost treat it as a car, they say I don't like this - my neck's getting saggy or I've got jowly, I don't like it and I want it fixed. So what we don't want to do is change the way someone looks, so they look like them but a younger fresher them. In fact my father, who had a face lift, what happened to him he got married to a younger woman and then had a child and he was feeling in the playground and he was socialising basically with people that were younger then him, so he had a face lift and was fine with it.

One of Adrian Richards' his recent patients was Vincent Roe, who came to see him after losing 10 stone which left him with a large overhang of skin around his abdomen.

Under clothes it doesn't - people don't know but I always knew and I only did it for myself, I didn't do for anybody else, sounds pretty selfish but it wasn't meant to be selfish because I wanted to be comfortable about myself.

And how did they actually go about doing it?

I try desperately not to think about that. What they actually did, obviously it's a general anaesthetic, it's a four and a half hour operation, they cut - I've got a two inch gap at the back of my spine where there isn't a scar and then it basically cuts all the way round, take away the excess fat, pull it all down, create you a new belly button and then stitch you back together again. Basically to give you an idea the surgeon cut off half a stone of excess skin.

That must have been quite some wound to recover from, was that painful?

It wasn't so much painful it was more uncomfortable. Certainly straightening up again when you've had it done initially, it feels quite tight because obviously that's the intention, it all needs to be tight again.

After his surgery, Vincent found that he not only looked better, but felt better about himself.

I was always a quite confident person anyway but it just made me feel physically more confident. As I say I'm six foot two, quite a good built now and I feel proud of myself and I can walk with my head held high and it feels very good. I've got to say when I first had it done I went through a bit of a guilt saga because obviously I spent the money and it was quite a lot of money and I was a little bit guilty afterwards but now I feel great about it.

Can I ask you how much it cost?

It was about seven and a half, eight thousand pounds.

Vincent is unusual in that he talks openly about his surgery. Adrian Richards finds that most of his male patients want to keep it secret from their friends and this is where being a man can help.

Face lifts are actually slightly easier to perform in men because the skin's much thicker, so the bruising doesn't tend to show so much and also because they've got hair in their sideburn region the scarring's hidden within it. So what I tend to do with men is ask them to grow their sideburns low, Elvis Presley like, just before the operation and then the skin's lifted up, so typically four centimetres of skin will be removed. So they might look a bit unusual for the couple of weeks before but you know it hides the scar afterwards. I had a very interesting gentleman who's a builder, so he had his face lift, and what he did, very craftily, because he used to go to the pub every night, so he didn't go to the pub for a week and grew a beard after the operation, so he went with his beard back to the pub and people couldn't really see what was going on underneath. And then two months later he shaved his beard off and all his pub colleagues sort of - you look so much younger, you look great.

There's nothing to be afraid of, at the end of the day so many women have it done why shouldn't men have it done, I think that's a very fair thing to say, that men deserve the opportunities as well.

There's sort of a certain amount of expectation on men when they go out to look their best, so I definitely think if people see the effects on men that they might think yeah I'll go for it. So I might be a pioneer, you never know.

John and Vincent talking to Claudia Hammond.

Simon, what else can we do to prevent the signs of ageing, we talked there about the possible use of Botox early on but what's the best way of looking after our complexion to prevent the signs of ageing or slow them down, can't prevent them?

Possibly avoid going to the South of France on holiday. I think ...


The sunshine is the worst thing - sunshine and smoking. So if you can stop smoking and you can make sure you wear a hat when you go on holiday and you can cover your face with full factor sun block you'll find that your face and your skin ages very much more slowly.

Going back to recovery times, we heard there about that chap who grew his beard, I thought that was quite a clever way of doing it, shaving the beard off and saying oh you look much younger. What about women - how long before they can go back and meet their close friends without their close friends knowing that they've had surgery - without seeing the scars?

I mean there is this great dilemma that people have. On the one hand they don't want everyone to recognise they've had surgery but on the other hand they do want people to recognise that there's something different about them. And very often they'll sort of - I think as Adrian suggested - they'll be quite clever about it, they'll take a holiday, they'll possibly go away somewhere so they have a bit of a tan and they'll come back looking quite a lot better.

What about the scars though, I mean are they not visible, I mean if you've had something done to your eyelids, for instance?

Well eyelids are pretty good, I mean eyelid scars do settle very, very quickly and you hardly notice them after a week to 10 days, very difficult, sometimes you go back as a surgeon to look at the scar at three weeks and the upper lid, particularly, and not see anything at all. The face lift scars certainly show a little bit more and scars do go through this period of maturation, so for a week to 10 days they're looking great and then slowly they get a bit pinker and they thicken up but at three months that will settle down completely.

Do many people do an Anne Robinson and come clean and say look I've had a face lift don't I look fantastic or do you think I look fantastic?

Yeah some of them do, some of them are forced to, I think most would choose not to. But some of them - I mean I've had a patient recently who acted as a guinea pig for a group of 10 of her friends and she was the one who was sent forward to go and have the face lift, they'd all talked about it, they all chose a surgeon - I think they picked straws one evening at dinner - and decided who was going to go first. And she came along and she talked about the experience with friends afterwards and we've a flow of various other patients who've come in since ...

Well the rest have been in since have they. I mean one of the problems I think that people have a perception of plastic surgery is they see people who've obviously had too much and have this sort of super taut stretched appearance and look a bit ridiculous sometimes. What you don't notice is the good plastic surgery where you just look very good for your age.

I think things have changed a lot actually. I mean the Californian face lift and nose jobs of the '70s have moved on. I think we understand really the anatomy of the face a lot better and what we can do to achieve an effect without things looking tight. I mean it's no longer about pulling on the skin, it's more about changing the volume of the face and lifting fat pads up to different positions and changing the face from being sort of square at the bottom to being much more round at the bottom and losing the volume at the bottom and moving it upwards. The idea of the wind tunnel look is something which most of us have moved beyond.

Glad to hear it. Okay now on to another common procedure - breast augmentation, known colloquially as the "boob job". Not a new procedure, but more popular than ever, and there's more than one way to go about it. Jacqueline Lewis is an oncoplastic breast surgeon at the Charing Cross Hospital,


All implants are made of a silicon shell and when you talk about the different implants you're implying that they're filled by something different. So when people talk about silicon implants they refer to silicon gel-filled implants and when they refer to saline implants, that's the salty water ones, it's the filler that's saline. We used to have on the market hydrogel implants and soya bean oil implants or trilucent implants, as they were called, but they have now been withdrawn from the market.

And those were withdrawn for what reason?

They were found to change in volume - the hydrogel ones - and the trilucent implants were found not to be satisfactorily safe in the long term.

There has been some concern of course about silicon implants as well, and I gather in the States that's one of the reasons why saline implants have become more popular.

There was a withdrawal of all of these silicon gel-filled implants in the States because one of the big companies went bankrupt and ...

They went bankrupt because they were being sued weren't they.

Yes and not because there was ever any real evidence to say that silicon was detrimental to health, it was because the company couldn't actually afford to defend all the cases brought against them. But more recently now, because no evidence has been brought forward and proven that there is a danger with silicon gel, they have actually introduced certain silicon filled implants on to the market in America. In this country we had an independent review group of people who looked at all of the research and all of the literature about silicon gel-filled implants and they came up with the view that there was no increased risk of breast cancer, of any real risk of significant connective tissue diseases and therefore we have always in this country been able to offer women silicon gel-filled implants.

Which do give a slightly better cosmetic result.

Well a bag of water will ripple and wrinkle and shake in your body like a bag of water, unlike gel that has the consistency of breast tissue.

Does it matter how the implants are put in - and what's the most common approach for doing it?

In this country a lot of surgeons use a little incision just beneath the breast in the inframammary crease. There are two areas where they are put in, behind the breast gland or behind the muscle. There are other access incisions, in and around the areola, which is the coloured part around the nipple or even through a small incision through the armpit. One of the less common areas that's used to introduce the implant is through a little incision around the naval and this incision is really only used for saline filled implants that can be rolled up and filled once it's in place.

So going in through the tummy button and literally burrowing up behind and then when the implants laid out you then pump it up with a ...

Yes. And so ...

No scars, I presume, that's the advantage is it?

Well the scar is around the naval.

Left to their own devices how long can you leave these implants in, what happens 10, 15 years down the line?

We know that the implants that were put in 20 and 30 years ago we're removing because some of them may have ruptured and we find leakage of silicon beyond the shell and it can cause what we call silicon granulomas. These are the old implants, they used to be made with very thin shells. Nowadays they make them with much thicker shells and they use cohesive gels that don't tend to move around if by chance the implant shell does rupture. If you talk to the manufacturers they say these implants may last a lifetime. But I question them - if you're putting them into a 20 year old you're going to have to ask that implant to last 60 or 70 years, so I always say to women you probably will have to have something done at a later stage and we don't know at what stage that is, but certainly factor that into your decision to have implants.

Breast surgeon Jacqueline Lewis.

Simon, let's talk about probably the most important thing of all and that's choosing the right person to do the operation, because it is a bit of a minefield out there?

I think it can be and I think it's probably getting a little bit more difficult as well. The answer's certainly not to choose from the back of Yellow Pages. It is difficult. You know I would suggest that people talk to friends and use guidance from them, although that can be quite difficult because someone who might have performed a very good face lift might not perform as well doing breast surgery or liposuction. GPs are often a good way to go and find out about well known plastic surgeons in the area and people who are ...

Yeah we often know the people locally don't we and who we'd send our wives to or go to ourselves but people are a bit embarrassed sometimes about going to see a GP, they don't want us to know.

You very often find that you ask a patient whether you can communicate with their GP because it's quite helpful beforehand to have that dialogue and some are very uncomfortable. They may have started the conversation with the GP and found that someone was quite dismissive, I think that happens rarely now. But I think you can go to what are effectively the trade organisations for these surgeons, which are British Association of Aesthetic and Plastic Surgeons, who look after aesthetic plastic surgeons in the country and the similar trade organisations, for instance ENT surgeons who perform some rhinoplasties. So I think ...

Nose jobs.

Yeah, the nose jobs. And if you go to those groups they will have a group of surgeons who are accredited, who all adhere to a certain code of conduct.

What about people who go abroad, driven by price mainly, who are looking for a bargain?

Yeah we're seeing more of that, I mean we're often picking up the pieces, both privately and in the NHS interestingly, and we're finding that's an increasing problem. I think the difficulty is that when you travel 5,000 miles and you decide to change your mind on the day of surgery it's a very difficult thing to do, you know very often we will get patients who a couple of days before surgery ring up and say actually I'm not quite comfortable with this at the moment and off they'll go and maybe they'll come back to you, maybe they won't. When you're in South Africa or wherever - I mean I'm not choosing South Africa specifically because they have a lot of problems, but it is a place that a lot of people go - it's a very different situation to be in. Very often they won't have met their surgeon in this country, they'll travel abroad, they'll have it done. If they then have a problem, if they're back in England, it's then very difficult to know who should pick up the pieces.

You talk about meeting the surgeon there, now that - before the operation - but that doesn't always happen here in the UK necessarily does it, I mean there are organisations that will assess people, I mean I've heard of patients who've been seen effectively by a non-medical sales advisor.

Well that would ring alarm bells immediately and it should. I mean no one should accept that because you have to be assessed to see whether you're suitable for surgery, it's not a question of selling the - or agreeing to sell a product to someone. The first meeting is all about deciding whether there is something physically which can be improved and whether the patient is physically well enough to have it done, whether they're fit enough to have an anaesthetic, but also whether they're psychologically attuned to what might be done. At the end of the first meeting you should really just be getting the feel for the patient, the patient should be getting the feel for you, then you should leave each other for a couple of weeks and come back and have a more detailed discussion about what the procedure involves.

Simon, I'm afraid we're going to have to leave it there. Mr Simon Withey - thank you very much.

Next week's programme - the last in the current series - is all about vitamins and supplements, including why the Food Standards Agency is concerned that the UK's best selling supplements - multivitamins and cod liver oil - could be damaging older people's bones.

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