What will surgery look like after lockdown?

The Coronavirus pandemic will have changed life for all of us in recent times. Surgery and medicine are at the forefront of its impact. Specifically, this will have had a significant impact on aesthetic surgery. Aesthetic surgery is elective surgery – therefore it needs to be as safe as possible and, in this case, we need to minimise the risk of lung complications and other potential COVID related side effects.

Bearing this in mind I have been having numerous conversations with colleagues, both surgeons and anaesthetists, about how we can maximise the safety of my patients in the future, once elective surgery can start up again.

One very promising approach is to reduce the number of patients having general anaesthetic procedures, making more use of sedation and local anaesthetic. This is something we already do for a variety of procedures, so we have a lot of experience with it. Therefore, extending its use to more procedures is something we are very comfortable with in the future.

For example, in the same way as caesarean sections are performed with spinal anaesthesia, we could perform tummy tucks in a similar way. We already perform local anaesthetic facelifts for less invasive approaches, so adding sedation will help us to perform more extended and involved facelifts in a safe and comfortable environment. Finally, breast surgery is an area that we can perform under local anaesthesia with sedation by combining the use of local anaesthetic with “regional nerve blocks” where some of the main nerves that provide sensation to the breast are targeted by specific injections.

Whilst these approaches may add some time to the procedures, they might help increase the safety profile with respect to COVID-19, and therefore I feel that this is an approach well worth considering. Every case will be reviewed on an individual basis, and the best overall plan made for each of my patients.

Exactly how we will be doing things moving forwards is still uncertain. We have the advantage of watching how other countries are starting back up – from Europe to the US, so we will be able to learn what works (and what doesn’t) from them.

Coronavirus testing will inevitably be crucial – when quick results turnaround testing becomes more widely available it will be transformational. Prospective surgical patients will be tested (and isolated as appropriate between testing and results) but also staff will need to be tested on a regular basis to ensure they are not asymptomatic carriers of the disease.

I am sure testing like this will become routine in due course, but again, I don’t yet know when.

So, there does seem to be some light at the end of the tunnel, but we should not be too hasty in getting back to elective surgery until we are as confident as we can be about minimising risks to our patients and the healthcare staff.

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ALCL – how do I know if I may have it? What does it look like? What should I do?

I wanted to write a blog to talk about BIA-ALCL – breast implant associated anaplastic large cell lymphoma.  There is a lot written about it in the media at them moment (and rightly so) but unfortunately I see a lot of inaccurate reporting and understandably lots of worry is created.

BIA-ALCL is a rare form of lymphoma (cancer of the immune system) associated with textured breast implant surface. To date, no causal relationship has been found – i.e. we do not know if textured breast implants cause ALCL, but we do know that in all cases of BIA-ALCL so far, the patient either has or has had a textured implant in place.

Not all texturing is the same – it seems that the rougher the texture, the greater the association. In my practice for many years I have predominantly used Mentor (Johnson & Jonhson) breast implants, which have microtexturing, in other words, fine texturing. The best estimate for the development of BIA-ALCL with Mentor textured breast implant is around 1:86,000, so fortunately, very unlikely. Furthermore over 90% of cases are cured by removal of the breast implant and surrounding capsule (scar tissue).

So…how would you know if you were developing BIA-ALCL?

The most common symptom is spontaneous breast swelling (usually one but can be two) normally at around 8-years after the implants were put in. Therefore if you notice one of your breasts starting to swell, please seek medical attention straight away. There are benign causes of breast swelling too, so just because your breast starts to swell, it does not necessarily mean you have developed ALC. In fact, the last 3 patients I have seen with this symptom all proved to have benign underlying causes.

Sometimes patients present with a lump they have found, so it is important that you regularly check your breasts for lumps once a month, as normal.

What happens if I have a swollen breast?

The first thing, as I mentioned above, is to seek medical attention – either come back to see me or see your GP. After a careful medical history and clinical examination, an ultrasound scan may be organised. This is useful for two reasons – the first is to identify whether there is fluid around the implant causing the swelling; the second is to enable a needle to be introduced to take a sample of the fluid to be sent off for testing.

There are very specific tests for BIA-ALCL that can be done on any fluid that collects around an implant.

What happens if the fluid comes back diagnosing BIA-ALCL?

If you were to be diagnosed with BIA-ALCL there would be some more tests that would need to be done, and your situation would be discussed in a breast cancer MDT (multi-disciplinary team meeting). If the tests suggest that the ALCL is confined to the capsule (which it normally is) then surgery to remove the breast implant and capsule would be planned.

If there is more advanced ALCL (which is much less common) then other treatment options as well as surgery might be suggested, such as chemotherapy and radiotherapy.

 

It is important to state again that this is a rare entity and by far the majority of cases are completely curable with surgery, which I hope is reassuring.

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Dr Instagram…

With so much information out there on the Internet of a variety of quality, it can be hard to know where to look for credible and honest information. Social media is such a dominant presence on-line, that many doctors are using it to educate and update their followers about a wide range of topics.

I have been using Instagram for just over a year, and I’ve found it incredibly helpful to demonstrate and discuss all sorts of aspects of plastic surgery. These include how operations are done (with some actual video clips from the operating theatre), updates on the world of plastic surgery (as well as the latest news from conferences around the world) and educational pieces and photographs that I hope my followers find interesting!

My Instagram handle is @marcpacifico – why not have a look (and follow me!) to see the sort of content I post.

With such a fast paced and ever-moving world, I think Instagram provides an excellent platform for me to keep you informed and educated about my world of #plasticsurgery

If you have any questions or would like me to post on particular topics, please let me know, or message me directly on Instagram!

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A short note about risk

As you will appreciate, there are risks with any medical or surgical procedure. These risks vary, and some of the variation will depend on the procedure itself, whilst other influences will include your medical and genetic background, smoking and sun exposure history and more.

On the whole, the incidence of surgical/medical risk is quoted according to population studies. In other words, a study may, for example, look at 1000 patients undergoing a particular procedure and work out the number (or percentage) who get a wound infection. They may find that, say, 5% of the study population get a wound infection. This figure may then be used as an indication of the likelihood (or risk) of getting a wound infection if undergoing this particular procedure.

So, if you then read that there is (in this example) a 5% risk of wound infection it gives you some information. However, whist you may hear that there is a 5% risk, it does not (and can not) tell you whether you will be in the 5% who get the wound infection, or the 95% of people who do not! So, perhaps not as helpful a statistic as it appears at very first glance…

How you interpret this statistic is also very individual and varies between people.

In addition, how the risk is presented to you can significantly influence your thoughts. For example, you may feel that 5% is quite a low risk, however, if you were told that the risk of infection was 1 in 20, you may feel that is high. In reality of course, these statistics are exactly the same.

At the end of the day, no-one can undergo a procedure with zero risk. Therefore everyone must weigh up the pros and cons of exposing themselves to risk, and then take a view on whether they feel it is “worth” exposing themselves to risks – of a complication, an adverse outcome or the risk of potential dissatisfaction with a procedure.

Surgery is not an exact science – there are factors out of the control of the surgeon and the patient. These are a result of genetics, smoking history, sun exposure, environmental factors, and many more.

Whilst risk cannot be eliminated, it can be minimised and I will always strive to do this, with my advice, surgical technique, and after care instructions. Importantly, if you are unlucky enough to have a complication, I will always ensure I look after you and get you through it.

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Detailed information about BIA-ALCL

I have recently received an email from the American Society of Aesthetic Plastic Surgeons (ASAPS) that provided a clear and well-written detailed patient guide to anaplastic large cell lymphoma, something that I always discuss with my breast implant patients. This is a very rare, but important, breast implant-related cancer of the immune system, that is being discussed more in the media.

I thought it would be useful to publish the ASAPS Q&A patient guide here. If you have any more questions or concerns, please do not hesitate to get in touch.

BIA-ALCL: Patients’ Frequently Asked Questions

Q: What is BIA-ALCL?

A: : BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma) is a rare spectrum of disorders that can range from a benign collection of fluids around the breast implant (seroma) to a rare lymphoma. BIA-ALCL is not a cancer of the breast tissue itself. When caught early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.

Q: What are the symptoms of BIA-ALCL?

A:  The first symptom of BIA-ALCL is usually a swelling of the breast between 2 to 28 years after the insertion of breast implants, with an average of about 8 years after implantation.  The swelling is due to a collection of fluid surrounding the implant. This fluid can cause the breast to enlarge significantly over a period of days or weeks. It can also present as a lump in the breast or armpit, firmness of the breast, or pain. It is usually easily and completely treated if patients see their doctor at the first symptom.

Q: What is the risk of developing BIA-ALCL?

A:  Based on current data, the risk can be explained by the texture grade of the implants as follows:

  • Grade 1 (Smooth only) – The current lifetime risk is zero.
  • Grade 2 (e.g. Microtexture, Siltex and similar) – 1:82,000
  • Grade 3 (e.g. Macrotexture, Biocell and similar) – 1:3,200
  • Grade 4 (e.g. Polyurethane) – 1:2,800*

Q:  Have there been any deaths due to BIA-ALCL?

AThere have been 16 confirmed deaths, (globally), attributed to BIA-ALCL since the disease was first reported nearly 20 years ago. However, when detected early before it becomes a lymphoma, BIA-ALCL is readily cured with removal of the implant and surrounding scar pocket or capsule.

Q: Is it a problem with Saline or Silicone implants?

A: Of the 414 reported cases of BIA-ALCL, 312 reports included information on the types of implants used. Of those,234 reported implants with silicone gel and 119 reported implants filled with saline. It appears to purely be related to the surface of the implant and not to what the implant is filled with.

https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm481899.htm

As of September 30, 2017, the FDA has received a total of 414 medical device reports (MDRs) of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), including 9 deaths1. BIA-ALCL are counted for those with a confirmed pathology test, or ALK or CD30 biomarkers, or reported by health care professionals. There are 272 reports with data on surface information at the time of reporting. Of these, 242 were on textured implants and 30 on smooth implants. There are 413 reports with data on implant fill type. Of these, 234 reported the use of silicone gel-filled implants, and 179 reported the use of saline-filled implants.

Q: How does this impact those with breast implants?

A: ASAPS and ASERF emphasize that the most important issue for women with breast implants is to screen for breast cancer with self-exam, a regular physician exam, and mammography/ultrasound/MRI as recommended by their physician.  All women should see their plastic surgeon immediately if they note a change to the size, feel, or shape of their breasts.

Q: Why would my surgeon have recommended textured implants for me?

A: There are two primary reasons your surgeon may have recommended textured surface breast implants. First is that some data has shown a lower rate of capsular contracture (firm scar tissue formation around the implant). Second, all teardrop or anatomic shaped implants have a textured surface to help hold them in place. Some surgeons believe these implants can offer an enhanced shape for certain patients, perhaps with a reduced risk of rippling.  

Q. How is BIA-ALCL treated and what is the prognosis?

ACurrent recommendations for the treatment of BIA-ALCL call for bilateral capsulectomy (removing all the scar tissue) and removal of the old breast implants. This is a very common procedure performed by plastic surgeons, identical to what is done when an implant has ruptured or capsular contracture has developed. Smooth implants can be put back in or the patient can choose not to have implants. In all but a few cases, the disease has been fully resolved by this surgery alone. The majority of patients require no additional treatment. However, if the disease has spread to lymph nodes or adjacent tissues, chemotherapy or radiation may be necessary. This has only been necessary in a small percentage of patients.

Q: Should patients have their implants removed because of a risk of BIA-ALCL?

A:  Since BIA-ALCL has only been found with textured breast implants, smooth implant patients do not need to be concerned.  For textured implant patients, neither the FDA nor any plastic surgery society currently recommends that women should preventatively remove textured breast implants to prevent BIA-ALCL. However there are women who have been concerned enough about BIA-ALCL and have chosen to have their implants removed. There are some women who were already considering a breast implant revision, and the BIA-ALCL issue gave them one more reason to decide to proceed.

Q: Should women with breast implants be screened for BIA-ALCL?

A: There is no blood test to specifically screen for BIA-ALCL. The expert opinion is that asymptomatic women without breast changes do not require more than routine mammograms and breast exams. But if a patient experiences a change in her breasts – especially if there is swelling or a lump – she should undergo immediate examination, imaging, and consultation with a plastic surgeon. If there is fluid around the implant the fluid should be aspirated under ultrasound guidance and sent for analysis.

Q: What causes BIA-ALCL?

A: ASAPS, ASERF, the FDA, and the implant manufacturers are intensely studying BIA-ALCL. To date, no specific causal factors have been identified.  Implant texturing, bacteriologic contamination, and genetic factors have been implicated and are undergoing further study.  The best theory today is that a combination of four factors are required for the development of BIA-ALCL: 

  1. Highly textured implant
  2. Chronic bacterial-inflammation
  3. Genetic pre-disposition
  4. Time

The source of the chronic inflammation is thought to be bacteria that have been identified around the implants in affected breasts.  Evidence is accumulating that a long-term inflammatory response to the presence of these bacteria is one of the factors that may cause BIA-ALCL. Research is ongoing and cases are being monitored.

Genetic factors may play a role. Some geographic areas have reported very few cases. Ongoing data collection worldwide will help to determine whether or not there are any genetic propensities for this disease.

Q: Does ASAPS recommend against the use of textured implants?

A: The available data does not support discontinuance of textured implants. The best practice is always for the physician to discuss with each patient the known risks and potential complications associated with any procedure. It is important for the patient and her doctor to frankly discuss all options available, and the risks involved.

Every plastic surgeon offers patients options regarding breast implants in terms of sizing, shape, and surface. Depending on a particular patient’s needs, a textured implant may be preferable. The plastic surgeon must provide a frank and transparent discussion regarding the benefits and risks of implants, both smooth and textured.  The patient must then make an informed decision, based upon her own assessment of her needs and the risks involved.

 

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Statement on “Breast Implant Illness”

There exists a cohort of women who request breast implant removal because of what has been referred to as “breast implant illness” (BII), a term used to describe a constellation of symptoms they attribute to their breast implants. However, there is no known medical or pathophysiological explanation for their symptoms and there is no diagnostic testing for BII.

Social media groups exists and discussions include mention of symptoms such as generally feeling unwell, fatigue, chronic pain, rash, body odour, irregular heart rate, anxiety, neurological abnormalities, hair loss and endocrine (hormone) dysfunction.

It has been speculated that some symptoms in some patients may be attributable to very low-grade infection after implant placement, perhaps with unusual organisms (such as fungal spores). However, to date, there have been no bacteria or fungi detected women who describe themselves as having breast implant illness.

Around 50% of posts about BII on social media appear to describe symptom improvement after implant removal.

From my perspective, I treat each of my patients as an individual. Whilst there appears to be no medical evidence for breast implant illness, if a patient seeks my help and desires removal of her breast implants in the hope that various symptoms she is experiencing will be improved, I will always listen, and try to help. I will, however, stress that I cannot predict whether removing her breast implants (with or without the surrounding capsule of scar tissue) will have any effect on her symptoms and only time will tell.

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Position Statement on Breast Implant Illness

There exists a cohort of women who request breast implant removal because of what has been referred to as “breast implant illness” (BII), a term used to describe a constellation of symptoms they attribute to their breast implants. However, there is no known medical or pathophysiological explanation for their symptoms and there is no diagnostic testing for BII.

Social media groups exists and discussions include mention of symptoms such as generally feeling unwell, fatigue, chronic pain, rash, body odour, irregular heart rate, anxiety, neurological abnormalities, hair loss and endocrine (hormone) dysfunction.

It has been speculated that some symptoms in some patients may be attributable to very low-grade infection after implant placement, perhaps with unusual organisms (such as fungal spores). However, to date, there have been no bacteria or fungi detected women who describe themselves as having breast implant illness.

Around 50% of posts about BII on social media appear to describe symptom improvement after implant removal.

From my perspective, I treat each of my patients as an individual. Whilst there appears to be no medical evidence for breast implant illness, if a patient seeks my help and desires removal of her breast implants in the hope that various symptoms she is experiencing will be improved, I will always listen, and try to help. I will, however, stress that I cannot predict whether removing her breast implants (with or without the surrounding capsule of scar tissue) will have any effect on her symptoms and only time will tell.

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“Its not what you want, its what you can have”

Breast augmentation is a particular and unusual plastic surgery procedure regarding the influence and decision making a patient is involved in prior to surgery. This is why typically, the pre-operative patient journey can be more involved and takes more time than for some other more complex procedures.

However, therein lies a challenge in itself. I have had numerous consultations in which the patient’s hopes and outcomes have been fairly fixed in their minds before they have even met me. This may be because of what they have seen on the internet, or perhaps because of what friends’ may have had my friend had 350cc implants, so I would like those too” is something I have heard more than once).

But we are all different! In this case breasts are different on everyone (and are even always different on each woman – “sisters, not twins”). Therefore there is no “one size fits all” breast implant, or decision-making that suits everyone. There simply cannot be.

The planning and decision-making in breast augmentation is determined by your individual characteristics. These include careful measurements of your breast (width, height, soft tissue thickness etc.), the position of the nipple on the breast, the looseness of your breast tissue (think 20-year old with no children, compared with 45-year old with 3 children) and more. These factors are used by plastic surgeons to work out what range of breast implants would fit your breast well (much like a hand comfortably fitting a glove) and produce a good result.

Therefore, whilst your desires are always taken into account in determining the best implant for you, they are constrained by your anatomy and other factors. Furthermore, decision-making should ideally “future proof” your result. An implant is unlikely to change over 5-10 years, all being well, however your breasts will age and change, which also needs to be taken into account.

If, despite this explanation and determination of what I feel is the best advice, a patient insists on wanting me to do something I am not happy about, I would not go ahead, or very clearly explain the implications of their request and ask them to go away to consider my viewpoint. Most commonly, this might be because their implant size request is overly large for their breast, or perhaps they really need a breast lift but want an augmentation alone.

Therefore, as much as we, as plastic surgeons, would like to give our patients what they want, we really have to give them what they can have, as dictated by each individual’s body.

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Reflections on Expectations Part III

As a plastic surgeon, it can be frustrating not to achieve the best possible outcome or result every time we operate. However, unfortunately (as some might view it) there is no uniformity to the results that can be achieved with plastic surgery procedures. There is no catalogue that a patient can choose a desired nose or breast from and no plastic surgeon can guarantee a particular result (please treat claims such as guaranteed not to bruise or totally invisible scarring with a significant degree of suspicion!)

Whilst this may seem incredibly obvious, a significant number of patients will (perfectly reasonably) bring to consultations screen shots or print-outs of results they have seen on the internet that they would like to emulate. It is infrequently possible to do this, as the result that can be achieved for any procedure is entirely dependent on the patient’s starting position, particularly with respect to their anatomy, genetic make-up and other history (smoking, pregnancies, weight loss etc.)

For example, if someone has widely spaced apart nipples, no matter what technique of breast augmentation performed, their nipples will remain widely spaced apart. If someone has a droopy breast with low-lying nipples, they are unlikely to achieve a satisfactory result from a breast augmentation without a breast lift.

If someone has thin, sun-damaged skin and is an ex-smoker to boot, they will not achieve the same quality or longevity of a facelift as someone who has better quality, less damaged skin. These are examples inescapable situations that have a direct impact on the result an individual patient can hope to achieve.

This is why a crucial part of the consultation process is termed “patient education”. This encompasses, in the first place, understanding and becoming aware of your starting position and its impact on decision making and future outcome. From there it leads on to a discussion about what is reasonably achievable in you, personally, and what factors contribute (positively and negatively) to your likely outcome. A recent example is a 45-year old mother of 3 coming to see me showing me “before and after” pictures of 24-year old patients who have not had children. After examining her and educating her about her breasts, their skin and soft tissue support quality and nipple position, she recognised the lack of reality in her expectations, and was able to re-adjust her expectations in to line with a much more achievable goal (and hence vastly improve the chances of her happiness with her result).

Even with all of this in mind, there is still a variation in results – after all, as plastic surgeons we are working with mobile soft tissues and skin, as opposed to rigid materials that will stay where we put them if we fix them securely enough. Hence being unable to judge someone’s surgical result until a few months after surgery once the swelling has subsided.

Therefore, there is a proportion of any patient’s result that is predictable and is within our control (as plastic surgeons), but there is also a proportion that is out of our control – predetermined by pre-existing factors, anatomy and genetics.

I wrote this blog not intending to be “glass half empty” and negative, but in fact to help anyone reading’s expectations to be realistic and gain an understanding of influences that may not have crossed their mind. In that way, I hope it has been useful reading!

 

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Highly Commended at the Diamond Awards for Safety in Beauty

On 7th July I attended my first Diamond Awards for Safety in Beauty, one of the most prestigious awards events in UK aesthetics and plastic surgery. It really focuses on patient safety, quality of outcomes, patient feedback and overall performance as a clinician.

 

I was very honoured to have been nominated in the category of Best Cosmetic Surgeon (I have been told it was by a colleague and two patients, but I am not allowed to know who!), and it was a great evening catching up with friends and colleagues, as well as a very glamorous event in itself.

 

With colleagues Naveen Cavale, Miles Berry and Nilesh Sojitra

I was even more surprised on the night to have my name read out as one of those to have been Highly Commended (although they did spell Marc with a “k”!). A big congratulations to my friend and colleague Taimur Shouaib who won on the night – a very worthy winner!

 

 

The nominees are announced…and a nervous wait to see who won!

The evening raised many thousands of pounds for charity and is something I was very privileged to have been part of. Well done to Antonia Mariconda who organised the event and runs the non-for profit Safety in Beauty campaign.

 

 

With the evening’s surgical winner, Taimur Shouaib

 

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