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.

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.

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.

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.

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!