This was a comment made during a consultation recently with a patient, and I think it perfectly summarised how important it is not to be judgemental or opinionated about people’s life choices, particularly when it comes to plastic surgery or aesthetic procedures.

I am only too aware of the widely varying views people might have about plastic surgery, and it frustrates me whenever I hear negative comments that are inevitably pejorative and condescending about an individual’s choice. You can only imagine the number of conversations I have on this topic when I am introduced to people who then find out what I do professionally! I sometimes have this situation arising with some medical colleagues from other specialties, and from general practice, which I find particularly disappointing. I expect these opinions are fuelled by the portrayal of stereotypical exaggerated cosmetic treatment outcomes in the media…which in no way reflect the broad spectrum that exists in reality.

I often describe myself as a psychologist, who happens to use surgical therapies rather than talking therapies to improve the self-confidence and self-esteem of my patients, and I see evidence of the benefits and effectiveness of this concept day in, day out.

People might consider undergoing elective plastic surgery for a number of reasons, but the fundamental link most have is related to self-confidence and self-esteem. At the end of the day, it is about how one feels about oneself, not about what anyone else thinks – how it feels to live in one’s own skin. If someone radiates positivity and self-confidence, it is reflected back everyday in their lives and becomes a virtuous cycle. If someone lacks confidence or feels insecure, it can lead to a progressively attritional negative cycle. In selected situations, plastic surgery is the right choice to address this.

There are innumerable occasions when I have heard incredibly rewarding comments following plastic surgery – “you’ve changed my life”; “this is the best thing I have ever done”; “I cannot thank you enough”; “it has transformed my relationship”; “finally I can go swimming/on holiday/wear a bikini”…I could go on! The positive impact plastic surgery can have is incredible – albeit in those who are fully informed, are aware of the risks, and in particular have realistic expectations.

We often talk about our quality of life, but perhaps those who are judgemental about plastic surgery do not consider this in relation to other people when they have a dogmatic resistance to differing perspectives and points of view. Life is not only about getting by or managing, it is also about quality, interpersonal relationships, and enjoyment – “life is for living”. Elective plastic surgery can have a tremendously positive impact on people’s quality of life, and one that is usually not short-lived.

The long-term positive effects can be evidenced in a number of ways. One simple example is when I consider my patients who have undergone breast implant surgery. Inevitably at some point their implants will need changing, or further breast surgery will be indicated, sometimes 10-20 years later. I always offer the opportunity to have the implants removed, but the most common response is a definite “no”. Even in cases when someone might have experienced discomfort, pain or significant issues relating to the appearance of their breasts due to their existing implants, most would rather have further surgery that involved new implants, than would want them removed. This is surely evidence of the long term net positive effects of having breast implants for these women in this example. There are countless other examples too, in the arena of facial rejuvenation or body contouring too.

Of course, nothing is permanent, and “maintenance” is a common word used in plastic surgery – whether it is ensuring core muscle exercises are performed and maintaining a healthy weight after tummy tuck surgery or having non-surgical interventions to prolong the rejuvenation effects of a facelift.

Proceeding with plastic surgery is a big decision, and if you are considering it you should be well informed, reflect on the reasons you would be having it for, the long term effects, and the inevitable changes in the effects of the surgery over the course of time, with ageing and gravity being unavoidable.

Plastic surgery is not magic – it is not going to solve all the concerns and problems an individual might have. However, it has the potential to make an incredibly positive contribution to the quality of life of many people.

So I hope that if someone who might have had a judgemental, dogmatic and negative opinion of plastic surgery, and those who undergo it has read this, they might pause to reflect on the variety of views and concerns people might have. Just because they might not consider plastic surgery themselves, I strongly feel they should not brandish anyone who would have plastic surgery in a negative way, after all, they do not know what it is like to live in someone else’s skin.

We are delighted to say that we have made plans to re-open Purity Bridge on 1^st June to start seeing patients following our closure of the clinic since mid-March. However, as we are sure you will appreciate, we have taken extensive measures to maximise your safety and the safety of our staff.

All patients attending the clinic will be sent a COVID screening questionnaire that must be completed prior to the appointment. If any answers to this questionnaire raise any “red flags”, you will be contacted and if necessary, the appointment rearranged.

Therefore we will be requesting that anyone attending the clinic for an appointment arrives wearing a face mask or nose and mouth covering. We would also request that you attend your appointment alone so we minimise the number of people in the building at any one time. Please therefore arrive for your appointment on time – we apologise in advance if we turn you away if you arrive early!

There will be alcohol gel for you to use on arrival and departure from the clinic and other strict protocols in place – please see below for more information.

Finally, in order to ensure that in-person clinic appointments are only for those whose needs cannot be met via video consultation, we will only be arranging in-person appointments for people coming for clinical examinations, treatments and procedures, and for post-surgical follow-up appointments. All other appointments will be via secure video link.

The clinic rooms will be thoroughly cleaned between each appointment and at the end of each day, and our staff will be wearing appropriate PPE as set out by Public Health England and other authoritative bodies.

We appreciate it will take some time getting used to the new way of doing things, and appreciate you bearing with us with these new measures.

Protocol for patients attending Purity Bridge

1. Patients to complete on-line screening questionnaire within 48 hrs of appointment
   1. If screening questionnaire ok, patients can attend
      1. Screening questionnaire to be on-line
      2. Alert is raised if red flagged answer
   2. If screening questionnaire raises anomaly, situation to be discussed and risk assessed on a case by case basis including phone call to patient
   3. Outcomes might be either to allow patient to attend, to postpone appointment for a further 1-2 weeks or to advise the patient to seek medical attention prior to re-booking.
2. All patients to wear face mask/mouth & nose covering for clinic attendance
   1. If patient comes without, we can supply on arrival
3. Patient to be provided with alcohol hand gel for use on arrival
4. Ideally patient to proceed straight to clinic room on arrival
   1. If patient required to sit in waiting room, patient to be directed to a specific seat by Front of House (seat to be wiped down after use)
5. Patient to wear mask throughout time in clinic – only to be removed if necessary for clinical examination or treatment
6. Patients to use alcohol hand gel on departure

Further measures:

• No refreshments to be provided to patients – unless required after a procedure (clinical judgement)
• If patients require toilet facilities they should be instructed to follow the signage regarding wiping surfaces

We are delighted to say that we have made plans to re-open Purity Bridge on 1^st June to start seeing patients following our closure of the clinic since mid-March. However, as we are sure you will appreciate, we have taken extensive measures to maximise your safety and the safety of our staff.

All patients attending the clinic will be sent a COVID screening questionnaire that must be completed prior to the appointment. If any answers to this questionnaire raise any “red flags”, you will be contacted and if necessary, the appointment rearranged.

Therefore we will be requesting that anyone attending the clinic for an appointment arrives wearing a face mask or nose and mouth covering. We would also request that you attend your appointment alone so we minimise the number of people in the building at any one time. Please therefore arrive for your appointment on time – we apologise in advance if we turn you away if you arrive early!

There will be alcohol gel for you to use on arrival and departure from the clinic and other strict protocols in place – please see below for more information.

Finally, in order to ensure that in-person clinic appointments are only for those whose needs cannot be met via video consultation, we will only be arranging in-person appointments for people coming for clinical examinations, treatments and procedures, and for post-surgical follow-up appointments. All other appointments will be via secure video link.

The clinic rooms will be thoroughly cleaned between each appointment and at the end of each day, and our staff will be wearing appropriate PPE as set out by Public Health England and other authoritative bodies.

We appreciate it will take some time getting used to the new way of doing things, and appreciate you bearing with us with these new measures.

Protocol for patients attending Purity Bridge

1. Patients to complete on-line screening questionnaire within 48 hrs of appointment
   1. If screening questionnaire ok, patients can attend
      1. Screening questionnaire to be on-line
      2. Alert is raised if red flagged answer
   2. If screening questionnaire raises anomaly, situation to be discussed and risk assessed on a case by case basis including phone call to patient
   3. Outcomes might be either to allow patient to attend, to postpone appointment for a further 1-2 weeks or to advise the patient to seek medical attention prior to re-booking.
2. All patients to wear face mask/mouth & nose covering for clinic attendance
   1. If patient comes without, we can supply on arrival
3. Patient to be provided with alcohol hand gel for use on arrival
4. Ideally patient to proceed straight to clinic room on arrival
   1. If patient required to sit in waiting room, patient to be directed to a specific seat by Front of House (seat to be wiped down after use)
5. Patient to wear mask throughout time in clinic – only to be removed if necessary for clinical examination or treatment
6. Patients to use alcohol hand gel on departure

Further measures:

• No refreshments to be provided to patients – unless required after a procedure (clinical judgement)
• If patients require toilet facilities they should be instructed to follow the signage regarding wiping surfaces

What is Breast Implant Illness?
A small proportion of women who have breast implants (for both aesthetic and reconstructive purposes) self-identify as having a number of symptoms they believe arise from the presence of their implants. Whilst not a medical diagnosis, they refer to their symptoms as Breast Implant Illness (BII).

What are the symptoms of Breast Implant Illness?
As stated above, Breast Implant Illness is not a medical diagnosis, but rather a term developed by those who have a variety of symptoms they feel are related to their breast implants. These include tiredness, “brain fog”, joint aches, immune-related symptoms, sleep disturbance, depression, hormonal issues, headaches, hair loss, chills, rash, hormonal issues and neurological issues.

Why has BII suddenly come to light?
It appears that the recent increase in patients reporting symptoms of BII is related in great part to social media. One Facebook group alone has more than 50,000 members who report symptoms of BII. This may account for the sudden increase in awareness of BII, however, BII is not an official medical diagnosis (see below).

Could these symptoms be caused by any other factors?
There are a variety of other reasons these symptoms might be found. These include other background illnesses or hormonal changes. In addition, there have been a number of scientific studies investigating similar symptoms experienced by women in the population in general.

For example, a Swedish study looking at a random sample of 4,200 women between 35-64 years old found a significant number experienced similar symptoms to those ascribed to BII, although they did not have breast implants. They concluded that the symptoms related to stress and depression.

A 20-year study on a Danish study population with breast implants regarding musculoskletal symptoms concluded that interestingly, the occurrence of mild, moderate and severe musculoskeletal symptoms was generally lower among women with implants, compared with women with other cosmetic surgery and women in the general population.

Do symptoms of BII improve when breast implants are removed?
On the whole, around 50% of women who self-identify as having BII feel that their symptoms improve after implant removal – sometimes temporarily and sometimes permanently. It therefore appears that removing breast implants does not necessarily improve symptoms in everyone. There is no research demonstrating which symptoms may or may not improve with implant removal – with or without removing its surrounding capsule (scar tissue).

In more detail:
A study on breast implant removal from 1997 (when older, less robust implants were still in use) looked at women in whom 186 implants had been removed. Over half the implants were ruptured or leaking, and many had other issues. Therefore in this study population, the women would theoretically have had a significant exposure to silicone from within the implants (compared with the more modern implants used today). Immune system blood tests showed no difference in levels of autoimmune antibodies between the study population and a control group of women without breast implants. The small number of women in the study group with diagnosed autoimmune conditions did not have any improvement when questioned over 2-years after implant removal. However, the majority of women reported an improvement in their psychological well-being after implant removal.

Is there medical evidence linking medical grade silicone to immune system problems or other diseases?
In short, the answer so far is no. Medical grade silicone is derived from the natural element, silica. Whilst silica has been shown to activate the immune system, silicone used in breast implants is very different, and to date has not been shown to cause any disease. Medical silicone does not exist is nature and is created to form polydimethylsiloxane. Medical grade silicone has had antioxidants, dyes, and plasticizers removed during processing.

Whilst there is no current evidence to support a direct link between breast implants and any specific disease process, it does not mean further research is not indicated. As stated below, further new research is being conducted principally in Australia and USA. It is important to recognize that in rare diseases (of any type), it can take many years to come to a scientific conclusion. In addition, there are many factors that can influence and confound the interaction of a patient and her breast implants – all of which have an impact on studying an entity such as BII.

A lack of evidence to date does not mean that the symptoms experienced by patients are not real. Therefore, as plastic surgeons, we take these symptoms seriously and are committed to supporting further investigation and research in this area.

Do tests exist for BII?
There are no tests that can show BII. However, there are a number of research studies underway, principally in Australia and the USA hoping to provide further information. In the meantime, there are tests that can be performed for autoimmune conditions. In a similar way to the population without breast implants, there are breast implant patients who have symptoms (they attribute to BII) with positive immune testing and others where all tests show no abnormalities.

What scientific data are there that shows that breast implants actually cause the symptoms of BII or any other disease?
To date there is no demonstrable link between breast implants and any systemic illness. There have been a variety of studies designed to look at the safety of breast implants and these have also looked at specific autoimmune disorders and diseases. Overall, these studies have shown few or zero links between breast implants and any disease. These studies have not shown any consistent laboratory test abnormalities to enable a distinct syndrome to be defined or categorized.

However, as in all areas of science, “absence of evidence does not equal evidence of absence”. Therefore further studies are on-going to investigate other possible links and symptoms in women with breast implants.

What should I do if I think I might have symptoms I identify with Breast implant illnesss?
If you experience symptoms you feel might be related to your implants it is important you see a doctor. It is important to bear in mind that your symptoms might not be related to the implants, and that other medical investigations should not be overlooked or ignored. Therefore you should involve your GP in the first instance to exclude any other underlying disease processes, such as autoimmune conditions, inflammatory conditions or neurological disease processes.

Should you wish for your implants to be removed, you should discuss this with your plastic surgeon. Most commonly, when patients are seeking to have their implants removed for symptoms they attribute to BII they request that their capsule is removed. This can either be done “en bloc”, referring to the whole capsule being removed containing the implant, or by other techniques. There is no evidence that en-bloc removal offers any benefit to the patient, and indeed this technique is more invasive and requires larger incisions. This should be borne in mind when discussing your situation with your plastic surgeon.

The “en-bloc” concept is one of the medical inaccuracies perpetuated on the internet and on social media. It is important to appreciate that sometimes it is impossible to remove the capsule without making a hole in it, even in the most experienced surgeon’s hands. Sometimes it is also not possible to remove the whole capsule, depending on how adherent it may be to the ribs, for example.

What is the risk of developing BII?
Due to the lack of official medical diagnosis, the disparate array of symptoms reported and the lack of definitive evidence, there is no “known” risk for BII. Many of the symptoms described by those identifying with BII are experienced by the general public on a regular basis, with or without implants. It is also important to understand the other recognized risks of having breast implants – related to the surgery itself and the long-term possible effects of having breast implants.

In summary, Breast Implant Illness is a phenomenon being discussed increasingly on the internet. As no link between silicone breast implants and a specific disease has yet been identified, more research is underway. Plastic surgeons need to listen and acknowledge that their patients may be experiencing symptoms, but must also ensure a general medical work-up to investigate other causes. Any woman concerned about symptoms of BII should feel comfortable bringing this up with their plastic surgeon.