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!

The significant majority of my patients have one thing in common, no matter whether they are seeing me about their face, their eyes, their, breasts or their body. What links them all is that their underlying reason for coming to see me is related to their confidence or self-esteem. Whether a result of the ageing process, post-pregnancy/breast-feeding changes to their breast and bodies, the results of weight loss, or developmental issues; this is the common thread I find with my patients week in, week out.

However, there is also another group of patients, who in my practice make up a much smaller proportion. These are patients who have no significant self-confidence issues, but would like a body or facial altering procedure for more cosmetic reasons. Perhaps they would just desire larger breasts, or fuller lips, or maybe they would like a particular wrinkle treated because it irritates them, but does not impact on their psychological or emotional well-being.

The reason for me writing a blog on this topic is related to the expectations of patients in the two groups, and how they differ. Following on from my last blog on expectations (Reflections on Expectations), I realise that there is another factor that can influence a patient’s satisfaction with the outcome of their surgery.

In the first group, where patients are psychologically and emotionally affected, which impacts on their confidence and self-esteem, a change or improvement to the cause of concern usually has a positive impact, and they are normally very happy with the outcome. Perhaps they regard their outcome against their pre-procedure self, and therefore recognise the positive difference and impact that has been made. Or maybe it is because they feel that an alteration, even if not “perfect” has put them into a better position than they were in previously. Thus, in this group, most patients are very happy with the outcome of their procedure.

On the other hand, the second group, who are choosing to have a procedure for other reasons, often have a higher expectation of their result. If they are going to undergo a procedure to address their body or face that does not overly bother them, then to be “worth it”, anything but perfection will often be deemed a disappointing result. Having an insight of these differences before undergoing procedure can help you ascertain your possible satisfaction with your result.

This is why as part of the pre-procedure consultation process it is so important for me to try to understand what it is that has stimulated my patient to seek my advice and help. It also enables me to tailor my consultation for them, and try to ensure that I can be as realistic as possible when advising them on what they can expect.

Sometimes, as a plastic surgeon, I observe that despite an objectively good outcome from a procedure, the patient is not happy (see Reflections on Expectations). It seems that some patients in this group may fit into the more cosmetic category I have described above. Perhaps this is also compounded by the patient taking away an overly optimistic message from their consultation different from the one I have tried to convey. This is why I sometimes insist on a 3^rd (or even 4^th) consultation in situations when I am concerned the patient and I are not on the same wavelength with respect to potential outcomes and realistic expectations.

So, if you are someone who I ask to come back to see me again for a 3^rd consultation for this reason, please see it as a positive part of my patient care, as in my experience, time before a procedure is always well spent, and never regretted.

In my experience I can broadly divide my patients into two groups based on their expectations for any form of plastic surgery – from a facelift through to breast surgery or body contouring surgery.

The first group (Group 1) have an understanding and appreciation of their starting point and how their face, breasts or body are. Their expectations are very much related to their body image mind map of their starting point. Therefore they perhaps better and more realistically appreciate the changes made through their plastic surgery. In my experience this group of patients has a far higher rate of satisfaction, as after they have had their surgery, they are comparing where they have got to with what they had before rather than any other ideal or target (please see my illustration).

The second group (Group 2) of patients are those that have a target or goal in their mind of where they would like to be, that perhaps is not related to their actual starting point. It might be that in this group of people they have less of an understanding of their actual starting point but in addition they might also have perhaps unrealistic goals of what they are hoping to achieve. The expectations in this group of patients can be far more challenging to meet. In this group of patients their final result, rather than being compared with their original starting point (and the patient having an appreciation of the positive difference and change that has been made), they compare their result with how close it has got to their previously future ideal image of what they hoped to achieve.

So in Group 1, who tend to be far more satisfied and happier with the outcome of their surgery they tend to look back and compare their new self with their old self. By contrast Group 2 tend to compare their new self with their idealised future self that they had in their mind, and are more at risk of being disappointed.

Whilst it is a subtle and nuance point, it is something that seems to become very apparent to me the more patients I talk to and the more I discuss expectations. I thought it was worth highlighting, because by openly talking about this it might enable some people, who are at risk of being in Group 2, to move into Group 1 and therefore achieve a much high satisfaction of outcome of their procedure.

As in any walk of life and arena of life, our satisfaction is very much related to our expectations. If our expectations are not met we are disappointed, but if they are exceeded we are delighted. I would always hope to exceed my patients’ expectations but that can only be achieved if their expectations are realistic, which means in this case, comparing themselves with their old self rather than an idealised version of themselves.

Therefore when preparing and researching a consultation I would not advise scouring the internet looking for ideal pictures of faces, breasts and torsos but rather look for pictures that very much relate to your current self to see how those post surgical photographs appear as these are going to be far more likely to be realistic than simply looking at idealised “after” photographs.

If you found this interesting, please also refer to my related blog about how to look at before and after photographs.

As part of everyone’s research (or virtually everyone), prior to seeing me for a consultation, they will have inevitably been on the Internet looking at before and after images. These may be from my personal gallery on my website (www.beforeandafterimages.co.uk) but it is also likely they will have looked at many other examples far and wide. This often leads them to find pictures that they very much like the look of (the “afters”, that is), and it can be incredibly helpful and valuable in understanding and learning about the procedure they may be interested in.

However, what often comes up during the consultation process is the fact that the after pictures that the patient very much likes and would like to look like would actually not be possible to achieve in their case – this is often because the before photograph they have looked at bears no resemblance to themselves. This can be looking at breasts, abdomens, facelifts or more.

Therefore during part of the consultation, after I have examined the patient (so I have a thorough understanding of their appearance), we then go on to look at before and after photograph examples together. One of the key things I point out to them is how to identify features within the photographs we are looking at that have a resemblance to themselves. Following the consultation if someone goes back onto the internet to have further searches for before and after photographs they are then far better equipped to understand what might be achievable in their situation and what is not.

Therefore the key tip before starting to browse any before and after photographs is to have an understanding of your own breasts, body or face. This can be very difficult to do objectively as we inevitably only see ourselves in the mirror and, much like listening to our voice being played back on an answerphone message when it does not sound the same as how we hear ourselves, looking at yourself in very objective medical photographs can almost be like looking at someone else – it is not the same as looking at ourselves in the mirror.

As a result my suggestion would be to take some photographs of yourself, or have your partner take some photographs, that are comparable to clinical photographs (in terms of positioning and style) to those that you see in plastic surgeons’ websites and only then can you start to identify people who have similar features to yourself in the before photographs.

Only the similar before photographs should really be then looked at to decide whether or not the results achieved meet your satisfaction. This, of course, means that part of the research of the before and after photographs is very much just finding the befores that really do look like you, and only by doing that can it be possible to understand what might be achievable.

I hope this short blog post is useful and helpful and good luck in your research!

I am continually delighted by the positive feedback and great results achievable with an upper lip lift. Yet, despite the success of the procedure, it is still not widely known about. People will often recognise what they are unhappy about or self-conscious about regarding their facial proportions, but will be unlikely to be aware of the treatment options available to them.

I am always interested in the evolution of my patients’ thought processes, and I have recently asked a number how they found out about the lip lift, and the replies were really quite interesting.

My first question to them was: what is the first thing you put into Google that led you to the lip lift?

Some people “got lucky”, by typing in phrases such as: upper lip shortening, lifting the lips, or raising the lip. Others already knew about lip lifts, so were very direct: lip lift, upper lip lift, bullhorn lip lift, gullwing lip lift, Italian lip lift, Batman lip lift (and more!).

But the majority of people had no idea of the concept of a lip lift, so started, quite sensibly, with the issue that bothered them: how do I shorten the distance from my nose to mouth; long upper lip solutions; lower facial proportions; how to improve my mouth proportions.

I was pleased to hear that those in the latter group were instantly led to the lip lift as the ideal procedure (and particularly pleased to hear that Purity Bridge ranked highly on Google for lip lift procedures!). We are continuing to get more and more enquiries about upper lip lifts from patients all over the country, and some from abroad too.

As a result, we have streamlined the consultation process as we recognise the impracticalities of travelling hundreds of miles for a consultation and then coming back for further visits prior to the procedure. We now take Skype or telephone consultations (with the addition of photographs our patients have sent in for the telephone consultations), which has really helped our “out of town” patients.

If I am ever seeing anyone in person at the time of the procedure, having only communicated electronically beforehand, it is always on the proviso that the final decision to go ahead is taken after my in-person assessment. Due to the comprehensive consultation process beforehand, by the time people get to this stage of the process, they are normally entirely suitable to proceed, but I will never commit until I have seen them face-to-face.

So…had you heard of an upper lip lift before? Let me know – I’m always keen to find out how many are aware of this revolutionary procedure!

As a plastic surgeon, good communication with my patients is vital at all times. This is particularly important in the pre-operative consultation process, to ensure that my patient and I are on the same wavelength, and that I ensure I am able to explain the realistic outcomes of a procedure. After all, managing expectations is critical to my patients’ happiness and satisfaction with their procedure. As in other scenarios, I would always rather under promise and over deliver.

This is relevant in all areas in practice, but I find it particularly helpful to give visual analogies when discussing facial ageing and facial rejuvenation options. In fact, the best analogy I have been using recently was actually one a patient gave to me

She said, getting older (and facial ageing) is like being on an escalator, continually going up in one direction. A facelift or other procedure cannot take you off the escalator, or make it stop; but it can allow you to go down some steps.

Taking this one step further (excuse the pun), the number of steps you can go down depends on the procedure or treatment you choose. For example, a comprehensive lower face and neck lift will take you down more steps than, say, a skin treatment or mini-procedure.

The corollary of this, is that if you only go down one step, the escalator will take you back up to your original position sooner than if you were able to go down several steps.

Having this visual analogy to use in my consultations has really improved my communication with patients, and helped me to describe the relative effects of the different treatments offered. I hope you find it as useful as I have!

It is interesting how times change – in the past, whether or not someone had had Botox was discussed in hushed tones between close friends. Nowadays, where you go for your Botox is openly talked about without any concern.

However, quite rightly, there remains a worry (particular for first timers), that muscle relaxing injections can change how you look, or even worse, can make you look strange. It is easy to spot the “mephisto brows” of those who have had Botox overdone in some facial areas and underdone in others. Therefore, the importance of getting treated by someone who knows and understands your face, and understands the delicate balance of the facial muscles is key. Following Botox injections, the key is that someone looks brighter and more refreshed, and not that they have had something “done”.

In my Botox practice, and that of the team at Purity Bridge, we certainly have a “less is more” approach. We aim to avoid the frozen appearance (unless someone specifically desires this) and would rather have slightly under-treated someone than over-treated them.

Furthermore, using advanced techniques for these wrinkle relaxing injections can make them widely applicable to other areas of the face and neck, and not just the areas around the eyes.

The way botulinum toxin works is by interfering with the impulses from the nerves to the target muscle. So whilst the effect can be wrinkle reduction, this is achieved through muscle relaxation. This means that Botox (as botulinum toxin is frequently referred to) can be used in other ways.

For example, if someone has a gummy smile, the position of the upper lip can be subtly altered to improve the appearance of the smile. This is done by injections into some of the muscles that lift the lip, meaning that it is not pulled up so much on smiling, hence reducing the gummy part of the smile.

Another use of Botox can be below the corners of the mouth, to subtly elevate the corners of the mouth/lip by reducing the pull down on the depressors, or the muscles that pull the mouth down. Botox given to tight neck bands can help them to relax and become softer and less obvious. Botox can even be used to help teeth grinding and to reduce the breadth of the jaw, at the angle of the jawline, by shrinking an overly large jaw muscle (the masseter) at this location. There are still more uses for Botox too.

I hope this brief overview demonstrates the versatility of using Botox injections, as well as reassures you that when carefully performed, a very natural and refreshed appearance can be achieved. The introduction of Botox 25-years ago truly was a game-changer

“How do you feel you look?” is a question I like to pose to people who come to see me to discuss facial rejuvenation. Whether they are in their 30s or 70s, the same question applies to all, and the answers they give are key.

Whether they say the look tired, sad, ageing, angry or even that they feel their facial features or expression gives people the wrong impression about them (mistrustful, exhausted), there is often a solution. In many cases the solution will be surgical – a facelift or neck lift, particularly in the ageing lower face once over 60, but often there will be a non-surgical approach that can be extremely beneficial.

The modern understanding of facial ageing and changes, combined with the very latest hyaluronic acid fillers and their advanced use has seen a sea-change in the approach to facial rejuvenation.

We now understand far more about the changes to volume (particularly bone and fat) that happens with age, as well as the sagging. Addressing facial ageing is not simply about lifting and tightening (which still remains an important part) but also about restoring volume and giving back support.

For example, the heavy nasolabial (nose to mouth) lines and the eye bags are created by changes in the mid-face. This is the triangle of the cheek below the lower eyelid. Not only does a reduction in support cause this to descend, but also the fat in this compartment withers with age, and the underlying bone shrinks back. Therefore addressing this area needs to bear all of this in mind.

The non-surgical approach using filler can help restore the lost volume and provide support to the tissue, in addition to subtly filling any residual contour defects. Typically, when I see someone in their 30s to 50s with mild to moderate signs of facial ageing, in whom we are going to take a non-surgical approach, I will use carefully placed filler to restore their freshness and youthfulness .

The filler is placed in a variety of areas – on the cheek bone (deep down, right on the bone, which is surprisingly painless), as well as to the tear trough (the lower eyebag groove), and deep in the upper corner of the nose to mouth nasolabial folds.

Other excellent targets to restore freshness and offer support to the face include the hollowing at the temples (which can also offer support to the outer eyebrow that starts to droop with age), the jawline (to support the development of early jowls), the chin and the angle of the jaw, just below the ear.

These all work best when combined with the use of carefully placed Botox (botulinum toxin), which complements the filler, and avoids the frozen or surprised look.

The use of filler in this way is not a cheap alternative to surgery, and that is important to say. The filler should last 12-18 months, and to perform a comprehensive rejuvenation as I have just described would normally cost in the region of £2000 (particularly if combined with Botox).

However, for many people, particularly the younger cohort of facial rejuvenation patients, this can be a far better approach than surgery. Surgery will have an important role at some point, but not initially.

For more information, come to see me for a consultation and review – just to find out about what the best approach in your individual situation might be.