Kate Comrie

Okay, I think we'll begin. So hello, everybody welcome to our webinar on body contouring. My name is Kate Comrie, and I’m the clinical nurse specialist in plastics and cosmetic surgery. And I am hosting this session, along with Consultant plastic surgeon, miss Anita Hazari. Please ask questions throughout the presentation. You can do so by using the q&a icon which is on the bottom of the screen. This can be done with or without giving your name. But please note that the session is being recorded. If you do provide your name. If you would like to book your consultation, we'll provide contact details at the end of the session, including an exclusive attendee offer.

As the screen says, I’m Kate. I have a diploma in higher education, in adult nursing from university of surrey, which I graduated from in 2010. I also have a mentorship degree. And I’ve done aesthetics training in foundation advance, including some master classes. My general background in the NHS. Was in the surgical assessment unit and A&E. I worked in the royal surrey county hospital and Frimley park hospital, and I moved to the private sector in 2015, and then became a cosmetic nurse specialist. And I support our cosmetic and aesthetic Consultants and patients throughout their journey. I'll now hand you over to miss Hazari.

Miss Anita Hazari

Hello, everyone! My name's Anita Hazari.

So, before I go on, I just thought I’d give you a flavour of what plastic surgery is, because everyone's used to seeing a lot of stuff in the media and equate plastics with cosmetic. But I’m a plastic surgeon primarily, who also obviously does cosmetics, and it started a long time ago.

The slide that you see on your left is, and in the middle is about the Italian rhinoplasty, where you can see the cartoon actually showing skin being transposed from the upper forearm to the nose, and then the one on the extreme right. And that picture is from several years ago. The one on the right is from the Sushruta Samhita book by Sushruta, from India, which goes back where you had a group of cobblers who used to actually design skin from the forehead to make the tip of the nose known as the Indian rhinoplasty. And there was a thing that happened during those days where, if anybody committed a crime, the tip of the nose would be taken off. So, to take away the stigmata of that the Indian rhinoplasty actually came along, so plastic surgery actually goes a long way. And the place where I work is at East Grinstead, the Queen Victoria Hospital. It was built during the battle of Britain. And this is a picture from 2006. And this is when I actually joined the hospital as a Consultant in 2006, and it feels as if nothing has changed. But everything on the inside has changed. The shell is the same, but everything's been refurbished on the inside, and, in fact. Some of the operating theatres are pretty world class actually now. And for those of you who may know the history, but not so much in detail. It was set up during the battle of Britain by this man, Sir Archibald McIndoe. And he was one of the surgeons to actually set up these units all over the country. So, he was here. Harold gillies was elsewhere, and there were other units, and the idea was that all spitfire, all pilots who had their hands and feet, but hands and faces burned during the battle of Britain would be treated at the McIndoe centre. And it started with the spitfire pilot. So, these were young lads who were flying spitfires, and one of the falls with the spitfires was that when it caught fire, the hands and faces used to get burnt, and here we have. Jack, when on the extreme left, is when he got burnt, and he was about years old, and then Archibald  McIndoe fashioned what's called the tube pedicle flap, which is where he transposed nose, transposed skin, which was fashioned as a tube from the nose, and then it went on from the forearm to the arm or to the shoulder, and then from the shoulder onto the nose. And that's how he reconstructed the burned face, especially the tips of the nose and the rest of the face was usually reconstructed with skin grafts. So that's where I work, just to give you an idea. In the same hospital which historically was Archibald McIndoe and his guinea pigs, and the guinea pigs were when I first joined, or was a trainee there? Back in the mid-nineties there were about 5 to 600, still alive, and they were a majority of them was the British air force, but there were also some from the Australian and the Canadian air force, and now not many of them are actually alive.

I’ve been a Consultant plastic surgeon at east Princeton since 2006, and as part of the NHS. Private combination, I do my private practice here at Benenden hospital. I am on the specialist register at the general medical council, which is the regulator for plastic surgery. So just being on the register as a doctor is no use if you have to be on the specialist register within your own specialty. So, for plastic surgery, just to know that there is no such specialty as a cosmetics, as cosmetic surgery. Anybody could practice cosmetic surgery, including Kate, if she wished to do that. You don't really need qualifications as such other than being either a basic doctor or having a healthcare qualification, including a nurse. It's I’m subject to annual appraisal, just like all doctors in the UK. Are, and most specialist doctors have a membership of their own specialty association.

So, within plastic surgery there's BAPRAS, which is British association of plastic reconstructive and aesthetic surgeons. And the sister arm of that which is mostly aesthetic surgeons, is barbs, as in British association of aesthetic plastic surgeons, and I also happen to be a member of the association of breast surgery. Because one of my predominant interests in the NHS. Especially is breast cancer reconstruction. So, there are a lot of degrees that are there when you see anybody's qualifications. And the MBBs usually is the basic degree which is your graduation. But just because you've graduated from med school doesn't mean you can practice medicine straight away. Most people have to go through a training program and through. When I was during my training, I also did a research fellowships. I've got a doctorate in medicine from UCL, and I was awarded the hunter inn professorship when I was in training by the college of surgeons. In 1999. The FRCS. Stands for fellow of royal college of surgeons, and there are 4 colleges in the UK. The English, the Glaswegian. The Edinburgh, and the Irish college, and I’m an English college fellow. And then when one finishes training, one has to do the intercollegiate exam, so it's organized by all colleges which gives you your specialty, so you may see an orthopaedic surgeon, and they will have FRCS in brackets, orthopaedics, or orth and an ENT surgeon who will have FRCS. In brackets ENT. Or general surgeon FRCS. In bracket general surgery. So that little clue is what's in the brackets as a specialty, one where you know what the primary sort of training is in which specialty it is. I’m a plastic surgeon, which is one of the longest. Actually so, from going into med school to becoming a Consultant in the UK. It takes on average, anything between 18 to 20 years, and it took me about 19, I think, because I took years out to do research and also had a baby. What do I do? I do mostly breast, reconstruction, and body contouring, and one of the operations that I do in the NHS is for one where I use the tummy to make a breast out of it when someone's had a mastectomy, and some of those principles of doing these reconstruction and getting a really nice result. Those principles technical principles are interchangeable, so things that I have done in my NHS practice I’ve sometimes transposed over to the private side to do the aesthetics to get better results, and vice versa.

So, in body contouring, what we're going to cover today is tummy tucks, which is abdominoplasties. And that goes back to what I said about for one, and I’ll explain that as I go along. Then we have excess skin at the arms also, or sometimes people call them bingo wings, which I think, is not a great term. But is referred in layman's terms as bingo wings, and it's really taking the excess skin out from the arms and then inner thigh lift and liposuction.

So, let's move on straight to abdominoplasty. I can see there's no questions there. But as I go through, if you have questions. Put them on. And we'll try and answer them as I go along. So, tummy tuck or abdominoplasty is useful for several scenarios. One is when someone's had a lot of weight gain and then weight loss. So, you have the overhang, and especially if there have been pregnancies and a caesarean, and the skin tends to overhang the caesarean scar. And as we get older that skin you just can't get rid of the skin and fat, no matter how much you exercise. And that's when a tummy tuck is really a useful operation, it is also useful when there is what's known as diversification. Which is when, if you look at your pack muscle, and if you're lying down flat on, say the floor, and you raise both your legs up in the air like that, keeping the knees straight, you might actually feel a gap between the muscles you can stick your fingers in, and which is what I would do when I’m examining you whether it's a gap of a centimetre. So, one finger width, finger width, finger widths, and in some women it can be as much that you can always put your fist in it. It's almost to â cm wide, and that can actually be repaired so that it, you know otherwise ever people feel that you know they still look a little pregnant afterwards, because tummy is bulging out all the time.

So, what happens in a tummy tuck? It's under general anaesthetic, usually with a stay of one night, takes me on average about and a half, sometimes â h, to do this operation. And the idea is to make a cut from hip to hip. So, women who've had caesareans or hysterectomies. The scar is actually just in the centre here. So, I have to make an extension all the way to the sides.

So, like a big, smiley face. This cartoon is from the old days, when, if you remember high leg knickers. So, you know, when sort of the Baywater days, when everybody used to have high leg costumes and high leg knickers. So, we had to fashion the scars so that they finished more like so that they were hidden under high leg bikinis. But this is more nowadays. We tend to make it more of a smiley face to get that scar to fit to sort of to be hidden underneath today's bikini styles. So, you have to make a cut from hip to hip. And then make a cut around the belly button, so you still keep your belly button, which is your old umbilical cord, because it's attached to your insides and let it drop in. So, when I say drop in, it doesn't go inside your tummy. It sits on top of your six-pack muscle, or even if it's separated in the middle. And then lift that skin all the way up to the ribs right up to there and then the next slide sort of shows the repair of the muscle. Now, this is just a cartoon, and it shows that somebody's put staples between the muscles. No, when, if you eat meat, you know how meat is covered with like a thick, wide gristle layer. That's exactly what covers our pack muscles as well. And in the midline, and that that lining is called the rectus sheath. So, it's like a sheet like a thick layer. And when somebody has divarication also known as diastasis. But basically, separation of the six-pack muscle that middle bit stretches out. And it's all about bringing that closer together and suturing it, and I tend to use a non-dissolving suture which is permanent. So that hopefully it stays there for a long time. It doesn't. A non-dissolving means it's there forever. Sometimes some people will use dissolving sutures, but one of the issues with that is, when that dissolving stitch dissolves. Some of that gapping may actually return. It's advisable to leave this operation until one has one, until you've completed your family, because if I do, the repair of the diastasis, and then one becomes pregnant. Then that puts a strain on that suture because what happens during pregnancy all of that muscle gets stretched and the gapping can come back.

It's a good idea to leave this operation until you've completed your family. So that is repaired, and it's a bit like I would say the suturing is a little bit like, if you remember the old made marionette where somebody was putting someone in a corset and pulling tight. That's exactly what I do. I'm pulling you tight. So, it does feel quite tight, like a, you know, quite tight, like a drum, almost like a like wearing a Victorian boned corset on the inside. So, one of the things you will notice afterwards is, when I have done repair of the muscle to give you a pretty tight looking tie. You won't get the bulging afterwards, but what you will find is you can't eat the same volume of food, because when you eat it there's lots of space for it to expand, and everything sort of comes out, and some of us have to undo a browser button just to let the food, have some space. So, after this operation you won't be able to eat as much. And sometimes if you've got pre-exist because it doesn't have enough space to come out. And if you have pre-existing reflux, or a bit of acidity or gastritis, it can actually make it worse because everything gets pushed up a little bit. So, this is really important to take into account. So, there is a feeling of tightness which takes a couple of weeks to actually start to ease off. And then this is one of the key slides. I've lifted the skin all the way up to the ribs, and then I have to pull it down, and that's what I’ll be assessing in clinic. I will be sort of getting hold of your little sort of bit of skin and fat, and then pulling it down for me to assess whether there's enough looseness or laxity for me to do a standard tummy tuck in a safe manner, and the idea is that where your belly button point is that needs to come all the way down almost to your pubic hairline, because we want to try and keep your scar as low as possible. And that's the key bit. Once I have taken that excess skin away, then I make a little hole which is designated by sorry about the cursor, a little hole for your belly button to sort of pop out and then stitch that into place. Now, you might say. Well, where's this reconstruction business coming in so that skin and fat below the belly button, which in a tummy tuck normally, I would sort of. We throw it away in somebody who's had a mastectomy. I can actually use that to make a breast out of it. But if I transpose the skin and fat onto the chest, then it would die because it's just skin and fat, so I have to take it with its blood supply. So, this makes it more complex and do a plumbing job under the ribs to reconnect that blood supply, to reestablish it and keep that new breast alive, which is the tummy sitting on the chest. So, if someone has a strong family history of breast or ovarian cancer, it's of those things where I would suggest that you know you may wish to hang on to your tummy just in case, because, as all of you will know, breast cancer affects one in women especially, and especially if there's a very strong family history. Now, one of the problems with this operation is where I have sorry about this cursor where I have lifted the skin all the way up to the ribs, and then pulled it down and then stitched it up. That skin underneath is that is a potential space for fluid to collect in this whole area. So, between the skin and the muscle, so you may come back to me and say in clinic, oh, I feel like a water bed, because what's happened is bit of fluids collected underneath that layer of skin, and that's called seroma. And to so one has to then, then what I have to do afterwards is put a needle in and drain that fluid. So, to reduce the potential for seroma formation. About years ago, I started doing, and this is more common in my ladies who have breast reconstruction. You know the complex tummy tuck. And so, what I started doing was using a special stitch which has got tiny little barbs on it. You can't see them with, we can. Well, you can barely see them with the naked eye and stitch that. Sorry about this stitch that skin back on to the muscle on the inside to reduce the space for fluid to collect, and that's called quilting. So, I pretty much do that in almost everybody, and I started doing it in my aesthetic abdominoplasty is about years ago, so my seroma rate is pretty low. The downside of it is that sometimes very rarely, in very slim patients with very thin skin that can give rise to minor puckering in the overlying skin. And if that happened, don't worry, because that suture is a dissolving suture, and that takes about two weeks to dissolve.

So, this is one of the ladies where she had twins, and you can see she's quite. She's got a lot of diversification stuff, you know. It's all bulging out here at the top, and I could actually sort of put my! It was about â cm wide. That's her old umbilical hernia repair, and that scars ended up down here. And she's had everything lifted up. But the skin is nice and tight, and that's her another lady, where she has a little overhang over her caesarean scar, where, in spite of doing loads of swimming, it wasn't disappearing, so I’ve taken all the skin below the level of the belly button. Put it away, and then she knew hold for the old belly button to come out, and then a scar from hip to hip. I'm going to show you another lady same issue. But look at the stretch marks.

If you have stretch marks above the belly button in the skin above the belly button. I'm afraid they're still going to be there, but they will be lower down, and that's her with a slightly red, angry scar, because that picture has been taken about two months later, so most scars, like all scars. Will remain red and lumpy for about two months and take months to fade. So, the main issues which you need to think about in a tummy tuck are scars which you know it's a big scar with the scar around the belly button as well. The fact that it'll feel quite tight, and the recovery is similar to a caesarean hysterectomy. So, you're walking a little bit bent over for about a couple of weeks, because if you stretch too quickly or put it putting tension on the scar line. And that may open up near the pubic hairline. So, it's important to sort of stay bent. And if you've got pre-existing back pain that may sometimes get worse while you're bending down for the first couple of weeks. So, bear that in mind, and then the seroma that holds skin in the lower abdomen remains numb for several weeks, if not a few months, similar to caesareans and hysterectomies. And then eventually most of that sensation comes back. But the scar from hip to hip remains numb forever. So, it's a useful operation to do for those ladies who have that overhang where you can't get rid of it, and it improves it, and especially if you've got underlying diastasis. Now, I do a little additional thing if it's required, which is the mons lift.

So, when sometimes in patients who have weight loss, or where the mons pubis is a little loose. It's sort of a bit saggy. We can sort of wake it up a little bit as well, and that's called a mons lift, and that's part of the operation. When it's indicated. I do that as well. It's useful to do a version of a tummy tuck known as a fleur delay, which is basically giving a vertical scar and a horizontal scar. So, this lady lost about stone in weight. So, when she was lying down and I pulled the skin, I could actually pull it. So, the skin looseness was in the vertical dimension. So up and down, but also side to side. So, when she was lying down above the belly button, I could pick the skin and lift it up several inches, and that's when a fleur de lys indicated. Now, in between these there are some versions as well known as the extended one, where you can actually go all the way, sort of extend the scar further towards the back, and then there is a newer version, which I have been doing for about and a half years now known as a lip abdominoplasty. That is, when you can combine quite aggressive liposuctioning with a tummy tuck.

I’m just going to go back to a couple of slides. The reason why we tend not to liposuck in this area or anywhere here in a standard tummy tuck is because the blood supply to the skin edge comes where those arrows are drawn. So, if you liposuck in this area, it sort of interrupts the blood supply, and therefore the risk of that skin dying is higher because of reduced blood supply. So liposuck lipoabdominoplasty is targeted liposuction, usually a little bit in the midline. Those little pouches on the side and aggressively on the sides, from the flanks up to sort of near the bra fat pad, and it's and very and avoiding this area where this area is where the blood supply comes in through the muscle and supplies the overlying skin. But that can only be offered in patients whose BMI is or less. Because anybody whose BMI is higher, the complication rate goes up significantly. And I’m going to just throw in here nicotine use, and that includes smoking, and you will know if you've attended the last webinar. You know I spoke about breast reductions, nipples, sort of dying. If you're smoking or vaping or nicotine use. And the same issues are here. I'm pulling you quite tight, so we're relying on the inherent blood supply, and if we compromise the blood supply with nicotine use. Nicotine is a vasoconstrictor, which means it makes the size of the blood vessels smaller, so there's less blood going into those skin edges. And then there's an increased risk of wounds opening up wound, breakdown and little bits of skin having necrosis, which means basically it dies so, nicotine use as in like smoking, but definitely vaping, even if it's % nicotine in your in the vape. Because if you send the vape off to a lab as you must have read in the tabloids a few months ago. It's a big problem in school children. They've sent loads of to the laboratory, and they found they had variable levels of nicotine within it, plus some contaminants like lead, etc. And the same applies to any nicotine, chewies or lozenges, or patches, so I am afraid you'll need to be off all nicotine use for at least weeks. So that's about months prior to the operation. To give the best chance and make it as tight as possible. Now there's a couple of questions already. Come up. There's a tattoo on the side of the body. Would a tummy tuck make this look bizarre? Well, if it's within the area of skin I’m going to take out, which is below the level of the belly button, and above that big smiley scar. Then that's actually going to end up in the bin. But if it is along that line, then I will sometimes try and even it up, but it may be that half of your tattoo, if it's below that line remains, and then you may have to get it retattooed above it and get that pattern done again. So, it doesn't make it look bizarre, but you need to be prepared, depending on the sort of tattoo you have, how taking that bit of skin out will actually affect it. Now, another question as cabin crew I will need to wear tight, fitting, high waisted skirt. How soon would I be able to after a tummy tuck? Now, one of the problems with being cabin crew is that you may be doing long. Haul flights. You're on your feet, and I know you're mobilizing, but it's still at different air pressures, and one of the big risks of long-haul flights, even if you're moving around as cabin crew is clots in your legs and lungs. So, I’m afraid, with this operation, just like any other operation in the UK. And these are nice guidelines and applies to all NHS and private operations. Is any major operation for weeks before and weeks afterwards. You are not supposed to have a long-haul flight, simply because simply because the risk of clots in your legs going to your lungs. Pe. It's quite dangerous. Quite a high risk, and tummy tucks are a little bit high risk for DVT. And pe. And if there's long haul suddenly thrown into it, then the risks are higher. So, even though we give you your lovely nylon stockings to wear for weeks afterwards and give you a blood thinning injection that still doesn't get rid of that risk completely. So, no long-haul flights before and afters. And yes, you can wear a tight, fitting, high waisted skirt, but actually to reduce the seroma formation and to get the skin to sort of stick down to where I have quilted it down. You're going to be wearing a surgical garment, but, like Spanx, actually like a body shaper, which comes all the way up to your ribs for two weeks. So, if you're on short haul flights, you probably can go back. But I would say definitely, take potentially weeks, weeks off work because it's a manual job. You're pushing hard, you know, trolleys, food, trolleys serving. And so, it's a good idea to avoid even short haul flights as cabin crew for about weeks, and the same will apply to anybody in a very physically intensive job. And we'll apply the same to any exercises like running, jogging, lifting weights and stuff, or I would say, about two weeks, and anything that involves things like Pilates or yoga with stretches, anything. Just think anything that engages your core. And you need to do core exercises. Avoid those for up to weeks similar to what's said after a caesarean or a hysterectomy. So, there's no more questions on tummy tuck.

I might move on to the other slides. But just going back to types of tummy tucks, there's the standard one. There's the extended where it goes to the back, the newer version, where it's a lipo abdominoplasty, only suitable for ladies who are BMI, or less. Having said that in a standard tummy tuck for those with a higher BMI, you can actually, I often do the flanks. You know, the love handles. Just do a little bit of liposuction there. So, it's a nicer shape, because that area which is liposucked on the side. For example. Here, you know the love handles those. This lady hasn't had it, but usually that can be done, and that doesn't interrupt the blood supply. I was talking about earlier. And you may wish to think. Do I really need it? Because that increases the price of the operation as well? So, if you want to maintain that shape of having a little bit more of a hip flare. Then keep those the bit of the hip fat. Age for these operations. Well, I would say. It's a bit relative. We're not trying to be ageist here, but it's about making sure that you are able to cope with that operation. And I think most patients I have done have been or less, but it depends on your fitness level. So, if you know you're over a certain age, but you're super fit, like, you know, I’ve had ladies who run marathons, and then it's a question of anaesthetic fitness. This is a long operation, and it's underlying medical conditions that contribute to it as well. So, something known as the anaesthetic safe ASA, which is the American classification where somebody who's ASA one is reasonably fit and healthy. Is when they've got a couple of underlying conditions, but generally reasonably healthy. And is where there's significant issues and anaesthetic becomes a little bit of a problem. And I think on the whole, these operations, when somebody's ASA or , where there's a high danger of problems during the anaesthetic. We tend not to do them at Benenden hospital simply because anything really complex. If you require very specialist care afterwards, like kidneys, lung support, or cardiac support, then it means putting you in an ambulance and transferring you out to a high dependency unit or intensive care elsewhere, because all that expertise is not here, so one has to sort of take into account the other the holistic approach, and look at everything else that's there in your background for underlying medical conditions.

I hope that answers the question. Let's move on to arms. Now, I’m showing you a very extreme case. This lady lost a lot of weight, and it's a lot of skin at the upper arms, but most ladies will have it at the upper arms. This lady's got it all the way going up to her wrist. And what I have done is taken all that excess out, and going all the way to the wrist and near joints one has to put a little zigzag there just to try and make sure the joint is mobile. You can't put a straight line across it. And no traditional way of doing brachioplasty or arm reduction. Borachio in, I think in Latin, is arm and plasty is reducing it so is to improve the appearance of the upper arms is an operation where, traditionally, or historically, it's like a big pizza slice, like a wedge taken out. But if you took your hand and sort of pressed it under your arm. Here you might actually get tingling in your fingers because there's some quite important structures that run just in the groove from there all the way along here. So, for several years now for about, years, again, I’ve been doing a combination procedure advocated by a surgeon called pascal, a Frenchman, where we liposuck. This overhang quite aggressively and a little bit elsewhere as well. So, it leaves only skin, and then just take the skin out. What that does is, it preserves the lymphatics. And it also preserves a lot of the sensation. Obviously, some of the cutaneous nerves goes when cutaneous, meaning nerves that supply the skin which is taken away goes. But a lot of the underlying structures don't have any issues. And one of the problems with this operation is seroma formation again, which is the fluid collection, and when the lymphatics are preserved that appears to be less of an issue.

This is another lady where she's got again it all the way up to here, and I have her scars faded really nicely, but the scars doesn't don't fade in everybody, and one of the issues with this is sometimes the quality of the scar is difficult to control, because this scar can sometimes stretch. Now, when I finish doing this operation, you'll be very pleased with it, and you will think, oh, my god, look at this at weeks! It's nice and tight. It goes without saying. I can't make the upper arm skinnier than the forearm that looks weird. So, we have to make the arm tapering into. It's like a tapering cylinder going from the upper arm to your elbow, and some people have a very wide elbow, and then it goes on to the forearm, and eventually to the wrist. So, it's about making it look sort of normal shape, and initially, you'll be very pleased and think, oh, it's nice and tight. But that's from the swelling as well, and when the swelling goes there is a little bit of recurrence of the laxity. So, a little bit of looseness like this lady has actually come back, so do expect that to happen. But it doesn't obviously go back to what it was before. Now. This is where you're seeing a vertical scar going on the inner seam of the arm, which is nicely hidden. And so, even when you, the only time somebody will see it is if you lift your arm up and wave like that they'll see the. So, you might have to start waving like our queen, you know, when the queen used to do it. It was just that you might have to do that instead. But it's a good operation when you are concerned about the way it looks, or it stops you from wearing sleeveless or spaghetti tops during the summer months, and sometimes some ladies have a lot of bulging fat near the elbow, so getting jackets over sleeves or jackets over is actually quite difficult. So, it's a good operation for that. There is a version of that known as a mini arm lift, where, if the looseness is restricted only to the upper third of it, then you can tuck it in and give it horizontal scar. But to be honest, you have to sort of think logically. We have got a looseness that is in that direction. So, if you had a pair of trousers which were really loose like this way. You know, you end up losing weight, and they're really baggy, and you want to take the seam in. You don't hike it up, do you? You take it down or make it tighter at the seam of the trousers? That's exactly what we're doing here. If you can imagine. This is like a trouser leg. Then we've taken the excess away and taken the excess off at the seam by tightening the seam. So that's the principle of that, and it's the same with thigh lifts as well. Generally, women. There are a lot more patients who have arm lifts because the scars are a bit better to control in a thigh. Lift again. A mini thigh lift is when the excess skin is restricted just to the upper one third and then you can sort of put it up. So, the scar is actually in the knicker line. One has to be a little bit careful of this, because if there is a downward pull, because these scars it's all very well, but everything comes south with time, including skin. And when that skin pulls down a little bit, it can actually avert the introitus. So, the labia, it can sort of avert it a little bit. So just be aware of that. But majority of the patients who present to me. We end up doing a vertical thigh lift because the skin excess is not just restricted here. It's all the way down, including down near the knee joint. So, the idea is similar to an arm. Lift liposuck the whole area, and then just strip the skin and stitch it up, because if you again take it out like a pizza slice or a wedge, there's a lot of important structures that run deep. And again, seroma formation can be a bit of a problem here. Thigh lift scars generally will do. Okay. But the bit, the place where it always has a problem, including for arms, actually is near the joint near the joint. So here in the groin area where the bug counts higher, and sometimes I have to make a little there to get rid of the dog here in the arm as well. Our armpits are not really clean areas. The bug count is higher. So, when the scar is like a zigzag in the armpit. That's the point where it usually breaks down. I have a question here. Can I have varicose veins. Veins. Sorry I have varicose veins. Could I still have a thigh lift varicose veins generally? It's probably a better idea to get them treated first, simply because if there are some incompetent valves, remember, varicose veins is an incompetence of the valves. The valves in the superficial venous system are not working very well, and they are connected to the deep system. And after this operation the clot risk is not that much, but you're still going to wear your lovely nylon stockings, and you're going to wear the pressure garment same as the tummy tuck. You're going to wear it for the arms and wear it for the legs and for the legs. It's like little capris which we supply. And so, it's doable. But the problem again is making sure that you don't have underlying health conditions. So, it depends on what your varicose veins are. I think they need investigating to see where the issue is, and if there is a huge incompetence between the deep and the superficial venous system. Better to get that sorted out before you go for this, but this is fairly superficial surgery, so shouldn't affect it. A huge amount, but I would advocate a consultation with a vascular surgeon or a varicose vein. Surgeons. If you're living alone, would you be restricted? You are, I think, with all these operations, whether it's arms, thighs, and tummy tucks. You are going to need help around the house, for you really need someone with you for the first week or so.

So, if you can get a friend, a relative to come in. Be with you, keep an eye on you. That's great. With an arm lift. You won't be able to lift your arms above your shoulder height, and you need to keep that wound dry for a week, and you're wearing the pressure garment. So, it's just bearing that in mind and with a thigh lift, thigh lift. If you are walking straight, that's fine, and you can definitely sit down and stand up. But you can't do splits, you know. You can't sort of have the legs going out. That's when it puts tension at these scars, and you can have a problem. Another. So, I hope that answers the question, would it be very restricted? Yes, you're likely to be restricted. But you, I would advise to have help at home and have everything lined up. And maybe have someone close by, so have a little network of people who can look after you, even though, and I don't want you lying in bed, either, because that's clots and legs and lungs. We want you moving straight away. In fact, when you're in hospital we'll try and get you out pretty much straight away. Can you have more than one procedure? Yes, you can have breasts and tummy done at the same time, or tummy and arms done at the same time. Why don't I advise tummy tuck and thighs at the same time it's all about blood supply.

So, if you can imagine in a tummy tuck, you've got a scar that's going from hip to hip like that. And then you've got your vertical scar from a vertical, and I have to do a little horizontal one to try and get that little excess skin called a dog ear out at the same time. What I’m worried about is blood supply between your tummy tuck scar like that and this central skin. Well, where's that blood supply going to come up? Because we've got scars at the bottom. We've got scars at the top, so if you do the whole thing in one go. I would not offer you thigh lifts and tummy tuck at the same time, but I’m happy if you've undergone massive weight loss. I'm happy to offer breast and tummy breasts and thighs. Or thighs and arms so far away. Combinations is fine, but breast and tummies is usually the most common one I tend to do, but they're certainly doable. I will not do more than procedures, because each of these the tummy tuck is and a half, â h. Arm lifts is â h. Thigh lifts can be up to and a half hours. Suddenly, with procedures. You're on the operating table for about and a half to â h. If you put in an extra procedure on top more than, the length is just too long. The longer you're on the operating table, the higher the complication rate higher the problems of DVT pe. And that's well documented in literature, not just for plastics, but across all surgery. So, I would say, maximum, but not procedures. I hope that answers that question, Julie. I have another question about having sex. Now, generally that can be quite vigorous, so I would say, avoid any intercourse, or for about weeks afterwards, until you feel fit enough to actually do it what you don't want, and I’ve had patients who had it done too soon after a tummy tuck, and they come back with a little bit of a blood, a bleed, a secondary bleed within the layers of the muscle, and that is all within the layers of the skin, and it's a secondary bleed that's called a secondary hematoma. So, hematoma is a collect. So, any operation there's a risk of bleeding a hematoma is a collection of jellified blood that happens fairly soon after surgery, or when you're in hospital. And that's called a hematoma, so that it means a return to theatre to evacuate the hematoma, and a secondary hematoma can occur when you do something a bit too vigorous, too early, when you're not supposed to. And then you end up with a bleed in that areas which swells up like a jellified clot, and then have to take you back to theatre to actually evacuate it. So, I would just sort of. Leave it for about weeks or so before you go for that I’m going to move on to the last bit on liposuction. Now. Liposuction. I suspect. Many of you have probably watched it on television. It is not a treatment for being overweight. It's a treatment for taking out the stubborn bits of fat, no matter how much you exercise, it doesn't go away. There is one question on their which I’ll address now, because what we're moving on to something slightly different male breast reduction. Yes, I did. We did include that in our last webinar which I think is pre-recorded. Is that right? So, it's there on the Benenden website. But male breast reduction. There's various types depends on the position of the nipples, the amount of tissue and the gristle ball behind the nipple as to whether it will. Is it amenable just to liposuction? Does that gristle ball the fibrous disc behind the nipple? Does that need taking away? Or, if it is a very large breast bit like a female breast, and that's going to need a different pattern of breast reduction. Yes, we do those quite regularly here, actually. But it depends again on your fitness depends on what is actually required, because it's not just male breast reduction as one operation. There's various grades of it. And there's a lot more information. If you're interested, there's the Simons classification which tells you different types of breasts as in like the fullness and what actual operation is required for each of those and the complications for each of those. So please do have a look at that., we'll go on to the liposuction, and then I’ll take some more questions, including yours, Pauline.

So, with tummies, with liposuction, it's not the treatment for being overweight. So, it's for taking out the stubborn bits of fat, like the flanks, you know. Crudely called the love handles, or even a horrible term is muffin talks or saddlebacks, which is at the outer thighs. So that's useful to actually do liposuction in targeted areas. So, let's so it's done. What we tend to do here at Benenden is wet liposuction, which is traditional liposuction. So, if you've ever watched liposuction on television, it's of the crudest operations known to man. Where with wet liposuction, the area is infiltrated with a solution of salt water, which is saline, or a version of fat adrenaline, which stops the bleeding and make the whole size twice, times the size of what it is. Then bash the fat and suck it out. And it's bashed or sucked out with these type of cannulas. The diameter of that is similar to a virus. It's not very wide, and it's got little holes on the sides, and it's got a blunt tip. So, the idea is to suck the fat out. And here this picture shows that's some of the infiltrate. But that whole rest of it is fat, so fat is like thick yellow fat. It's sucked out. Now, obviously, the success of the operation depends on the ability of skin to shrink. And that can take, , months. And things that will give you a relatively poorer result, or the skin may not shrink completely is when somebody's lost a lot of weight.

So, it's about collagen, isn't it? Whether the elasticity is there, so weight, loss, age as we get older, over, . That skin may not have that ability to shrink back. So, the idea that it will shrink back to nothing is just, it's not going to happen. And then finally, multiple pregnancies where the skin has sort of distended, and there's a lot of stretch marks so doing, for instead of a tummy tuck, if one wants liposuction to the tummy when there's in the presence of a lot of stretch marks, and the patient is a little bit older. Then I’m afraid that's not going to work very well, because that skin the skin doesn't go anywhere, it has to shrink. And if it doesn't shrink, you're just left with a lot of loose skin. So, one has to take a bit of a pragmatic view on thinking about the potential outcomes taking into account weight loss again, pregnancies and page. So, it's about elasticity and collagen. I'm afraid so. Liposuction is useful, but, like, for example, this lady she had, if I were to draw a line. So, this is the before from here to here. This is all the outer bit, and that's all I’ve done. I haven't done a huge amount. Okay, the picture here is a bit zoomed out. But if you look, that's all I’ve done, and maybe a little this this lipping here that she's got underneath in the fold. I've done a bit there and the outer bit the rest. I haven't touched it. So that's when she's had the liposuction. It's taken early, because you can probably see just that skin, slight looseness there which needs a little bit of time to actually shrink down.

I’ve just shown you a very isolated case of liposuction which can be done in isolation or can be done in combination with other areas. But I think pragmatism and you know, being realistic about the potential outcome is very important. So, my job is to manage your expectations as to whether it'll actually work or whether will we be sort of from the frying pan into the fire in the sense that you've got the excess fat. But if the fat is sucked out and that skin hasn't shrunk down completely, are we going to be then in a worse situation, especially somewhere like the inner thighs left with very loose skin, which hasn't shrunk down. And this sort of stretch, you know, stretch marks or wrinkles all there, and that is not a nice look. So, I hope that was useful. There is one more question which I’ll address now and then come on. Come on to about choosing surgeon, and a few more things which you need to sort of take into account before you go into this. How soon after an arm reduction, can I resume aqua aerobics? That's the same as what I said about tummy tucks or thighs. Aqua aerobics, even though the water is actually supporting you, and you're not doing. You're still doing a fair bit of resistance.

So, there are things when you go into the swimming pool. One, I presume, aqua aerobics is a class in the leisure centre with other people, in which case one of the things is, people do pee in the swimming pool. So do you really want a new surgical wound to go into, even though it's chlorinated, you know, where kids have peed and stuff like that. You don't want cross infection, and that goes back to even things postoperatively, which I would discuss with you at the time of the consultation. I don't want you having a bath for about weeks, to weeks, until everything's completely healed, and any little niggly problems have all settled down. Because I don't want a surgical wound in the same bath water as with pubics floating around, because there's a very high risk of infection. I know it sounds awful. But that's the reality. So, it's the swimming pool is different because it's chlorinated. So, I don't want you getting into the swimming pool for about two weeks. I think that will apply to aqua aerobics. But if you just wanted to do stretches and stuff, you're pretty much full range of movement. Two weeks later. You're driving at about a couple of weeks, lifting heavy things like in your biceps, curls, and triceps. I wouldn't do that for about two weeks, similar to aqua, really aqua aerobics. So, I hope that answers your question there. If I haven't answered any of the questions to the depth you wish. Just put it up again and get me to clarify.

So, whenever you go, for any of these procedures doesn't have to be with me. Whoever you go to make sure you check the qualifications. Are they on the specialist register for plastic surgery? Remember, cosmetic surgery is not a qualification. There is no training for it. Anybody can do it. A GP can do it. Any specialty can do it. Check the qualifications, make sure they're members of various associations, simply because that's a little check to get accepted into a membership has got certain hoops one has to jump through to make sure you've actually hit all the training targets. So that's important. Never, ever rush into these sort of operations. They're big operations with long recovery periods. They're expensive operations that time commitment has to be there from your side. I'm not doing just a I’m not doing a job on you. This is you and me in it together as a team. So, we have to meet each other halfway. So, I need that commitment from you to actually for the postoperative care. Don't try and cram it into different, you know, in a tight schedule. Make the time for it for a start. You're going to be spending an awful lot of money on these operations, and you know it's a good idea to make sure we come through the operation with a happy patient, a very happy patient, with the least number of complications and a happy surgeon. We don't want things to sort of go a little pear shaped because of anything that's happened. So, it's all about optimizing your body. And we'll talk about that about diet, etc, in during the consultation, how you can optimize. That's it. And obviously nicotine use and giving enough recovery time. Make sure, whoever you go to understands what you are wishing for, and if the surgeon can't deliver, and certainly, if you come to me, and you say, this is what I would like, and I look at you, and technically, I think I cannot really achieve what your desire, what you desire, then I will be really upfront and say, handle my heart, I totally get what you want, but I don't think I can technically achieve what you desire, so I may not necessarily be the right surgeon for you, and I’ll be very upfront about that in the first consultation. Usually, it's quite a lengthy one from to â min, and we go through your medical conditions. Psychological suitability. Now, that's an interesting one, because there are certain times in life when one shouldn't really have this operation. If you've undergone a bereavement, a separation, or a divorce, or you're in the middle of moving house, because these are times when you are at your most vulnerable, and you need that commitment to actually absorb what's going to happen to you? Because, you know, I’m not sort of sort of saying cosmetic surgery is unimportant. It's very important for quality of life, for self-esteem, giving you the confidence that you need. And also, physiologically making you feel better, you know, when you have your diversification placated and the muscle repaired, it sometimes gets rid of your back pain, it improves your posture, etc. But it's about being realistic that you have, you know. If you were to have an operation for, say, hip or knee replacement, it's because of pain. It's movement. This is something where we're doing it for improving your confidence. So just make sure that you know we're going into it, understanding what the outcomes are, and if there are other, you know, underlying mental health issues, I will involve your mental health, your GP. Or your psychiatrist, and it's nice to be upfront, because then we know it's about supporting you through that process and making sure the timing is right realistic goals, and you need to be fully informed.

In the first consultation I go through a lot of stuff. I actually go through some of these slides as well as I said earlier. There's lots of before and afters. They're my patients who've given special permission for their photos to be used. They're not being photoshopped or anything like that. And then I see you for once you've got all that information I write to you, summarizing everything that I have said, including copying your GP. In GPs, don't stand in judgment, but they are responsible for your holistic care, so I do like to copy them in. And then I see you for a second consultation. If you wish to proceed, and then you can make, and then you can sort of liaise with the hospital about the surgery date. But generally, I insist on a cooling off period of weeks before we give you an operation date. And that is the guidance from the regulator, from the general medical council minimum. Two weeks. Cooling off period. Because pretty much the general medical council and most people. Though you may not feel yourself, you're vulnerable. Cosmetic surgery does happen to make people vulnerable. And obviously we want to make sure you're absolutely fully informed before you proceed with this. And then â min consultation written letter, I will reset that actually second consultation operation. I see you at a week, days to do the dressings. Either Kate or I see you, and then I if Kate's seen you, then I see you a couple of weeks later.

So, we sort of make sure we've seen you enough number of times for follow ups, and then I see you again a few sort of weeks later, and then finally, , months later, just to make sure everything's settled down, because at that point sometimes you can get minor little problems like dog ears. Now, dog ears, you may say, what's that? It's a medical term, where the scar finishes, you may get a knobbly bit of skin called a dog ear, and then that is included in your package price, which covers all your complications that are covered by the your package price. So, there's no further cost to you, including things like dog ear correction, which I usually tidy up at about months or so. We'll go to. So yes, while we're I’m answering the last question, please go to the q. And a bit, and we'll go through everything.

What is your opinion on a review on a review tummy tuck? I'm not sure I understand. But correct me if I’m wrong, is it, when it's already been done elsewhere? And it's whether it can be rectified. If you're unhappy with the outcome of the previous tummy tuck. Yes, I can see and see whether I can certainly see you for a consultation and give an opinion as to whether things can be improved. So, review of a tummy tuck done elsewhere. Yes, we can. But generally, if it's very recent ideally, you should be going back to your primary surgeon to sort out things like. For example, if you've had it done elsewhere or abroad, and come back with either wound healing problems or seroma collection, then it's best to go to your primary surgeon because they should be covering you for all your follow ups, including any complications. But if it's several years down the line, for example, you've had a tummy tuck ten years before, and then, you know, things have changed, you know, just like what you have. But I’ve had the menopause. Things change, your body changes, and you think well, you know tummy's gone this way or the other, and you end up putting on a bit of weight, or whatever. Then certainly I can review and see whether maybe a bit of liposuction, etc. Can sort that out, but happy to consult, and it's a very open one. I can't give any details unless I know what the circumstances are.

I have another question, dramatic weight loss, and you feel you have a lot of excess skin everywhere, and you wish to come and have things done. Yes, there will be lots of concerns in those areas. It's a good question. There are things after a dramatic weight loss, whether it's after using gastric band having gastric sleeve or doing it just completely, you know, with diet and exercise. Either way, it's a good idea to have had the weight stable for about months to months, simply because if you rush into it, then the result that I give you is not sustainable in the long term. For example, if you end up losing more weight, I made you nice and tight, and then we end up, having the looseness come back again.

So, it's a good idea to have the weight stable, and if you had something like a gastric sleeve or gastric band, your vitamins, and all sorts of levels in your body need to sort of stabilize before we undertake a big operation, just to make sure you don't end up with wound breakdown, for example. Which is not uncommon so important to do that a good idea is to actually list your priorities. What is it that bothers you the most? Is it the arms, or is it the tummy, or is it tummy first then breast and then arms? Because if you sort of prioritize. What is the thing that really bugs you. And it'll be different for each person. It's so personal what bothers you make a list come with those concerns, and then we can talk about maybe a couple of combination procedures and then do one as the last one. If it's things. So, these are usually so if you are interested in arms, tummy, and thighs well, most for most people arms tummy, which are more on show. Is, or tummy in clothes for tight fitting clothes is more of a problem. Then get the arms and tummy sorted out at the first operation. Have the thighs done at a later day because it's a shorter operation. I can't do arms, tummy, and thighs especially not a combination of tummy and thighs like I mentioned earlier. So, I have done tummies, just tummies on their own. I have done tummies, breasts as a combination. I've done tummies, arms as a combination. I have never done tummy and thighs because blood supply is a big problem and then obviously optimizing the body as well for what is essentially a â h operation. I think I have a last question. Is there a time limit between initial consultation and choosing to have surgery? Well, I’m I am making you wait for weeks as a cooling off period. So definitely that week comes in without, say, because you have to have that time to think it through. It's the way I put it is if you were going and having, I don't know, buying a really expensive thing like a massive car in a car or buying a house, you don't rush into it straight away. You give yourself time to think about it. And for all major purchases. And this is, I’m not saying, this is a purchase, but well. I suppose it is. It's an investment to improve how you know quality of life and confidence, but so I do make you think about it, and I give you all the information. So yes, weeks cooling off period, and I do need a second consultation. So, the earliest I will schedule. The surgery is weeks. I hope that answers your question sometimes. When you come, I might say, well, you need to lose a little bit of weight, because I might be able to give you a better result, or stop the vaping nicotine, etc, that inherently brings in a stopgap as well, because you may not be able to achieve that weight loss straight away. So, it's just about being realistic. I've had some patients where they've had the initial consultation come back to me years later and achieved everything that we've set out, and they've got way beyond, because they wanted the best result I could give. And that's certainly possible as well. So, there's no time limit on that. Having said that the hospital changes its package price come first of April, I think. Is it first of January that most hospitals do that pretty much? They change on annual basis, just like everywhere else. I suppose that's the only thing to take into consideration. I hope that has been useful. I can't see the time. It's almost o'clock. Yes, so if you have any questions please put them on, and I think I’m going to hand you over to Kate because there's a few more things you'd like to mention, Kate.

Kate Comrie

So, thank you very much. I hope that was useful, and you enjoyed it.

Anita Hazari

And yeah, apologies for putting those initial bits on McIndoe and stuff. I just thought, it's nice for you to know where I come from, what I actually do as my day job other day, job, because this is not just me doing aesthetic surgeries, the whole package, and I am afraid I’m I do sort of give you a very honest opinion about what I think about things, so please don't be offended. It's never meant as offensive. But just being very honest about things.

Kate Comrie

Thank you. Okay, thank you. I'm sorry if we didn't get to answer your question. If you provide your name, we can contact you via email if you'd like that. So as a thank you for joining this session, we are offering % of your initial consultation. Just need to use the code COSMETICS50, a callback from your dedicated private patient advisor. An email with the recording and updates on news and future events. We also have a loyalty rewards scheme which isn't on the screen right now. But if you have a look online. You can see that we would be grateful if you could complete the survey at the end of this session to help us shape future events. If you would like to discuss or book your consultation, our private patients team could take your call until pm. Tonight. Or between am. And pm. Monday to Friday, using the number in the purple circle on the screen. Visit our website to sign up for future webinars and consultation events on behalf of miss Anita Hazari and our expert team at Benenden hospital. I'd like to say, thank you for joining us today, and we hope to hear from you very soon. Take care! Bye-bye.