Mr Azhar Aslam FRCS(G), FACS, FEACS

Consultant Plastic Surgeon, Specialising in Cosmetic Surgery

PROFILEAzhar Aslam is the current President of the British Association of Cosmetic Surgeons (BACS). Azhar trained in Surgery for ten years; out of which five and a half years was in Plastic Surgery in the NHS. Pursuing his chosen speciality of Plastic Surgery, he was awarded a scholarship by the Royal College of Surgeons and Physicians, Glasgow, which took him to Louisiana, USA, for a Fellowship in 1996. He furthered his expertise in Cosmetic Surgery, training and working in America, Mexico and Germany, obtaining a Fellowship of the American College of Surgeons in 1999.

Azhar continued to work in the NHS, finally working as Consultant Plastic Surgeon at the Countess of Chester Hospital in Chester, where he helped set up a specialist hand unit. He left the NHS in 2000 to work privately and has since built up a private Cosmetic Surgery practice and a Health Village in Harley Street, London. Azhar works from other clinics located across the UK as well. He has worked actively with the Department of Health, IHA and expert groups to improve the regulation of the cosmetic surgery industry. He has worked as panel advisor to the European Academy for Cosmetic Surgery and as Academic Secretary of the British Association of Cosmetic Surgeons, recently becoming President.

MEDICAL QUALIFICATIONSFellow Royal College of Surgeons (Glasgow) Fellow American College of Surgeons

MEMBERSHIPSPresident of British Association of Cosmetic Surgeons (BACS) Fellow Royal Society of Medicine Fellow European Academy of Cosmetic Surgery Member British Association of Cosmetic Surgeons Member British Medical Association

DISTINCTIONS/CITATIONSWho’s Who in Science and Engineering 2001 - 2002 Who’s Who in Medicine 2002 – 2003 Nominated as one of The 100 Best Cosmetic Surgeons of the world by the scientific committee of the 52nd World Congress of the IACS, Colombia 2008, for ‘selfless work and scientific contribution in the development of cosmetic surgery as a new medical discipline around the world’.

ACHIEVEMENTS IN COSMETIC SURGERYDeveloping and expounding the principles of S-Facelift Surgery Expounding and furthering the principles of Breast Enlargement Developing an objective criteria to select breast implants Expounding and further developing the principle of Cosmetic Surgery under local anaesthesia Popularising and raising awareness of the accessibility of Cosmetic Surgery to the general public

PUBLICATIONS A new flexor tendon repair - biochemical analysis BJHS August 2000 Pre-operative patient education affects the eventual satisfaction ANN.PLAS.SURG April 2000Never throw away a living thing ANN.PLAS.SURG Dec 1999A new method to facilitate skin graft harvest ANN.PLAST.SURG July 1999Dog Bite resulting in Hand Fractures INJURY June 1999DIC Following Dog Bite Jour. Roy.Soc.Med. March 1999No sense; no sensibility - A tale of two adult hair dryer burns Burns 1997.23:5Review of Regional Flaps in Reconstruction of Head and Neck J Soc Surg of Pak 1995; 7 IIIAetiology and Symptomatology of Gastric Carcinoma in Multan Region Journal of PMRC 1993; 38:77Monograph on wound healing and dressings 1994 Pak Publishers

INTERNATIONAL PRESENTATIONSPhilosophy of Cosmetic Surgery and the Five Dimensional Framework EACS International Meeting, 2003

Choosing Cosmetic Surgery EACS International Meeting, 2003

S-Lift Facelifts - Registering a new technique EACS International Meeting, 2003

Breast Augmentation - Choosing an implant size EACS International meeting, Berlin May 2001

Versatility of Open Rhinoplasty EACS International Meeting, Berlin May 2001

Soft Tissue Tumours in Children - Two rare cases Royal Society of Medicine, London

Wexham Quality of Life Scale - A Prospective study of vaility and effectiveness BAPS Summer Meeting, July 1997

Biomechanical Analysis of a new type of Flexor Tendon Repair BAPS Summer Meeting, July 1997

Patient Satisfaction after Breast Reduction BAPS Summer Meeting, July 1996

Septicaemia and DIC following Dog Bite Royal Society of Medicine, April 1995

Dermatofibrosarcoma Protuberans of Groin Masquerading as Hidradenitis Suppurtiva: Royal Society of Medicine, London

Does Pre-operative Scar Awareness Effect the Eventual Outcome? Frank Cort Prize Meeting, Wordsley, West Midlands, October 1996

COSMETIC SURGERY PUBLICATIONS How to Choose the Size of a Breast Implant BODY LANGUAGE - Cosmetic Surgery Journal Patient selection in Cosmetic Surgery NAPC ReviewPerforming Breast Enlargement- A Guide. NAPC Review March 2007Cosmetic Surgery - How to get a great result and be happy. Available for sale.

EXPERIENCE IN RECONSTRUCTIVE SURGERY DURING NHS TRAINING:FACE 100 HAND 600 LOWER LIMB 65 BURNS 70 SKIN CANCER 400 BREAST 40 CONGENITAL 35

PHILOSOPHY OF COSMETIC SURGERYCosmetic Surgery is unique in that unlike other surgical specialities, the surgeon is changing healthy tissue which is not diseased in the traditional sense. The surgery is being performed to fulfil the patient’s desire. Therefore unlike all other specialities, the ‘wants and desires’ of the patient take a central role. Cosmetic Surgery is performed using a five dimensional framework. By this it means there is a three dimensional framework of the physical body. In addition, a cosmetic surgeon has to take into consideration the fourth dimension of Time to visualize the desired final result after the healing process is complete, since tissues can change during healing period. Finally, but even more importantly, a cosmetic surgeon must delve into the patient’s mind and ascertain the nature of what the patient dreams of and wants — and what the patient expects. Understanding this desire is fundamental to a successful cosmetic surgery operation.

SURGICAL PROCEDURES NON-SURGICAL PROCEDURESMAIN - • Botox• Breast Augmentation • Fillers• Liposculpture • Facial Peels• S-Lift Facelift • Volume Filling • Breast Reduction • Fat Transfer • Breast Uplift • Chin/Cheek Enhancement • Body Reshaping • Abdominoplasty • Nipple Surgery • Body Lifts • Facial Rejuvenation Including Minimal Access Facelift Techniques • Neck/Temple Lift • Ear Surgery • Eyelid Surgery • Nose Reshaping • Male Breast Reduction

SUMMARY OF COSMETIC SURGERY LOG BOOKBreast Augmentation 3,600 Liposuction 1,800 Facelift (inc. temple, brow lift) 1,605 Blepharoplasty 550 Breast Reduction 268 Mastopexy (Nipple procedure) 250 Rhinoplasty 216 Abdominoplasty (including reconstruction) 187 Body Contouring (Arms, buttocks, thigh lifting) 70 Others, including Fat Transfer, Otoplasty, Gynaecomastia, Buttock, Cheek and Chin, Calf Implants, Reshaping 330

Non-Surgical procedures 7,000+ (Peels, Fillers, Botox, etc)

Revision rate: 6.68%

Cosmetic SurgeryHow to get a great result and be happy

By Azhar Aslam

Cosmetic Surgery

UK £9.99 RRP

How to get a great result

Linia Publishingwww.liniacosmeticsurgery.com

and

This book is not just another guide to Cosmetic Surgery. Here we explore patient’s motivations, expectations and limitations and discuss the crucial aspects of procedures and importantly, how to get a good result and be happy with the outcome of cosmetic surgery.

A good result of cosmetic surgery is not the same as being happy. One can have excellent results yet still be unhappy with their look. This book addresses why this happens and gives guidance on how this situation can be avoided.

Azhar Aslam trained in Surgery for ten years; out of which five and a half years was in Plastic Surgery in the NHS. Pursuing his chosen specialty of Plastic surgery, he was awarded a scholarship by the Royal College of Surgeons and Physicians, Glasgow, which took him to Louisiana, USA, for a Fellowship in 1996. He furthered his expertise in this cosmetic surgery, training and working in America, Mexico and Germany, obtaining a Fellowship of the American College of Surgeons in 1999.

Azhar continued to work in the NHS, finally working as Consultant Plastic Surgeon at the Countess of Chester Hospital, where he helped set up a specialist hand unit. He left the NHS in 2000 to move into private and has since built up a private cosmetic surgery practice in Harley Street, London. Azhar works from other clinics located in other cities in the UK as well. He has worked actively with the Department of Health, IHA and expert groups to improve the regulation of the cosmetic surgery industry. He has worked as Panel Advisor to the European Academy for Cosmetic Surgery and the Academic Secretary of the British Association of Cosmetic Surgeons where he has recently been elected to the post of Secretary to the Association.

behappy

Azhar AslamConsultant Plastic Surgeon

FRCS(G), FACS, FEACS

Cosmetic Surgery H

ow to get a great result and be happy A

zhar Aslam

The Actual Book Cover.indd 1 10/10/2013 11:37:26

Cosmetic SurgeryHow to get a great result and be happy

By Azhar Aslam

Cosmetic Surgery

UK £9.99 RRP

How to get a great result

Linia Publishingwww.liniacosmeticsurgery.com

and

This book is not just another guide to Cosmetic Surgery. Here we explore patient’s motivations, expectations and limitations and discuss the crucial aspects of procedures and importantly, how to get a good result and be happy with the outcome of cosmetic surgery.

A good result of cosmetic surgery is not the same as being happy. One can have excellent results yet still be unhappy with their look. This book addresses why this happens and gives guidance on how this situation can be avoided.

Azhar Aslam trained in Surgery for ten years; out of which five and a half years was in Plastic Surgery in the NHS. Pursuing his chosen specialty of Plastic surgery, he was awarded a scholarship by the Royal College of Surgeons and Physicians, Glasgow, which took him to Louisiana, USA, for a Fellowship in 1996. He furthered his expertise in this cosmetic surgery, training and working in America, Mexico and Germany, obtaining a Fellowship of the American College of Surgeons in 1999.

Azhar continued to work in the NHS, finally working as Consultant Plastic Surgeon at the Countess of Chester Hospital, where he helped set up a specialist hand unit. He left the NHS in 2000 to move into private and has since built up a private cosmetic surgery practice in Harley Street, London. Azhar works from other clinics located in other cities in the UK as well. He has worked actively with the Department of Health, IHA and expert groups to improve the regulation of the cosmetic surgery industry. He has worked as Panel Advisor to the European Academy for Cosmetic Surgery and the Academic Secretary of the British Association of Cosmetic Surgeons where he has recently been elected to the post of Secretary to the Association.

behappy

Azhar AslamConsultant Plastic Surgeon

FRCS(G), FACS, FEACS

Cosmetic Surgery H

ow to get a great result and be happy A

zhar Aslam

The Actual Book Cover.indd 1 10/10/2013 11:37:26

Azhar Aslam has followed these two maxims in his life as a Surgeon:

The one who works with his hands is a labourer, the one who works with his hands and head is an artisan, the one who works with his hands, head and heart is an artist.

A Surgeon must first know when not to cut, then when to cut, where to cut, how to cut and most important of all, when to stop cutting.

BOOK INTRODUCTION

Cosmetic Surgery. These two words are no longer a taboo in British Society. But these can still invoke passionate debates.

Cosmetic Surgery, long considered a branch of Plastic Surgery, has rapidly established itself as a separate speciality in its own right. While the Medical and Health establishment continues to drag its feet, chained by the weight of the vested interests, the Public sees Cosmetic Surgeon and Cosmetic Surgery as independent in their own right. Over regulation is being recommended in the name of Patient safety, while so called Specialists have been let loose with minimal training. More on this later.

For present I want to talk about what is Cosmetic Surgery and why do we want it?

It is natural to try to look normal and it is also natural to try to look one’s best...

CHARITY WORKVision21 and the Speed Literacy Program (SLP)

Azhar is the founder of Vision 21, a Pakistan based non-profit, non-party Socio-Political organization. It is a registered body under section 42 of the Companies Ordinance 1982 by the Securities and Exchange Commission of Pakistan. It is established with the explicit purpose/objectives of alleviating human misery, poverty, lack of empowerment and injustice in Pakistan in particular and the problems faced by humanity in the 21st century at global levels in general.

The Charity’s vision is to promote and actively seek human well-being and happiness. Their mission is to work towards developing and improving human capital by focusing on poverty alleviation, rights awareness, human dignity, women empowerment, education and justice as a right and obligation.

Speed Literacy Program (SLP)

This is a unique program that aims to teach the illiterate children. The students achieve literacy levels of Primary to Middle grade levels within a period of one year. The Free-for-Children program is aimed at developing Pakistan’s human capital, and taking children back to school, using a cost effective system that is easy, fun to learn, and delivers results.

Why Speed Literacy?

In Pakistan 25 million children are out of school and illiterate Pakistan is bracketed in the world’s poorest regions when it comes to education. Pakistan’s ranking in public spending on education is the lowest in the region. The total enrollment in the primary schools is nearly 25 million. The net enrollment ratio of the children aging between 5-9 years is ONLY 57 %. At least on paper… This still means that a staggering 43 % never enroll.

Extremely High Illiteracy remains prevalent among Females, in the rural areas, and among the members of poor households. According to all Pakistan Labor Force Survey 2007 and 2008 there are over 21 million children of the school going age, 73% boys & 27 % girls who do not go to school and remain in labor. 60 million adults are illiterate in Pakistan

The target of SLP is to literate 25 million illiterate kids in Pakistan, starting from Rawalpindi and Islamabad. After the successful completion of the pilot project, the next part program will be rolled out. In this respect 10 centers will have been established in Rawalpindi by the end of 2013, with more centres across the country to follow.

MEDIA SECTION

Azhar has featured regularly in media publications and on television throughout his career. This section provides examples of media coverage, along with articles that have

been published in journals.

HarleyHealthVillageL I N I A

TELEVISION WORK includes:

The Clinic — The first TV series on Cosmetic Surgery. Azhar Aslam featured on eight out of ten programmes.

Silicone Chicks Facelift Diaries Extreme Makeover UK Channel 5 News Sharon Osborne Show Beauty & The Beast

Extreme Makeover UK Jackie Budden - Jade’s Mum

Facelift Diaries

MEDIA ARTICLES include:

Daily Mail Sunday Mail Supplement Daily Express Daily Mirror The Times - Panel Expert The Observer The Sun She Magazine Love it! Glamour Metro HEAT Magazine Real New! Magazine Mayfair Times

Channel 4 - Beauty & The Beast

At Home With Nicky Hambleton-Jones Woman Woman’s Own Take A Break Top Sante B Magazine Let’s Talk - Norwich Wedding Magazine

Daily Mail, October 2008 - The £1bn Scalpel Scandal

An undercover investigation where the journalist posed as a patient and compared the UK’s top four lead-ing Cosmetic Surgery companies — Linia, Transform, MYA and the Harley Medical Group. The reporter had a consultation at each of the clinics. It was only at Linia that she actually met a Surgeon (Azhar Aslam). This is what she said about Azhar ……

“Mr Aslam carries out a physical examination on Alice, who is asked to remove her top. He’s professional and friendly and refuses to recommend any particular procedures off the cuff, saying that it has to be a ‘partnership between you and me’. He explains: ‘You have to define why you want certain things done and how you want to see yourself and then I will then examine you and say this is suitable, this is not suitable and perhaps we should do this instead of that.

‘Once you have made your decision then we say this is what you want to achieve and this is how we will achieve this.”

Linia were recommended as one of the top 5 clinics by a leading consumer watchdog in 2008.

48 |

HEALTH & BEAUTY

Thousands of overseas visitors will be seeking the most advanced healthcare in Mayfair this summer. A recent study by the Medical Tourism Association (MTI) found

that the UK came second in the world in terms of its attractiveness as a medical tourism hub, with a rating of 74.85 out of 100.

It is therefore no surprise that everything from cosmetic surgery, dentistry, orthopaedics and intravenous treatments attract everyone from Chinese, Russian and Arab clients to our shores, with Harley Street, in particular, widely regarded as a centre of medical excellence since the late 1800s.

Recently, the Dubai Health Authority revealed its aim to become the world’s medical hub, indicating that by 2020 it plans to attract 500,000 tourists, which will be a 20 per cent increase, despite currently not featuring in the world’s top 10 countries.

LONDON ATTRACTS A HUGE NUMBER OF HEALTH TOURISTS EACH YEAR, BUYING

MEDICAL SERVICES NOT AVAILABLE ELSEWHERE. BUT WITH DUBAI HOT ON

OUR HEELS, SHOULD THE UK INDUSTRY BE WORRIED? SOPHIA CHARALAMBOUS

FINDS OUT

--- • ---

m o r e t h a n a

holiday

ARTICLES have included:

CLINICS HELD IN: HARLEY STREET, LONDON, BIRMINGHAM, BRISTOL, CAMBRIDGE, CHESTER, GLASGOW, MANCHESTER, NORWICH, AND PLYMOUTH.

How to choose the sizeof a breast implant

By Mr Azhar Aslam, FRCS(G), FACS FEACS, Consultant Plastic Surgeon

This article was published in BODY LANGUAGE, the journal of cosmetic surgery

email: azhar1302@yahoo.com

the essence of real beauty

Call 0845 230 1700

www.liniacosmeticsurgery.com

Cosmetic Surgery

C L I N I C A L

all the factors. This reconciliation may involve a patient’s desire to modify and create realistic expec-tations, which will lead to patient satisfaction. For example, a pa-tient may desire a D cup. How-ever, a surgeon may assess that the volume needed to achieve the patient’s desire, in adding to the pre-existing volume, may cause tissue damage.

In such case, a detailed expla-nation is necessary to change the patient’s desire, or to explain the consequences, in terms of chang-es in the future and what other corrective surgery may need to be performed if the patient were to fulfi l her desires and go ahead with what is seen to be a larger implant.

Trade-offsNo surgical option is without trade-offs. The question is how to pick the option that maximises the benefi ts and minimises the trade-offs.

Perfection or change to a dif-ferent breast is never an option. Improvement in the existing breast is the only realistic alter-native. No surgeon can totally predict what a patient’s tissues will do over time, but every sur-geon and patient should consider these issues when making implant choices. No implant will produce the same result in two patients as already explained.

It is crucial to understand that a range of volumes, instead of a spe-cifi c volume, will result in a spe-cifi c cup. For example, in patients with a height range of 5’2-5’7 (about 158-173cm) and a weight range of 8.5-9.5 stones (about 52-58kg), the chest measure-ments, generally are 29-32 cm. To achieve a C cup in such patients, a volume range of 265-330g is gen-erally needed. The precise volume depends on the pre-existing breast volume, the thickness of tissue, expected tissue stretch and the strength of the holding ligaments.

Similarly, the distance be-tween the NAC and the IMC in-fl uences the cup size. In the frame

range mentioned, a distance of 9-11cm will achieve the basic di-mensions of a C cup requirement. This means that, if the distance between NAC and IMC is less, it will need to be increased in addi-tion to an adequate volume.

On the other hand, if this dis-tance is more, then the patient should be informed that the cup size dimensions are already big-ger than the desired cup — in this example, C. It will be a rare situation when she doesn’t already know this.

In such cases, the loss of vol-ume has resulted in the loss of cup size, but the dimensions are still intact. Hence, a smaller volume, compared with the dimensions needed to reduce the cup size. This relationship between dimen-sions and volume is crucial to un-derstanding cup sizes as generally spoken by patients.

For most surgeons, choosing

the correct volume is less of a sci-ence and more of an art, based on their personal experiences. Crude methods such as the rice test — in which a patient is asked to try a certain volume of rice in their bras — are commonly used to assist in deciding the correct volume. The main advantage of such tests is not their accuracy but the onus they place on the patients to contrib-ute in the decision making and in helping them understand the limi-tations a surgeon faces.

Identifying critical variables and decisions in order to create a simple system to provide sur-geons with guidance is desirable. More elaborate systems, such as the biodimensional system and high-fi ve measuring systems have

been described. But they suffer from the problems of rigidity and uniqueness to the surgeon who created them.

Many surgeons in busy prac-tices fi nd it diffi cult to adopt such a system 100 per cent, due to their cumbersome nature. A study of such systems can help the surgeon decide the implant volumes more easily, but these are guidelines only and the wishes of the patient still stay paramount whichever system a surgeon applies.

I use a much simpler guideline, essentially based on all factors discussed. For the sake of simplic-ity, this description is based on only the round silicone implants most commonly used in the UK.

First, the distance between two anterior axillary lines (AA) is measured. Next, the NAC to IMC distance and sternal notch to NAC distance is measured.

Then an implant with the base

‘The patient’s wishes must always be paramount’

‘Elaborate systems, such as biodimensional system and high-

fi ve measuring systems, have been described. But they suffer from the

problems of rigidity and uniqueness to the surgeon who created them’

size of half the AA measurement is chosen. The base size of such an implant will be only slightly larg-er that the base size of the breast, hence, creating fullness both me-dially as well as laterally. The me-dial fullness gives cleavage and the lateral fullness balances the shoulder and hips and creates the female curviness.

The volume of this implant is noted and based on the patient’s desire, the pre-existing breast tissue, expected change in di-mensions and desired shape; this volume is increased or reduced in 20g increments. Almost always, adjustments and ideal implant volume can be found in the +/- 40-50g range.

Correct Cup sizeAs described, the second impor-tant measurement is NAC-IMC distance. In an aesthetically ap-pealing breast, the wider the breast, the longer this distance. Determining optimal inframam-mary fold position at the end of breast augmentation is a major factor that affects the aesthetic result and achieves a certain cup size. We take the following gen-eral guideline to achieve proper cup size. NAC to IMC 7cm or less provides an A cup; B is 8-9cm; C is 9-11cm; D is 10.5-12cm DD is 12-13cm, and so on. The chosen volume is then inserted with the incision placed according to the measurement given, taking into account any stretch that may have taken place, hence the volume and the measurement help the desired cup size. This is a simple and ef-fective method.

As mentioned, the concept be-hind this is that, by performing breast enlargement, the whole fi g-ure is enhanced. The importance of explaining this to the patient is she understands the breast sits on the body and the operation is being performed to enhance the whole body.

Each individual has her own special needs and desires, and once the volume has been deter-mined, the shape, feel and pro-jection of implant should be ex-plained. Lastly, the issue of the cup size and the impossibility of guaranteeing a precise cup size should be emphasised.

The main aim of cosmetic sur-gery is to make a patient happy; this aim should never be ignored for any surgical procedure. My report provides general guide-lines, and each patient, should, of course, have their own tailored operation.

Mr A Aslam is a cosmetic surgeon at Linia Cosmetic Surgery, 17 Harley Street, London W1G 9QH.Email azhar1302@yahoo.comwww.liniacosmeticsurgery.com

Sizing up breast implantsC L I N I C A L C L I N I C A L

Breast implant selection is not straightforward, particularly when patients have misconceptions about the size of their breasts. Mr Azhar Aslam identifies critical variables and gives guidance for creating a simple system for surgeons without imposing a rigid framework that is ultimately self-defeating.

Breast enlargement is the most popular cosmetic surgery procedure in the UK. The increasing

popularity and accessibility of cosmetic surgery has seen a sig-nificantly increased demand. Yet, few patients truly understand the risks, limitations and long-term effects. Although the past few years have seen much media hype associated with the good effects of breast augmentation, most information is less than satisfac-tory.

An even more disturbing fact is that, due to lack of proper train-ing, few surgeons beginning their practice really understand the factors and variables paramount in achieving a good, long-term re-sult. Everyone knows that a breast augmentation involves adding an implant onto a pre-existing breast. However, relatively few surgeons and hardly any patients grasp the relationship of patient desire, expectations and the physical as-pects of volume enlargement.

Five DimensionsCosmetic surgery is unique in that, unlike other surgical spe-cialities, it is performed in a five dimensional framework. To un-dertake any successful cosmetic surgery operation, an understand-ing of this framework is a basic requisite. Breast enlargement is no exception.

By ‘five dimensional’ I mean the three dimensional framework of the (physical) body and ac-counting for the fourth dimension of time. A cosmetic surgeon has to look into the future to visual-ise the desired final result after the healing process is complete, taking into account the physical characteristics unique to each in-dividual.

Even more importantly, a cos-metic surgeon has to delve into the patient’s mind to ascertain what the patient dreams of, wants, de-sires and expects. Understanding this is fundamental to a success-ful cosmetic surgery operation.

Most patients try to describe their desired result in vaguely defined concepts and unquanti-fiable terms. In my experience, many female patients are even unaware of what a breast cup size means and how cup sizes are measured. Without the basic understanding, achieving patient expectations may be impossible. Hence, educating the patient to make her understand her own de-sires and relating them to the lim-itations imposed by her own body and tissues is the most significant contributor towards patient satis-faction.

For many surgeons and pa-tients, proper implant selection is an art, not a science. No single method has been proven to pre-dict the size or shape will provide long-term satisfaction. With de-tailed patient education, discus-sion, counselling and respect for implant soft tissue dynamics, the rate of dissatisfied patients can be reduced significantly.

The goal of augmentation is to improve the size and the shape of breasts. And while this creates a more positive self-image, the only predictable change is larger

breasts. Positive psychological ef-fects are common but are not nec-essarily predictable.

At the beginning of each con-sultation, patients are asked about two elements of what they seek. First, why do they want their breasts enlarged; second, what do they want to achieve?

Understanding the answer to the first gives a clearer picture of the motivation behind why they are seeking surgery and makes it easy to root out misconceived expectations and to filter out an obsessive element of the patients desire. The answer to the second question helps the surgeon to define and quantify the patient’s desire in physical and measurable terms.

Three categoriesPatients seeking breast augmen-tation fall into three broad cat-egories:

• young patients whose breasts have not grown to achieve a ‘nor-mal fill’;

• patients, mostly in their 30’s, who have suffered the effects of pregnancy related changes and those related to weight fluctua-tions; and

• middle-aged patients, late 40s onwards, who have started with small breasts and have changed further because of ageing.All practising surgeons have come across patients who have

complained that their desired cup size has not been achieved. This has been despite the insertion of the desired volume and good, aes-thetic results.The discrepancy between a cup size and the volume arises be-cause a cup size is not a scientific measurement and means differ-ent things to different people. In this regard, patient education is crucial, as almost all patients will indicate the desired cup size they want.However, if at this stage one asks the patient what she means, almost always it is the case that she does not specifically know the size of a particular cup. Cup size is ex-tremely variable and inconsistent from one brand of bra to another, and it should be pointed out and explained that a cup size is only a general guideline and can’t be ordered or delivered.Cup size is not a measurement of a particular volume. Rather, it takes into account the volume as well as the dimensions of the breast. Hence, the same volume placed in two women will create a different tissue stretch during healing and settling. This means that the same volume can achieve different dimensions in different bodies and, hence, the importance of tissue characteristics as well as difference of the cup size.We always point out to the pa-tients that they will be measured as different cup sizes by differ-ent shops. As well, if they pick up the same size bras from different manufacturers, these will be dif-ferent in terms of proper fitting. Hence, the most crucial piece of information that a surgeon must pass to the patient before the sur-gery — precise cup size cannot be guaranteed.It is, however, not as despairing as it sounds. With proper measure-

‘In my experience, many female patients are even unaware of what a breast size means and how cup sizes

are measured. Without this basic understanding, achieving patient expectations may be impossible’

ments and accurate assessment of tissue characteristics, it is almost always possible to choose an im-plant volume that will match the patient’s desire. That we do not guarantee this to the patient does not mean we do not endeavour to achieve it.Once the surgeon has quantified the patient’s desire, defining the implant volume is the most im-

portant decision. This is the sin-gle most important determinant of failure or success of the opera-tion.The answer to the question — how much breast is enough? — de-pends on breast size in proportion to body size; the characteristic of each woman’s breast skin; and breast tissues. The variables af-fecting the final breast size are

numerous, but the most important are:

• body frame — a breast cannot be seen in isolation as if hanging in the air. It has to be seen always in relation to the body. Hence, assessing the patient’s build in height and weight, and assessing the shoulder and hips provides a basic measurement.

• dimensions of the breast —

the base width of the breast is the most important dimension. A second important measurement is the distance between the nipple (NAC) and the inframammary crease (IMC). Others are the dis-tances between both anterior axil-lary lines and the distance of the nipples from the sternal notch.

• breast tissues — the most im-portant element to measure is the thickness of the breast tissue. This will determine whether there is adequate cover for an implant. However, most surgeons make the mistake of taking absolute thickness as the important meas-urement. Thickness of the tissue should always be judged against the intended volume of the im-plant. In other words, the bigger the volume, the more the desired thickness.

• quality of breast tissue — thick-ness of tissue is not enough to pro-vide adequate cover if the quality of these tissues is not good. By quality, I mean the adherence be-tween the skin and breast tissue to act as a single unit and envelope.If the skin is dehisced from un-derlying tissue, the thickness needed to provide cover to the im-plant will have to increase signifi-cantly. Every woman’s breast skin can stretch and enlarge by only a certain amount without sustain-ing damage, such as excessive stretching and thinning.

• strength of ligaments — it is crucial to understand that any implant adds volume into the breast. This is extremely impor-tant in groups two and three, as their breast tissue and ligaments have already been damaged. The stronger the breast ligaments, the more volume they can hold.

• pre-existing volume — it is important to remember, as well as to remind the patient, that the final volume achieved is the to-tal of pre-existing breast volume plus the volume of the implant inserted.

• patient desire — although this is being listed as the last of the factors, it is the most important. The skill is to reconcile the pa-tient’s desire with the appropri-ate volume, taking into account

Sizing up breast implantsC L I N I C A L C L I N I C A L

Breast implant selection is not straightforward, particularly when patients have misconceptions about the size of their breasts. Mr Azhar Aslam identifies critical variables and gives guidance for creating a simple system for surgeons without imposing a rigid framework that is ultimately self-defeating.

Breast enlargement is the most popular cosmetic surgery procedure in the UK. The increasing

popularity and accessibility of cosmetic surgery has seen a sig-nificantly increased demand. Yet, few patients truly understand the risks, limitations and long-term effects. Although the past few years have seen much media hype associated with the good effects of breast augmentation, most information is less than satisfac-tory.

An even more disturbing fact is that, due to lack of proper train-ing, few surgeons beginning their practice really understand the factors and variables paramount in achieving a good, long-term re-sult. Everyone knows that a breast augmentation involves adding an implant onto a pre-existing breast. However, relatively few surgeons and hardly any patients grasp the relationship of patient desire, expectations and the physical as-pects of volume enlargement.

Five DimensionsCosmetic surgery is unique in that, unlike other surgical spe-cialities, it is performed in a five dimensional framework. To un-dertake any successful cosmetic surgery operation, an understand-ing of this framework is a basic requisite. Breast enlargement is no exception.

By ‘five dimensional’ I mean the three dimensional framework of the (physical) body and ac-counting for the fourth dimension of time. A cosmetic surgeon has to look into the future to visual-ise the desired final result after the healing process is complete, taking into account the physical characteristics unique to each in-dividual.

Even more importantly, a cos-metic surgeon has to delve into the patient’s mind to ascertain what the patient dreams of, wants, de-sires and expects. Understanding this is fundamental to a success-ful cosmetic surgery operation.

Most patients try to describe their desired result in vaguely defined concepts and unquanti-fiable terms. In my experience, many female patients are even unaware of what a breast cup size means and how cup sizes are measured. Without the basic understanding, achieving patient expectations may be impossible. Hence, educating the patient to make her understand her own de-sires and relating them to the lim-itations imposed by her own body and tissues is the most significant contributor towards patient satis-faction.

For many surgeons and pa-tients, proper implant selection is an art, not a science. No single method has been proven to pre-dict the size or shape will provide long-term satisfaction. With de-tailed patient education, discus-sion, counselling and respect for implant soft tissue dynamics, the rate of dissatisfied patients can be reduced significantly.

The goal of augmentation is to improve the size and the shape of breasts. And while this creates a more positive self-image, the only predictable change is larger

breasts. Positive psychological ef-fects are common but are not nec-essarily predictable.

At the beginning of each con-sultation, patients are asked about two elements of what they seek. First, why do they want their breasts enlarged; second, what do they want to achieve?

Understanding the answer to the first gives a clearer picture of the motivation behind why they are seeking surgery and makes it easy to root out misconceived expectations and to filter out an obsessive element of the patients desire. The answer to the second question helps the surgeon to define and quantify the patient’s desire in physical and measurable terms.

Three categoriesPatients seeking breast augmen-tation fall into three broad cat-egories:

• young patients whose breasts have not grown to achieve a ‘nor-mal fill’;

• patients, mostly in their 30’s, who have suffered the effects of pregnancy related changes and those related to weight fluctua-tions; and

• middle-aged patients, late 40s onwards, who have started with small breasts and have changed further because of ageing.All practising surgeons have come across patients who have

complained that their desired cup size has not been achieved. This has been despite the insertion of the desired volume and good, aes-thetic results.The discrepancy between a cup size and the volume arises be-cause a cup size is not a scientific measurement and means differ-ent things to different people. In this regard, patient education is crucial, as almost all patients will indicate the desired cup size they want.However, if at this stage one asks the patient what she means, almost always it is the case that she does not specifically know the size of a particular cup. Cup size is ex-tremely variable and inconsistent from one brand of bra to another, and it should be pointed out and explained that a cup size is only a general guideline and can’t be ordered or delivered.Cup size is not a measurement of a particular volume. Rather, it takes into account the volume as well as the dimensions of the breast. Hence, the same volume placed in two women will create a different tissue stretch during healing and settling. This means that the same volume can achieve different dimensions in different bodies and, hence, the importance of tissue characteristics as well as difference of the cup size.We always point out to the pa-tients that they will be measured as different cup sizes by differ-ent shops. As well, if they pick up the same size bras from different manufacturers, these will be dif-ferent in terms of proper fitting. Hence, the most crucial piece of information that a surgeon must pass to the patient before the sur-gery — precise cup size cannot be guaranteed.It is, however, not as despairing as it sounds. With proper measure-

‘In my experience, many female patients are even unaware of what a breast size means and how cup sizes

are measured. Without this basic understanding, achieving patient expectations may be impossible’

ments and accurate assessment of tissue characteristics, it is almost always possible to choose an im-plant volume that will match the patient’s desire. That we do not guarantee this to the patient does not mean we do not endeavour to achieve it.Once the surgeon has quantified the patient’s desire, defining the implant volume is the most im-

portant decision. This is the sin-gle most important determinant of failure or success of the opera-tion.The answer to the question — how much breast is enough? — de-pends on breast size in proportion to body size; the characteristic of each woman’s breast skin; and breast tissues. The variables af-fecting the final breast size are

numerous, but the most important are:

• body frame — a breast cannot be seen in isolation as if hanging in the air. It has to be seen always in relation to the body. Hence, assessing the patient’s build in height and weight, and assessing the shoulder and hips provides a basic measurement.

• dimensions of the breast —

the base width of the breast is the most important dimension. A second important measurement is the distance between the nipple (NAC) and the inframammary crease (IMC). Others are the dis-tances between both anterior axil-lary lines and the distance of the nipples from the sternal notch.

• breast tissues — the most im-portant element to measure is the thickness of the breast tissue. This will determine whether there is adequate cover for an implant. However, most surgeons make the mistake of taking absolute thickness as the important meas-urement. Thickness of the tissue should always be judged against the intended volume of the im-plant. In other words, the bigger the volume, the more the desired thickness.

• quality of breast tissue — thick-ness of tissue is not enough to pro-vide adequate cover if the quality of these tissues is not good. By quality, I mean the adherence be-tween the skin and breast tissue to act as a single unit and envelope.If the skin is dehisced from un-derlying tissue, the thickness needed to provide cover to the im-plant will have to increase signifi-cantly. Every woman’s breast skin can stretch and enlarge by only a certain amount without sustain-ing damage, such as excessive stretching and thinning.

• strength of ligaments — it is crucial to understand that any implant adds volume into the breast. This is extremely impor-tant in groups two and three, as their breast tissue and ligaments have already been damaged. The stronger the breast ligaments, the more volume they can hold.

• pre-existing volume — it is important to remember, as well as to remind the patient, that the final volume achieved is the to-tal of pre-existing breast volume plus the volume of the implant inserted.

• patient desire — although this is being listed as the last of the factors, it is the most important. The skill is to reconcile the pa-tient’s desire with the appropri-ate volume, taking into account

CLINICS HELD IN: HARLEY STREET, LONDON, BIRMINGHAM, BRISTOL, CAMBRIDGE, CHESTER, GLASGOW, MANCHESTER, NORWICH, AND PLYMOUTH.

How to choose the sizeof a breast implant

By Mr Azhar Aslam, FRCS(G), FACS FEACS, Consultant Plastic Surgeon

This article was published in BODY LANGUAGE, the journal of cosmetic surgery

email: azhar1302@yahoo.com

the essence of real beauty

Call 0845 230 1700

www.liniacosmeticsurgery.com

Cosmetic Surgery

C L I N I C A L

all the factors. This reconciliation may involve a patient’s desire to modify and create realistic expec-tations, which will lead to patient satisfaction. For example, a pa-tient may desire a D cup. How-ever, a surgeon may assess that the volume needed to achieve the patient’s desire, in adding to the pre-existing volume, may cause tissue damage.

In such case, a detailed expla-nation is necessary to change the patient’s desire, or to explain the consequences, in terms of chang-es in the future and what other corrective surgery may need to be performed if the patient were to fulfi l her desires and go ahead with what is seen to be a larger implant.

Trade-offsNo surgical option is without trade-offs. The question is how to pick the option that maximises the benefi ts and minimises the trade-offs.

Perfection or change to a dif-ferent breast is never an option. Improvement in the existing breast is the only realistic alter-native. No surgeon can totally predict what a patient’s tissues will do over time, but every sur-geon and patient should consider these issues when making implant choices. No implant will produce the same result in two patients as already explained.

It is crucial to understand that a range of volumes, instead of a spe-cifi c volume, will result in a spe-cifi c cup. For example, in patients with a height range of 5’2-5’7 (about 158-173cm) and a weight range of 8.5-9.5 stones (about 52-58kg), the chest measure-ments, generally are 29-32 cm. To achieve a C cup in such patients, a volume range of 265-330g is gen-erally needed. The precise volume depends on the pre-existing breast volume, the thickness of tissue, expected tissue stretch and the strength of the holding ligaments.

Similarly, the distance be-tween the NAC and the IMC in-fl uences the cup size. In the frame

range mentioned, a distance of 9-11cm will achieve the basic di-mensions of a C cup requirement. This means that, if the distance between NAC and IMC is less, it will need to be increased in addi-tion to an adequate volume.

On the other hand, if this dis-tance is more, then the patient should be informed that the cup size dimensions are already big-ger than the desired cup — in this example, C. It will be a rare situation when she doesn’t already know this.

In such cases, the loss of vol-ume has resulted in the loss of cup size, but the dimensions are still intact. Hence, a smaller volume, compared with the dimensions needed to reduce the cup size. This relationship between dimen-sions and volume is crucial to un-derstanding cup sizes as generally spoken by patients.

For most surgeons, choosing

the correct volume is less of a sci-ence and more of an art, based on their personal experiences. Crude methods such as the rice test — in which a patient is asked to try a certain volume of rice in their bras — are commonly used to assist in deciding the correct volume. The main advantage of such tests is not their accuracy but the onus they place on the patients to contrib-ute in the decision making and in helping them understand the limi-tations a surgeon faces.

Identifying critical variables and decisions in order to create a simple system to provide sur-geons with guidance is desirable. More elaborate systems, such as the biodimensional system and high-fi ve measuring systems have

been described. But they suffer from the problems of rigidity and uniqueness to the surgeon who created them.

Many surgeons in busy prac-tices fi nd it diffi cult to adopt such a system 100 per cent, due to their cumbersome nature. A study of such systems can help the surgeon decide the implant volumes more easily, but these are guidelines only and the wishes of the patient still stay paramount whichever system a surgeon applies.

I use a much simpler guideline, essentially based on all factors discussed. For the sake of simplic-ity, this description is based on only the round silicone implants most commonly used in the UK.

First, the distance between two anterior axillary lines (AA) is measured. Next, the NAC to IMC distance and sternal notch to NAC distance is measured.

Then an implant with the base

‘The patient’s wishes must always be paramount’

‘Elaborate systems, such as biodimensional system and high-

fi ve measuring systems, have been described. But they suffer from the

problems of rigidity and uniqueness to the surgeon who created them’

size of half the AA measurement is chosen. The base size of such an implant will be only slightly larg-er that the base size of the breast, hence, creating fullness both me-dially as well as laterally. The me-dial fullness gives cleavage and the lateral fullness balances the shoulder and hips and creates the female curviness.

The volume of this implant is noted and based on the patient’s desire, the pre-existing breast tissue, expected change in di-mensions and desired shape; this volume is increased or reduced in 20g increments. Almost always, adjustments and ideal implant volume can be found in the +/- 40-50g range.

Correct Cup sizeAs described, the second impor-tant measurement is NAC-IMC distance. In an aesthetically ap-pealing breast, the wider the breast, the longer this distance. Determining optimal inframam-mary fold position at the end of breast augmentation is a major factor that affects the aesthetic result and achieves a certain cup size. We take the following gen-eral guideline to achieve proper cup size. NAC to IMC 7cm or less provides an A cup; B is 8-9cm; C is 9-11cm; D is 10.5-12cm DD is 12-13cm, and so on. The chosen volume is then inserted with the incision placed according to the measurement given, taking into account any stretch that may have taken place, hence the volume and the measurement help the desired cup size. This is a simple and ef-fective method.

As mentioned, the concept be-hind this is that, by performing breast enlargement, the whole fi g-ure is enhanced. The importance of explaining this to the patient is she understands the breast sits on the body and the operation is being performed to enhance the whole body.

Each individual has her own special needs and desires, and once the volume has been deter-mined, the shape, feel and pro-jection of implant should be ex-plained. Lastly, the issue of the cup size and the impossibility of guaranteeing a precise cup size should be emphasised.

The main aim of cosmetic sur-gery is to make a patient happy; this aim should never be ignored for any surgical procedure. My report provides general guide-lines, and each patient, should, of course, have their own tailored operation.

Mr A Aslam is a cosmetic surgeon at Linia Cosmetic Surgery, 17 Harley Street, London W1G 9QH.Email azhar1302@yahoo.comwww.liniacosmeticsurgery.com

Section Heading Required

PATIENT SELECTION IN COSMETIC SURGERY Linia Healthcare Limited

Cosmetic surgery has becomemore and more popular in theUK due to cultural acceptance

and easy availabil ity. While mostpeople who have sought cosmeticsurgery had successful results, therehave also been several stories,involving real people, who havesuffered disappointments. For amajority of the patients, cosmeticsurgery is a lifestyle option and theywant to look more refreshed and asexuberant as they feel inside.

With an increased life expectancy, theage at which people stay active andoutgoing has reached early 70's. Undersuch circumstances, it is natural thatmany people, both women and menwant to gain the looks, which go withtheir lifestyle. In this article we contendthat the most important element forachieving a successful outcome incosmetic surgery is the patient educationand choosing appropriate procedure.

Sadly, in UK there continues to be alack of any formal training in cosmeticsurgery. Regulations to regulateprivate practice in cosmeticsurgery place noemphases on formaltraining. The provisionof cosmetic surgery isfragmented and inmajority of thecases, there is lackof a general practi-tioners input. Variousreasons for thisinclude, lack of infor-mation materials for theGPs and a certain lack ofinterest on their part.

Cosmetic surgery is different fromother surgeries in three important

respects. First, it is performed mostly,on disease free tissues (I have deliber-ately not used the word normal).Second, it is performed to satisfycertain expectations andpersonal desires. Third, itis a surgery performedin a five dimensionalframework, ratherthan the threedimensional frame-work of humanbody.

EXPECTATIONS ANDDESIRES

At the beginning of myconsultation, I always ask thepatient the following:

1) ' What part of your body concernsand bothers you and how? How doyou want it changed?'

2) 'What are your expectations at theend of the surgery and what resultswill make you happy and satisfied?'

The answer to these questionshelps the surgeon under-

stand the problem froma patient's perspective.

This is extremelycrucial, as peoplehave differentdesires. Manypatients still expectthe surgeon to 'tell

them' what theyneed doing. If so, I

always say thatcosmetic surgery is not

done to treat a diseaseprocess. It is being performed to

meet the patient desire. Hence, it isimportant for me to understand whatthey want.

This approach has two major advan-tages. First, it involves the patient indecision making and exposes their

understanding or lacks thereof,of their own wants and

desires. Second, it helpsthe surgeon under-

stand what thepatient wants. Takefor example, apatient asking for abreast enlarge-ment. While onepatient may seek

natural looking, fullerbreasts, the other may

want significantly largerbreasts. If such a patient

were to say to me that 'theywant to look normal', my reply is thatthere is no fixed, absolute normal.

SUBJECTIVE NATURE OF COSMETICSURGERY

It is extremely important to explainto the prospective patient that theresults of the surgery vary from onepatient to another and people reactdifferently to surgery. I have found thatmost patients understand and acceptthese facts. In certain cases, it is impor-tant to get the parents and/or partnersinvolved and also provide a secondconsultation. It is standard in ourpractice that the consent forms aresent to the patients two weeks beforethe surgery. These form reiterate thesepoints. It also allows the patients timeto understand what they areconsenting for and raise any questions.

A classic example is of a 42 year old,male patient, who sought consultationbecause he was extremely self-conscious about his 'large earlobes'. Heinformed me that he had always kept

1

Patient education and

choice of appro-priate procedureleads to successful

outcome

Contact InformationAZHAR ASLAM

Consultant Plastic Surgeon17 Harley Street

LondonEmail: azhar1302@yahoo.com

GPs lack of information leads

to lack of input in patientcare

Linia Healthcare 7/6/06 9:40 am Page 1

Facial Rejuvenation

Face is the epitome of who we are. Beauty is

intimately related to one’s face. Enhancing this

beauty is a basic human desire, over the ages

people have adopted different ways of making

them look more beautiful.

Over the past century more and more

treatments have been developed to reverse

the signs of ageing from surgery to simple

creams and lotions. The ageing process is being

addressed from the molecular level upwards to

cellular levels.

Facial ageing is the end product of four factors:

1. Ageing of the Skin, from exposure

to environmental factors and natural

ageing.

2. The volume loss in the face. As we grow

older we lose fat as well as the skin

becomes thinner and fragile.

3. Gravitational ageing happens as skin and

underlying ligaments are stretched and

pulled. This leads to saggy jowls and mouth

and dropping neck.

4. Gravity also pulls down underlying fascia

and muscles, which slack as we grow

older.

A successful

facial rejuvenation

addresses all of these

factors. The goal

standard for facial

rejuvenation, the

traditional full face-lift,

has been supplanted

by short scar

techniques and non-

surgical solutions.

A successful facial

rejuvenation

programme combines

several of these

treatments to create a personalised plan and

achieve a balanced natural look.

The main advantage of short scar face-lifts

is not only smaller scars, but also that these are

generally performed under local anaesthetic with

sedation on a day case basis.

This means a quick recovery, less bruising and

swelling is minimized. Another major advantage

of these procedures is the natural results.

S Lift is used to lift the lower half of the neck and

face as well as the upper part of the neck.

N lift is used to treat the whole neck as well as

the jowls.

Macs lift is designed to lift the mid face and

upper jowls through scars hidden in the upper

part of the ear and hairline.

C lift is used to lift the cheeks through small

incisions on the outer sides of the eyes or

temple.

I- lift Involves using threads with tiny hooks to

lift and tighten underlying fascia and muscles.

Lateral Browpexy Small incisions in the hairline lift

sagging brows and outside eye areas with excess

skin in the smile line area.

S-Facelift Surgery under local anaesthetic

A major benefit of opting for S-Lift

surgery is that it is possible, even

preferable, for a surgeon to perform the

procedure using local anaesthesia. The

patient is given twilight sedation to make

them more relaxed and comfortable

whilst the operation takes place. More

people than ever are now opting for

this method of anaesthesia, as it can

often achieve better and more natural

looking results than when using a general

anaesthetic.

There are a number of reasons why

it is beneficial for the surgeon and the

patient. Firstly, it is better for the surgeon

to perform such surgery on the dynamic

face, so they can make the face move

as they want, with no distortion or

anaesthetic tube. Secondly, the patient’s

recovery period is usually much shorter

and there is no need for a long hospital

stay, in fact in most cases this surgery

can be performed on an out-patient basis.

The patient also benefits from less risk of

bruising and swelling.

This is the ideal solution for those

patients who would like facial surgery but

do not want, or cannot have, a general

anaesthetic. Patient’s who have had

S-Lift surgery whilst awake have spoken

positively about their experiences and

have been delighted with the results.

The S-Lift doesn’t give what is more

commonly known as the ‘wind tunnel’

look, where the face looks drastically

lifted. It gives a naturally refreshed and

youthful look, which is what most patients

desire when seeking facial rejuvenation.

Combine this with the benefits of using

local anaesthesia, you can see why this

is becoming an increasingly popular

procedure.

AZHAR ASLAM FRCS (G); FACS; FEACS. Consultant Plastic Surgeon Call 0845 230 1700 Linia Cosmetic Surgery www.liniacosmeticsurgery.com

BEFORE ONE MONTH AFTER

By Azhar Aslam

You can contact Azhar Aslam by calling 0845 230 1700