About Ethical Dilemmas in Aesthetic Surgery 

Link to the Episode

Anshu Bahanda: This is Anshu Bahanda on Wellness Curated. Thanks for joining me on this podcast. My mission is to empower you with health and wellness so that you can then go and empower others. We have Dr. Raj Ragoowansi, who’s a consultant plastic and aesthetic surgeon. He has been with the NHS for 19 years. He works at a private practice as well. He’s a senior consultant at Barts Hospital. He’s a full member of the British Association of Plastic Reconstructive and Aesthetic Surgeons. He does reconstructive surgery. He specialises in areas like body contouring, chest wall reconstruction. He does management of problem scars and lots of other things. We got so much invaluable information today. Listen to this. 

In today’s day and age, when fillers and Botox are so common, what is considered to be plastic surgery, what is aesthetic surgery, and what is the difference between that and getting Botox and fillers? 

Raj Ragoowansi: Plastic surgery is from the Greek word Plasticos, meaning to mould or to reconstruct or to make. That essentially refers to reconstructive surgery, be it of the breast, a bit of the face, be it of the upper and lower limbs. So I, for example, on the reconstruction side, do upper limb work on the nerves. I do facial reconstruction and I also do breast reconstruction. That’s done under the microscope. And that essentially is reconstruction, to restore form and function as opposed to aesthetic surgery, which is synonymous with cosmetic surgery, that essentially is beautification. In other words, antiaging with nature, with other elements of nature. We age, as we age, skin droops and that’s from head to toe. And essentially aesthetic or cosmetic surgery is there to restore that youthfulness, take away the excess skin and to suspend the deeper tissues to recreate the look when we’re in our twenties and thirties. Plastic surgery and cosmetic surgery are synonymous. It is very, very popular. The UK’s most popular plastic surgery procedures in 2019, just before the pandemic, in women is breast enlargement with seven and a half thousand cases. Second most frequent is breast reduction with four thousand cases. The third blepharoplasty, which is eyelid, upper and lower lid, and that’s 2800. In men, it’s very interesting. Can you guess what the top procedure is in men? 

AB: Something to do with the V shape. 

RR: It’s the nose. 570 cases of rhinoplasty in 2019 in men, and the second most common, and this is incredible, is ear pinning back. Yeah, lots of us are born with our ears pointing forward. A lot of people tend to live with it. They get teased as they grow up in adolescence, but then get used to it again, their confidence, and they leave it alone. But quite a few have problems in adolescence, in childhood, and then later on in life, when they, for example, get divorced and meet another partner, they change a job and it becomes a focus for feeling nervous, losing self esteem, losing confidence. So men, more than women, are more conscious of this particular anomaly. 400 cases of ear pinning back, done in 2019. The third one, again, is eyelid tuck, which is 330 cases. Breast reduction, quite a few of those are done in men, this is a term called garnacha mastia, which is male breasts or man boobs. In my practice, 92% are women, 8% are men, of which the majority are man boobs. They come for man boobs and gynecomastia reduction, when a man develops fullness of the chest, and on some occasions, it’s mild to moderate. But I see the most severe cases where literally they have a B or a C cup breast size in men. 

AB: Okay. 

RR: Of course, during the pandemic, people like me were working in the NHS. We went straight back to the NHS. We closed our prior practices down, and essentially no cosmetic surgery was done for a good one year to 18 months. 

AB: You make people look beautiful, basically. A great quality of life when they’ve had medical conditions. 

RR: Yeah. So it’s essentially a very fulfilling role. That’s why I do reconstruction and cosmetic, I don’t just like doing cosmetic and I don’t just like doing reconstruction. And I have a healthy mix in my practice. Of course, there is an overlap, because when you reconstruct a breast, for example, after breast cancer, you’re restoring function, but you’re restoring form as well. It’s like a Venn diagram. There’s cosmetic and aesthetic and there’s reconstruction, and there is quite a big overlap in between as well. 

AB: So how much of it is cosmetic? How much of it is reconstruction? What is non-medical? So I’m intrigued about this whole botox and filler thing as well. 

RR: Okay, well, let me elaborate then. So essentially, there’s surgical and non-surgical. Non surgical is where the botox, filler, chemical peel, laser comes into practice. So if you look at botox, for example, that’s an injection of a toxin into the muscle to relax the muscles and therefore help reduce wrinkles. Filler is a substance, usually hyaluronic acid, which is injected under the skin to restore volume and as one ages, you lose volume and the tissues descend, especially in the face. For example, the fold between the upper lip and cheek, the nasolabial fold gets deeper and gets laxer as you age, more little dips that you get inside the lower lid, which occur when you age, the fatty tissue that gives you that youthfulness perishes as one ages. Okay, so that’s filler. Then, of course, there’s ancillary procedures such as lasers. Lasers are used to tighten and rejuvenate the skin. Chemical peels are essentially agents which are useful in breaking down the top dead layer of skin, in refreshing the pores, in providing you with a uniform tone to your face and your forehead. So that’s a chemical peel. And these are all non surgical procedures, and they’re actually much more popular than surgical. Now, of course, because I’m a surgeon, primarily, I don’t have those figures to hand. But I can tell you non-surgical procedures are done far more than surgical ones.

AB: So tell me, if they go somewhere and get something done and they come to your doorstep, do you have to look after them even though they’ve gone elsewhere and got something done that might be unqualified and not okay? 

RR: I’m a doctor first and then a plastic surgeon. So at the end of the day, a patient is a patient, and my colleagues will all agree with me that whenever a patient comes to our door, the first thing we do is make sure that they’re comfortable and we look after them. It doesn’t matter where they’ve been to. We go through their history, we examine them, look at the problem, and try to solve it for them. A lot of patients now going abroad for medical tourism are having plastic surgery done elsewhere in Turkey, Malta, Poland and then they come back to our doorstep problems because the follow up here isn’t as good as it should be. Again, a patient is a patient. We, as doctors, are individuals who look at facts, who assess the patient and treat them based on clinical findings. We don’t tend to judge. We don’t tend to be biassed. We just look at the patient, look at the problem, and solve it. 

AB: So tell me, in terms of dilemma, I’m sure there are times when you need to turn people away because your profession is such. So when and why do you turn people away when you say, don’t get this done? 

RR: This is a really nice, interesting question, Anshu and actually, this is where ethics come into the equation. Technically, a senior person like me can do virtually everything. But now, in the latter years of my career, I’m learning to say no more and more, because I have seen what can be done. I’ve seen the problems that can occur if the wrong patient is operated upon and the wrong technique is used. So, to answer your question, I think it’s probably easy to divide it up into patient factors and anatomical factors. As far as patient factors are concerned are, one, if I don’t see eye to eye with a patient, they walk in, they sit next to me or opposite me, and if I just feel there’s no rapport, there’s no eye contact, I don’t feel comfortable with them. That’s a red flag straight away, number one. Number two, those patients who have been to lots of other surgeons. Now I’m in central London, in Maliban, and you all know each other. We’re all friends and we’ve been together for many, many years, my colleagues. So we pick up the phone and we talk. And if I see that a patient’s been to Mr. X, Mr. Y, Mr. Z, and then come to Raj Ragoowansi, there’s an issue there. Number three, if the patient has had lots of previous surgery, that’s a red flag, because that indicates to me that they’ve almost become addicted, which is actually more common than you think. And essentially it’s a condition where a patient looks in the mirror and sees something that we just cannot see. They may be beautiful, but actually to them, they look ugly. Those patients where what they can see, I can’t see, is a problem. And finally, those patients where you really are not able to meet their expectations, they sit with me, they start chatting with me, and the first thing they do is they’re on the phone showing me pictures. “Oh, Mr. Ragawansi, I want to look like this. I want to look like this. I want my breasts to look like this. I want my waist to look like this. I want my nose to look like this” whenever you have that kind of patient, especially after you’ve examined them and you know that that is not achievable, that is again, a red flag. So the last point I would summarise by saying is if the expectation gap is wide with what they aspire to and with what I can deliver, I say, no.

AB: That’s really interesting. 

RR: Anatomical factors are concerned. For example, a patient may have a C or D cup, a good pair of breasts, commensurate with the rest of the physique, and they want to be larger. And you cannot fathom why it is that they want to be larger. So breast size for me is very important and equally, if patients are of a reasonable cup size and they want to be smaller, that’s again, a red flag. To say, “look, what you’re asking for here is unreasonable, it’s not required.” That’s the first thing. Secondly, young patients, those patients in their late teens, early 20s, I’m very cautious about because I’m a father. And it’s important that we have a moral compass that we operate within. We should not be saying yes to patients straight away, especially those who are young, who may have been influenced by social media, by friends, by teasing. A lot of the time when these young patients come, I do say to them, I want to see your mom with you. I want to see your father with you. For example, I saw a patient the other day who is 18 years old and is requesting a breast reduction, and she is a 32K cup size. And in my 30 year career, I’ve only seen that twice, and that was the third time. The problem here is that she is completely convinced that she wants the breast reduction done. And I can see why. I can see why. She can’t play tennis, she can’t go swimming, she can’t wear nice tops, she’s uncomfortable on holiday. She always wears baggy clothes, baggy jumpers. I can see that. But, you know, also at the age of 18, you cannot imagine what experiences you’re going to go through in your second and third decades. So, for example, a breast reduction involves scars. And even though my scarring is very fine, a scar is a scar. And when looked closely, the scar is always visible. And that scar stays for life, number one. Number two, if you reduce the breast, there’s a small chance that after a breast reduction, you may not have sensation and you may not be able to breastfeed. Breastfeeding is very important for maternal bonding, but also for nutrition, for the baby. So these are all factors I have to look at. So again, I haven’t said no to her. I said to her, “these are the facts. I want you to convince me that this is what you want done and you understand that there are certain things which I cannot change, like scarring”. 

AB: So interesting. Wow. So that made me think, when you talk about young people and making them think twice, about saying, come back with a parent or give it a real serious thought, have you worked on sort of gender transformations as well? 

RR: I have, but not transformation per se. I don’t do gender surgery, but I do do breasts. So I do for a man to a woman, once they’ve had everything else done and the only thing left is to give them a decent chest dimension. I then do a breast augmentation with or without uplift. Or if a woman goes to a man, then obviously a breast reduction. But that’s the only kind of arena that I cover as far as transgenders go, and it’s rare. I think I do maybe about one or two cases a year. 

AB: Tell us a little bit about the latest developments in this field because things are moving at such a fast pace, right? 

RR: Yeah, that’s true. I mean, I have to say that my specialty is one where they are, which is why I enjoy it, which is why it’s my passion, and I love it because it’s a beautiful marriage between art and science, because there are parameters that one has to be within in terms of reconstruction or cosmetic. But a lot of it is the third eye, it is that perception, that fourth space that you have to imagine what you want to achieve from a patient and what shape you want to achieve from what they are now. It is one of the few specialties where there’s nothing new majorly. Yes, there’s tissue engineering to produce new skin. Yes, there are certain types of fillers which are new, which are longer lasting. For example, yes, there are certain instruments that we use to make access easier and to make the scar shorter, for example, in the breast. Breast implants have evolved considerably in the last five years, and the implants we use now are nanotextured. So they don’t cause the capsule, but also they prevent the risk of lymphoma. So there are small steps as far as innovation is concerned. And yes, in the lab there are things like tissue engineering, 3D printing for new skin, 3D printing for producing ear cartilage for those babies who have deficient or small ears. There are certain things like that. But actually, in the main, Anshu, in the clinical arena, nothing much has changed. This specialty, which is mainly your hand eye coordination and your clinical skills and your hands. It’s a very manual specialty. 

AB: Interesting.

RR: Robotic surgery has entered the arena of general surgery, orthopaedics, ENT, but I don’t think my particular specialty, be it reconstruction, be it cosmetic, robotic surgery is imminent purely because you cannot account for the fact that you need that human touch. You need that ability to be able to make decisions as you advance in your surgical planning and also to have that third eye, to be able to imagine what you want to create. But I don’t think yet we have software that’s sophisticated enough to emulate that kind of cortical thinking that we do as plastic surgeons. 

AB: Right. So say someone comes to you for breast reconstruction or eye reconstruction or cosmetic or reconstructive surgery. Won’t the computer be able to give them lots of options and they pick one, or is it still fairly manual? 

RR: There are simulation software programs whereby you essentially scan your face together with the abnormality and then the software morphs you into what you could be. Yes, I do use it in my practice to a certain degree, but to be honest, as I get more senior, I don’t like to use those devices because they give the patients a false sense of security, give the patient some kind of image that they will be. Now, nothing is “will” in medicine or surgery, and I think it almost gives a patient a certain benchmark, which, if achieved, is fantastic, but if it doesn’t, then it becomes a source of disappointment for the patient. What I like to do instead is to show my huge gallery of pictures, to then show the patients, “look, this is what I have done in the past in patients of your ilk, of your physique. These are the results I have achieved.” And I think that’s a more earnest and honest way of approaching the problem and being able to tell the patient, “listen, I’m guaranteeing you anything, but if you look at my track record, this is what I can produce.” And equally I say to them, “these are patients I’m proud of. And there are some patients where this has happened.” For example, I do a lot of Asian patients in terms of breast work, or I did, for example, in Asians, and you and I are both Asians, and we know that we can pigment. So the first thing I say to any Asian is, there’s a small chance the scar may pigment. So that they are aware that, you know what, there’s a good chance 90%, 95% things are going to be fine. There’s a small chance scar may pigment. 

AB: For people who are going to be listening to this chat, when should they think about reconstructive surgery and when should they think about aesthetic surgery?

RR: For example, you’ve had breast cancer, you’ve had a mastectomy, had your radiotherapy and chemotherapy, and you now want to be equalised as breasts are concerned. Similarly, if you’ve had trauma, if you’ve had an accident and you’ve injured your nerves in your wrist, for example, a glass cut to the wrist can be devastating. And essentially, you lose a nerve of your hand, and therefore you can’t feel. You lose a nerve of your hand i.e. ulnar nerve and you can’t move your fingers in a fine fashion. Now, those kind of things are functional reasons to have surgery done. And there’s no real time frame that I can give you for that. That is the patient deciding. There’s time, they have better function, a better quality of life. As far as cosmetic is concerned, there is actually no such age. There are all these myths coming from America that, yes, have it done before you age or have it done at an early age. So you prevent ageing or you slow ageing. I have to say I don’t believe in that. You have to be very circumspect, have to be very careful and measured and seek advice, read the literature, take what you see on the Internet with a pinch of salt and go and see people who are sensible, senior people for advice before you do anything.

AB: Okay.

RR: But it is important that you see a consultant plastic surgeon who has followed the guidelines of our BAAPS, which is the British Association of Aesthetic Plastic Surgeons. And essentially we, as a fraternity, don’t tend to advertise our services. We see the patient, we do an earnest consultation. We send them a letter of consultation. We give them a cool off period. Very, very important to leave the patient alone for a good three or four weeks. Let them think about it. Let them let them sleep on it. And I, like my colleagues, always offer a second consultation because the first consultation can be an hour long, an hour and a half long. It’s never quite enough because aesthetic surgery is personal surgery, and you need to, I say to my trainees, get under the skin of your patient, learn to know what their aspirations are, learn about their fears, about their goals, about why they have come to see you now. What’s the reason? Are they looking for a new job? Have they met a new partner? Do they want a better quality of life? So that conversation, the first time you meet them, may be slightly stuttered, maybe slightly impersonal. And therefore it’s very important that you see the patients twice. And sometimes I see my patient three or four times before I convert to surgery. They ask me this question time and time again. How do I choose a plastic surgeon? Again, it is not something that I can give you one, two, three about, but what I can tell you is two tenets, which is-do look them up and research them and make sure that they have had or are in an established NHS practice. I think that’s very important because in the NHS we have full appraisals yearly. We are measured, we do monthly audits. We are actually scrutinised. Our results are scrutinised, our methods are scrutinised, our consent forms are looked at, our processes are all regulated. And it’s very, very important that if you are undergoing aesthetic surgery, you can choose someone who either has been in the NHS for a long time and then retired from the NHS or someone who’s currently in the NHS. 

AB: Fabulous. 

RR: Secondly, please don’t be dazzled by great clinics, plush clinics, plush receptions, huge websites and instagram for 2000 followers. Because actually, I’ll tell you, it’s those who’ve got millions of followers, those are the ones who need those followers to get the work in, if you know what I mean. So don’t be dazzled by that. And I’m afraid in our world of social media, there’s a lot of that going on. And the other thing to say to you is that do make sure that they show you their own gallery of pre and post pictures. Please make sure that you sit down with that consultant. They need to show you their own pictures, not modified raw pictures of pre and posts. And not just the good results, but also the average and slightly poor results. Surgery is not an exact science and we as surgeons, especially plastic surgeons, we plan and we plan. I plan right from the time the patient converts the surgery to them being on the table, I’ve already thought the patients through six or seven times, especially the morning of surgery. I get up early in the morning, I sit with their picture and I study them and I make a plan. On the table, I measure like my colleagues do. We measure everything. We maintain symmetry, we establish symmetry. But the tissues as they’re left on the table may not be in the same place six months on. 

AB: That’s really interesting.

RR: For example, facial skin heals differently to eyelid skin. The neck heals very differently from the breasts. The breast heals very differently from the tummy. So even within territories, there are regional differences, therefore it’s very difficult to predict. And all this counselling under the umbrella term of informed consent, it’s very important that when a patient decides to have surgery, that on the day of surgery, or before, preferably, the patient is given a consent form with all these risk factors within it. The patient has had time to digest them, think about them, ask questions and then sign the dotted line. 

AB: What I would love you to do is talk us through all the steps that a patient should go through up to surgery. 

RR: Let’s say there’s a patient who has had two or three children breastfed and now is looking to rejuvenate the breast from a cup size point of view, from the nipple position point of view and general laxity point of view. The first thing that needs to be done is a thorough research of what they’re after. And the internet is good for that. I was slightly damning of the internet earlier, but it has its advantages. Look at various pictures and then start to look for the appropriate plastic surgeon for that procedure. For that, I have to say our website, the British Association of Aesthetic Plastic Surgeons, the BAAPS, is a very good, informative website. From that website, try and identify three or four potential consultants you would like to be treated under and then, of course, research them in terms of their track record, NHS status, in terms of their experience and so on. 

AB: Okay.

RR: Try and talk to a friend who’s had the procedure done because then you get a very different perspective on things in terms of what it was like being a patient under a particular surgeon. I, for one, have a list of patients who are happy to talk to potential patients. So if a patient rings my practice and says, “Raj did a mastopexy augmentation”, which is an uplifting augmentation on a particular patient, I want to speak to a patient who’s had it done before. And we have a list of patients who are kind enough, allow them to call them and speak to them and even make them. The assessment is important. After the assessment consultation letter, read through it carefully, understand it, make lots of notes, and then see the consultant again. 

AB: Okay, so that very clearly you’ve outlined. Thank you for that, Dr. Ragoowansi. I think that’s going to help a lot of people. What is the percentage of risks involved in both surgical and non-surgical procedures? And are these procedures reversible? 

RR: Okay, so on the non-surgical side, it’s a very general question because obviously each particular procedure has their own risks and so on. But I think, for example, Botox, within four to six months, the effects reversed. So obviously it dissolves, the nerves then start to work and the muscle then fires and the wrinkles then come back. So as far as Botox is concerned, the risks are when it’s injected in the wrong place, when it’s injected in the wrong muscle and the wrong dose. In those patients, you can get eyebrow asymmetry, upper lip that can drop, asymmetry of the forehead. And although it’s a complication as such, which may be correctable by injecting the other side, or equalising it with some more botox, which is done at ten days-two weeks. If left alone, eventually that’ll disappear, we’ll normalise or equilibria. Same with filler, you inject the filler if it’s too lumpy, if it’s too much. You know that by six to nine months at the most, the filler will resorb, the body will absorb it, and you’ll be back to where you were. As far as surgery is concerned, complications can either be early, within the 48 hours of surgery, or later on, which is two weeks thereafter. And the complications of surgery can be irreversible. For example, scarring. Scarring, you cannot reverse scarring. Yes, you can fade it, yes, you can lighten it. And of course, if you’ve had good surgical closure of your wound and you’ve had good healing, then you’ll heal in such a way you’ll hardly see the scar. But if you have a scar, scar is there for life. There’s of course, the risk of delayed healing, scar can stretch. You can get asymmetry, which may be noticeable, and also loss of sensation, which can be disconcerting. Hypersuction carries some complications, which are things like asymmetry lumpiness and also swelling that takes time to settle down. So every procedure, be it non-surgical and surgical, does have an element of risk. Now, as a percentage, I would say to you that 92% to 95% of patients in my practice walk away without any problem. That’s my figure, as far as surgery is concerned. Non surgically, i.e. Botox and filler, the complications are probably in the same realm. I’d say probably 90% lazy, fine, 10% has niggling issues. But it’s very important that the patient knows these potential complications before embarking on the procedure. 

AB: Would surgical procedures harm the growing up process in youngsters? 

RR: Harm is probably too harsh a word. What happens is that if patients enter the arena of aesthetic surgery at a very early age, say 10, 12, 14 years, ageing, gravity, sunlight, exposure, all these things lead to laxity. But I know, and I tell my patients this, in about seven to ten years, whatever you say, whatever goes up has to come down and therefore you need to have those procedures done again. If you’re young, then it is twice or three times in your lifetime you have to have the procedures done. If you’re young, let’s say in your twenties, and you’re sort of in the process of have a relationship, then those are very difficult years, both socially, psychologically and so on, to have a burden of aesthetic surgery on top of that, I think it’s actually sometimes overwhelming to a patient. I normally say to them, listen, you’re building your career, you’re making relationships. Wait a little bit. Half the time I see young patients come through my door, they don’t really know what they want. They’ve actually just seen something on the Internet or they’ve been influenced by Love Island or the Kardashians, and on a whim, they want to get something done. Plastic surgery is not the solution. 

AB: Do you have any last words of advice?

RR: Don’t jump into any formal procedure without thought. This is not done on a whim. These are very important, life changing procedures. Don’t jump into it because there is time. 

AB: Yes. Thank you so much for that chat, for being so open and honest. That’s what was incredible about this chat. Thanks for joining us. Hope you enjoyed the Wellness Curated podcast. Please subscribe and tell your friends and family about it. And here’s to you, leading your best life.