A tattoo is created by driving ink into the deeper layers of the skin via a needle. When the ink pigment reaches the middle layer of the skin, certain cells ‘eat’ the pigment. These cells cannot ‘digest’ the pigment and so the pigment remains inside these cells and can be seen from the surface of the skin – what we commonly call a ‘tattoo’.

There are two options for removing a tattoo: surgery or laser depigmentation.

With surgery, the skin bearing the tattoo is cut out and the hole in the skin is sewn shut to leave a scar. The aim is to leave as small a scar as possible, in the best direction to result in the most ‘hidden’ scar – which often just looks like you have had an operation. Small tattoos can usually be treated in a single procedure under local anaesthetic (with you awake) in the outpatient department. Larger tattoos may need to be removed in two, or more, procedures. This allows the tight skin to stretch and go slack between excisions so that more of the tattoo can be removed after several months (known as serial excision)

Laser treatment works by firing an intense light at the tattoo. Certain pigments absorb certain lights and ‘heat up’. This heat destroys the cells which hold the pigment. This can work quite well with some colours (red, green) but  is much less effective with other colours (eg blue-black). However, often the pigment which is released from the cells is simply ‘eaten’ by other nearby cells and this results in ‘smudging’ of the tattoo. Occasionally the ‘heating’ effect may change the colour of the tattoo but not remove it.

You may consider it worth trying Laser treatment in the first instance because if it works well and the colours fade then you would have minimal scarring. But in reality, many many laser treatment sessions are required, which can prove very costly, and the final result is that the colour often ‘fades’ or ‘smudges’ – but it still looks like a tattoo!

What is liposuction?

Liposuction is an operation in which selective fat deposits are removed by sucking the fat out through a hollow metal tube.

Who will the operation NOT help?

Liposuction is not an operation to help you lose weight. All surgery is potentially dangerous, so if you are overweight it is far better to lose weight by a combination of diet and exercise. However, some people find that despite losing weight, they are unable to shift certain deposits of fat, such as the “love handle” area, the thigh area, the central tummy area etc. If, having lost weight you still find certain areas are more “fatty” than you like, then liposuction may help.

Who will the operation help?

Liposuction is commonly used to reduce the fatty deposits shown in this diagram:

What types of liposuction are available?

There are several different types of liposuction available. Each has a specific advantage in different clinical situations. The choice for which type of liposuction is most appropriate will be discussed and decided upon during the consultation:

•  Suction Assisted Liposuction: the original liposuction method, suited to smaller areas of liposuction
•  Power Assisted Liposuction: the handpiece oscillates thus reducing surgeon fatigue, which in turn improves the safety of liposuction. This is my preferred device for the majority of liposuction cases.
•  Ultrasound Assisted Liposuction: tends to be better in more fibrous areas such as the breast and upper back regions. It allows liposuction in areas that are too tough for SAL or PAL alone.

Is the effect permanent?

Any fat cells which are removed by liposuction, are removed permanently and the body does not replace them. If a patient does put weight on following liposuction, the fat is stored more or less equally in all fat cells throughout the body; thus, all remaining fat cells will enlarge, but the contouring effect of the missing fat cells will remain, so the effect is permanent.

Is liposuction available on the NHS?

Liposuction for cosmetic reasons is not available on the NHS.

How is the operation done?

Small areas of fat can be removed under local anaesthetic, but generally the operation is done under a general anaesthetic (with you asleep). The extent of the fat deposit is marked out on your skin with a pen, and then several 1cm long stab incisions are made. Initially a dilute solution of anaesthetic agent and adrenaline is injected into the area to reduce pain and bleeding. Then a slim (3-4mm diameter) hollow metal tube is inserted through the stab incision. One end of the hollow tube is connected to suction tubing and a vacuum source. The metal tube is then vigorously moved back and forth and the fat is literally broken up and sucked out.

Once the desired result has been achieved, the tiny holes are closed with buried dissolvable stitches and surgical tapes applied. Finally the skin is taped into position to encourage it to shrink up and stick, and to prevent any fluid from accumulating in the spaces where the fat has been removed. A tight elasticated pressure garment is then put on over the surgical tapes to add further compression.

What are the limitations of the procedure?

The main limitation of the procedure is that if the skin quality is poor and lacks elasticity, once the underlying fat is sucked out if the skin cannot retract to take up the slack, the skin may hang in an ugly redundant fold.

Another limitation is judging the exact amount of fat to remove. If too little fat is removed, the bulge will remain (though will obviously be smaller). If too much fat is taken, a permanent dent will remain. It is fairly simple to go back and take a little more fat away, but much harder to put fat back in. For this reason I usually err on the side of caution and would much rather leave a little too much fat in than take too much away.

How long is the operation?

The length of a liposuction procedure varies according to how much fat needs removing. Generally liposuction takes between 30 minutes and 2 hours.

How many days in hospital?

Liposuction is usually done as either a day case procedure (home on the same day) or a single night stay.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If the wounds have healed you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. You should continue to wear your pressure garment until you see me. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

What are the possible risks?

Any surgery has the potential for complications. Although liposuction is generally a very safe operative procedure, it does carry the following risks:

Infection; infection is a fairly rare complication (1%) and can result in swelling, redness and tenderness either spreading out from the stab incision scar or may develop anywhere over the liposuctioned area at any time for up to 3 weeks after surgery. This usually responds well to a course of antibiotics.

Bruising: bruising happens almost always with liposuction and should be considered inevitable. The bruising may range from very minor to black and blue. It usually settles within 2-3 weeks.

Bleeding: bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. For the first week after surgery you should try to limit movements at the liposuction site. Should a bleed occur under the skin, the area may swell quite dramatically, it can be quite painful and tender. If this happens you may need to return to theatre to have the blood clot removed and the bleeding stopped.

Ugly scarring: most stab wounds will initially be red and a little thickened for the first six months or so, but will eventually settle very nicely to leave a thin, pale, flat scar. Occasionally however, scars may become red, raised, wide, itchy or ugly. This is fairly uncommon.

Numbness: The nerves to the skin can be stretched or even torn during the liposuction procedure and result in numbness of the overlying skin. This is quite common and it usually recovers completely, though there is a small chance that a small area of numbness may be permanent.

Seroma: occasionally fluid can collect in the area following liposuction. This results in a bulge or swelling. It is treated by inserting a needle and sucking the fluid out, though it often recurs and can take several months to settle. This seroma may lead to internal scarring and create ugly folds and irregularities in the overlying skin. To reduce the risk of a seroma, you should wear the compression garment for the first 6 weeks after surgery.

Blood clots: occasionally a blood clot may form in the deep veins of the legs (deep vein thrombosis). These clots can have the potential to break off and travel inside the veins into the lungs (pulmonary embolism). Any liposuction to the leg carries a slightly higher risk than average of causing a blood clot in the leg veins. To reduce the risk of this happening you will be given surgical compression stockings to wear throughout the first 2 weeks after surgery. If possible, special inflating compression devices will be applied to your legs in theatre and worn for the first 24 hours in hospital, and you will be given a daily injection to slightly thin your blood.

Skin redundancy: as already discussed above, if the skin fails to retract adequately it may hang in a redundant fold. This fold can be removed but this is likely to result in an unsightly scar. It is best therefore to avoid liposuction if your skin quality is poor, or only remove a little fat if there is any doubt.

Irregularity: great care will be taken to ensure the remaining fat is left smooth to form a natural contour. However, internal scarring, seroma formation, bleeding etc can result in irregularity and unevenness at the liposuction site. This is difficult to correct, but deep massage over several months may help to smooth it out.

Under or overcorrection: The amount of fat which needs sucking out is a matter of judgement and there is therefore scope for error. In general, it is better to remove too little rather than too much fat; as it is far easier to repeat the procedure than it is to put fat back. In general terms it is not possible to restore fat to areas which have been over-reduced.

Postoperative Advice Sheet

What is abdominoplasty?

An abdominoplasty is an operation which tightens the skin of the tummy resulting in a flatter tummy and (often) less stretch marks.

Who will the operation help?

Abdominoplasty can be a useful procedure for several groups of patients who have:

• a redundant fold of abdominal skin hanging over the pubic area
• thin wrinkly skin (often after childbirth or following massive weight loss)
• stretch marks on the skin of their lower tummy
• a “pot belly” due to stretching or laxity of their tummy muscles
• multiple or unsightly scars on the lower abdomen

Who will the operation NOT help?

An abdominoplasty is not an operation to help you lose weight. All surgery is potentially dangerous, so if you are overweight it is far better to lose weight by a combination of diet and exercise. However, despite losing weight, some people find the skin of the tummy does not retract and they are left with an excess of saggy skin on the lower tummy. This is a very good indication for a tummy tuck.

Is abdominoplasty available on the NHS?

Abdominoplasty is rarely available on the NHS, however, there are occasions when it may be offered:

• Massive weight loss: weight loss of more than 6 stones followed by a period of sustained weight loss in which a patients lower tummy skin hangs in folds.
• Unsightly abdominal scars: if a patient has had significant problems with wound healing from previous abdominal surgery and has been left with indented, tethered awful lower abdominal scars, it is possible to have these scars revised on the NHS and an abdominplasty can be offered as a good way of improving these scars.

Before and after photos

How is the operation done?

The operation is done under a general anaesthetic (with you asleep). There are 4 elements to an abdominoplasty operation (see pictures):

Skin and fat removal: An incision is made in the skin above the pubic region and the skin and fat of the upper tummy is then lifted off the underlying muscle. A second incision is made around the belly button, leaving the belly button attached to the underlying muscle. The upper abdominal skin is then stretched downwards towards the pubis, and any excess skin and fat is trimmed off.

Muscle tightening: the underlying tummy muscles can be pulled together with stitches to tighten them. This provides a flatter tummy and also pulls the waist in a little.

Reforming the belly button: the belly button is then resited by cutting a hole in the skin of the tummy at the correct place and pulling the belly button out through this hole. It is then stitched in place with buried dissolvable stitches.

Liposuction: any minor bulges or excess fat is smoothed out by undertaking a little liposuction, to ensure the best possible cosmetic outcome.

Three drains are usually placed which emerge from your skin in the pubic hair area. The skin is then closed using buried, dissolvable stitches. Your wounds are then dressed and surgical tapes are applied all around the tummy. The tapes help to support your new wounds and prevent the collection of fluid beneath the skin and fat.

Which incision is best?

The final scar shape is tailored to be hidden within your choice of underwear. If you wish to wear the high leg thong type, the scar can be curved upward; or if you wish, the scar can be kept very low to allow you to wear “hipsters” and crop tops without showing your scar (see picture). You should bring your choice of underwear on the morning of surgery to allow me to plan your incisions accordingly.

How long is the operation?

An abdominoplasty usually takes about 2-3 hours.

How many days in hospital?

Most women undergoing abdominoplasty stay in hospital for 3 or 4 nights after surgery. Occasionally the drain bottles may continue to produce fluid and may need to stay in for a further day or two, delaying your discharge from hospital.

Postoperative period in hospital

You will be on bed rest for the first 24 hours after surgery. A catheter will have been placed into your bladder in theatre so you will not have to get up to pass water. You will have a drip in your arm and there will be 3 drains coming out of your lower tummy dressings.

If you have had a substantial muscle tightening procedure your tummy will be fairly tight and tender, but the regular painkillers you will receive will keep you fairly comfortable. It may be difficult to breathe in deeply due to the tight tummy but you should follow the physiotherapists instructions and do your deep breathing exercises every hour.

When you do start getting out of bed and walking on the second postoperative day, you will probably not be able to stand fully upright due to the tight tummy closure. It will take several days (usually 5-7 days) before you can straighten up fully.

Before being discharged from hospital you will be fitted with an abdominal binder which wraps around your tummy and adds additional support to your tightened tummy muscles. You should wear this constantly for the first 2 weeks (removing it for one hour a day for hygiene purposes) and then during the day time only for a further 2 weeks.

Postoperative Follow Up

After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your wounds, which may or may not have healed at this time. If the wounds have healed you will be given advice on wound care, bathing and exercise advice. If they have not quite healed by this one week visit, she will reapply the dressings and arrange to see you again the following week. Once your wounds have healed you will be given an appointment to see me six weeks after your operation. At this appointment I will check on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.

What are the possible risks?

Any surgery has the potential for complications. Although abdominoplasty is generally a very safe operative procedure, it does carry the following risks:

Infection; infection is not an uncommon complication (5%) and can result in swelling, redness and tenderness along the abdominal scar at any time up to 3 weeks after surgery. This usually responds well to a course of antibiotics. Occasionally however, it can result in some opening of the wounds. This wound breakdown is not a disaster and is usually managed by regular wound dressing and usually heals in four to six weeks.

Bleeding: bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid any strenuous exercise over this time. For the first week after surgery you should do very little and rely on your partner/friend to help do almost everything. Should a bleed occur under the skin, the tummy may swell quite dramatically, it can be quite painful and you may develop visible bruising and tenderness. If this happens you usually need to return to theatre to have the blood removed and the bleeding stopped.

Delayed wound healing; this is one of the commoner complications (5%) after abdominoplasty. The wound may initially appear to be healing well but may, in the first 3 weeks become red and a small hole appear. This is not a disaster, and will usually heal spontaneously with regular district nurse dressings over the next 4-6 weeks. This can leave a somewhat wider scar. Delayed wound healing is far more common in smokers and you are strongly advised to stop smoking before your operation, and not to start again (if you must!) until the wounds have finally healed.

Ugly scarring: most wounds will initially be red and a little thickened for the first six months or so, but will eventually settle very nicely to leave a thin, pale, flat scar. Occasionally however, scars may become red, raised, wide, itchy or ugly. This is fairly uncommon, but any wound breakdown which occurs in the early postoperative period may result in a stretched flat scar. If this is unsightly it can be revised 6-9 months later under local anaesthetic by cutting it out and stitching it up again

Dog ears: dog ears are small folds of skin which occur at either end of the scar, caused by a natural folding of the skin when the wound is closed. Great care is taken during the operation to avoid producing dog ears, but occasionally (5%) they cannot be avoided. Small dog ears seen in the early postoperative period will eventually settle on their own in the first 6-9 months after surgery. If they do not settle after this time, they can be simply cut out in a minor procedure under local anaesthetic.

Altered sensation; because the skin of the tummy has been lifted and stretched downwards, the nerves to the skin can be stretched or even cut. Almost inevitably, the skin of the lower tummy will be numb after the operation. Initially the patch of numbness will be very extensive, but gradually the size of this area of numbness will shrink to leave a small area of altered sensation just above the scar over the pubic hair area. It can take up to 2 years for this to recover. During this time, it is possible to injure or burn this skin without realising it. For this reason you should carefully inspect the skin of this area regularly, and in particular I recommend that you avoid using hot water bottles as you could easily develop a full thickness burn without realising.

Thigh numbness: in a similar way, the nerves to the outer aspect of your upper thighs can be damaged resulting in numb patches over the top of your legs. Again, this usually improves with time, but can occasionally be permanent

Seroma: occasionally (2%) fluid can collect beneath the skin and fat of the tummy. This results in a bulge or swelling of the tummy. It is treated by inserting a needle and sucking the fluid out, though it often recurs and can take several months to settle. To reduce the risk of a seroma, I use drains and an abdominal binder in the early postoperative period.

Umbilical necrosis; the blood supply to the belly button can be damaged during the procedure resulting in the belly button turning black and eventually turning into a scar. This is a fairly uncommon complication and is usually only seen in smokers.

Flap necrosis: this is perhaps the worst complication of an abdominoplasty. Fortunately it is very uncommon, and is usually seen only in smokers. Treatment requires either another operation to remove the dead skin and a skin graft is applied, or the black crust can be dressed regularly until it comes of spontaneously over the following months. Either treatment produces a very ugly result, though after about a year it can be improved by further surgery.

Fat necrosis: if the blood supply to part of the skin/fat of the tummy is damaged during the operation, an area of fatty tissue may die. This usually becomes apparent about 2-4 weeks after the operation. The wound may appear to be healing well, but then a firm, tender lump may develop. This lump of dead fat is called fat necrosis and does not usually require any treatment. It usually settles on its own over the following few months; though occasionally may discharge old liquid fat and fluid through a small hole in the scar and need regular dressing until this heals on its own.

Blood clots: occasionally a blood clot may form in the deep veins of the legs (deep vein thrombosis). These clots can have the potential to break off and travel inside the veins into the lungs (pulmonary embolism). Any surgery near the pelvis carries a slightly higher risk than average of causing a blood clot in the leg veins. To reduce the risk of this happening with an abdominoplasty, you will be given surgical compression stockings to wear throughout the first 2 weeks after surgery, special inflating compression devices will be applied to your legs in theatre and worn for the first 24 hours in hospital, and you will be given a daily injection to slightly thin your blood.

Postoperative Advice Sheet

Arm reduction is fast becoming one of the more popular cosmetic surgical procedures. The two main concerns patients have are ‘bingo wings’ and ‘wrinkly arm skin’. ‘Bingo wings’ are the loose skin and fat folds at the back of the upper arms which will just not ‘tighten up’ with any amount of exercise. ‘Wrinkly arm skin’ occurs in women with fine skin; as the skin loses its natural elasticity, the skin on the upper arms forms many fine wrinkles and looks really old. In order to disguise this appearance some women will no longer wear sleeveless or short sleeved clothes. In both of these situations an upper arm reduction will remove the excess skin and tighten up the remaining skin producing a taut, more youthful appearance.

In order to fully remove the folds and tighten the remaining skin, a long scar is required (from the armpit to just above the elbow), but this is usually well hidden inside the upper arm. The operation can be done under either a local or general anaesthetic and takes about an hour and a half. There is usually no need for an overnight stay in hospital. Buried dissolvable stitches are used so there are no stitches to be removed. The wound usually heals by about 2 weeks, though it takes up to 6 months for the scar to become fully mature.

The inner lips (or labia minora) of the vagina can occasionally be oversized, resulting in embarrassment and occasionally discomfort during sex, exercise or even when wearing jeans or underwear. A labial reduction operation is a simple surgical procedure which reduces the excess skin and corrects these problems.

There are two surgical approaches to reducing the labia. Some surgeons simply cut them off, but this results in a somewhat odd postoperative appearance. It is better to refashion the labia, which involves a little more surgery, but a much more natural postoperative appearance.

The operation can be done under general anaesthetic (with you asleep) or occasionally under local anaesthetic and sedation. The procedure takes about an hour and a half and there is usually no need to stay in hospital overnight. All sutures are dissolvable so there is no need to have stitches removed. Most patients return to normal sexual activity after 6 weeks.

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Whenever the full thickness of the skin is damaged it creates a scar. Scars can be the result of burns, trauma, assault or surgery. Scars cannot be removed, but ugly scars can be improved – an operation called ‘scar revision’.

If you have an ugly scar, it may well be possible to improve it. This usually means cutting the old scar out, releasing any underlying tethering and either accurately suturing the tissues, or rearranging the scar so that it lies in a better position.

After surgery, it is important to take great care with the new wound to avoid healing problems which could result in a less than perfect scar again. This may involve keeping the wound meticulously clean and dry, avoiding stretching or knocking the wound, taping the wound for six weeks and then commencing moisturisation and massage of the new scar in order to achieve the best possible result.

If you have a problem scar and would like to discuss the likelihood of me being able to improve it for you, please contact me on the above number.