Dr Ross Farhadieh Answers your Questions

Ross Farhadieh: Hi. I trained in Melbourne and finished my fellowships in Great Britain before I returned back to Australia. I’ve got a practise in Sydney’s Double Bay, I do some public work at the Canberra Hospital. I’ve also got a private practise there as well. Recently been the Chief Editor of the Currents Reference Textbook in Plastic Surgery. Trish has kindly arranged us, with some technical difficulty, to actually finally get me online, which is excellent, and she’s sent me some questions, which I’ve thought for my first effort at live video, I’ll start … Thank you Kimberly. I’ll start by reading them out and go from there.

So, your first question, Kimberly: What is the scarring like after breast reduction and what is the public waiting time for a category three for a breast reduction? So, breast reduction generally are divided into short scar breast reductions, which are vertical pattern, or what’s called the lollipop, breast reduction and the classic wise pattern reduction. The scar seems very long and people often are worried about it to begin with. In general, in white skin, even though it looks fairly red to begin with, at about a year you’ll find that the scars have faded out. There is often small areas that will break down in the breast reductions, all of which heal, and often by the end of the year, it’s very difficult to actually surmise that. Obviously there are some people who have some keloid scarring, so that makes the scarring a little bit different.

We’ve got a series of breast reductions on our website, looking at three months and 12 months, and you can actually see the difference between the scarring during that time period. So at three months, the scarring’s still not mature, it’s still obvious, but the time you get to 12 months, everything’s settled down and the scar’s very much faded into the background. It doesn’t mean that you don’t have a scar and one of the main things about it, that the nipple, which normally doesn’t look very regular, so it naturally, a nipple doesn’t look completely like a perfect circle, but with breast reductions, that’s the one thing that tends to become most obvious, even at six months, 12 months, 18 months, and that’s something that we all try to make sure that there is some hint of regularity to make it look normal.

I might move down now and discuss the public waiting time. I know at the Canberra hospital, we’re no longer allowed to offer public breast reductions. This has been a public government initiative over the course of the last 10 to 15 years. Initially it started off by saying that in medically indicated circumstances, you can have that, so that was provisions of back pain or any other related medical circumstances, but, increasingly in public hospitals, because the strain it had gone through from a budgeting perspective, have actually point blank refused to have any of these, so we’ve had 55 patients in the last six months all referred to me because we do quite a lot of it, turned away, so hospitals often tend to write to the patients who have been referred by GPs and say that we don’t offer those services, which is unfortunate. This wasn’t the case in Britain but it is part of the process here, I’m afraid.

Hi, is it Renz said, “I would like to know …” Yeah, Kimberly, just to go back to that. So we have a few people who have been on a waiting list and generally, it used to be 12 to 18 months on the public list but it could be longer, depending on how busy the unit was and increasingly, so in our hospital, the hospital has actually written back to all of our patients saying that you are no longer going to be on the waiting list and they’re going to be removed, so you’re lucky that you’ve remained on the waiting list, hopefully you can get your surgery done. What state are you in, can I ask, Kimberly?

What are the weight limits for tummy tuck and liposuction in size? The best answer to that question is to work out your BMI. BMI is weight divided by your height squared, so your height in centimetres, one point whatever it is, squared, and any BMI of about 35 is universally considered to be an independent risk for surgical complications, so this is something that I recommend to most of my patients, that unless your BMI is under 35, you should probably consider having surgery sometime down the track. This is not possible for all patients, there are some patients that for … Related to their body habits is that they’re not going to get a BMI under 35 and it is an area that you would proceed with caution if you decided to have it done.

Yeah, Kimberly, I just saw your text, so you’re very lucky that you can still have a breast reduction on the New South Wales, yeah, you’re quite … That’s quite a size, so you’re probably suitable, so hopefully you’ll get … Because you’ve been now put on the waiting list that you’ll be able to have that surgery done but I think the waiting time list anticipation in New South Wales is a little bit longer than other hospitals because the Territories Hospital is … It’s got a bit more resources sometimes in regards to putting patient on there.

I’ll move down the list. There’s one from anon saying, “the inside of my nipple on one side has been intensely itchy since breast lift and I’ve had an ultrasound and it showed nothing. Is this at all common after a breast lift and is it possibly related to scar tissue? That’s exactly what it’s related to, anon, so scar tissues are, with breast reduction, is not unusual and it is very common to have that happen to you. Often the reason for that is because when you make an incision around the nipple, there small ends of the smaller nerves joined up with regeneration and that regeneration is what’s causing the itching. With regular massage, touching, so that the nerve ends become more accustomed to proprioception, you often find that that does resolve. It does take a little bit of time but it often resolves. If it hasn’t resolved at 12 months, it’s unlikely to resolve beyond that. It will probably get better but it’s unlikely to resolve beyond that.

So, Margaret. My son is 11 and is constantly teased about his big ears. Yes, it is covered by Medicare, and what’s the process? So traditionally this is called bat ears, and these days they’re called prominent ears, and it is normally undertaken by the age of 7, so I worked at a paediatric hospital in London, Great Ormond Street, which is the oldest paediatric hospital in the world, and we did a lot of these. See if you get a referral from your GP and get them referred to a plastic surgery service, often the paediatric service do this, so if you’re in Sydney, North Shore Sydney Children’s Hospital or the new Westmead Children’s Hospital would be the places where you want to get referred to. If you’re in Melbourne, the Royal Children’s Hospital will provide those services. The wait list is a bit of time. In general we try to have those surgeries done before the age of 7 because that’s the age that kids go to school and unfortunately kids can be a bit cruel and this is about the age that they start picking on other kids.

Justine, post plastic… “I think I might have made a mistake when getting a breast reduction and lift. I wanted my surgeon to take them all off.” Yeah, that’s what everybody says, unfortunately, but said that he will make them as small as possible for my friend. He has reduced me from a J cup to a C cup and although they sit nicely, meaning I can do … oh darn it, yep, I think I would like them a little fuller. And that’s actually, that’s very common, so people who’ve been suffering from large breasts for a long time, they often come to the rooms or clinic and say, “Just cut them off, I don’t really care what you do.” And I saw it when I was a registrar, where the breasts were reduced, similar cup size, in fact, and the patient was really unhappy. Unfortunately, there, the only thing to do now is to consider actually having an implant put in there. That would probably be the most effective way of providing fullness for the top of your breast.

I’ll move down the questions a little bit, just to see. There is a question about “What you recommend for lines around the eyes and forehead. I’m only in my early forties, however I’ve spent a lot of time in the sun.” It’s a little bit difficult without seeing the photographs. Generally, botulinum toxin, Anti-wrinkle injections, which really should be in the water these days, has resolved a lot of these issues in relation to wrinkles. Now, wrinkles or frown lines that are very deep set, so they’re … And particularly if they’ve been in relation to sun exposure, it is not easy to fix those with botulinum toxin. It does tend to ameliorate the intensity of them but really the only way to fix them is with surgery and so on the forehead with brow lift surgery and, even then, it doesn’t quickly resolve it. Afterwards, you should consider having botulinum toxin regularly, and around the eyes, especially if there’s any loose tissue, you should consider having blepharoplasty, which is a lower eyelid or an upper eyelid lift. It’s a pleasure, Justine. No problem.

So, Trish, “I need a rhinoseptoplasty”, yeah. This is an interesting question. Look, rhinoplasty by definition involves a septoplasty. The question is the extent of it. So if there’s a significant amount of breathing difficulties, and many of the patients do have that, then the septoplasty is a bit more extensive. The septum is the central part of the news, where you see the dorsal hump, and when you do a rhinoplasty, which involves the tip, you often expose the septum as well, so the distinction here is between just the tip rhinoplasty, where you just address the tip, to a rhinoseptoplasty, where you’re addressing the septum as well. Whether you go to a ETA with a plastic surgeon, it’s not really a significant difference, the key is that it has to be somebody who is experienced at it, so in plastic surgery circles, it has to be somebody who’s done facial aesthetic surgery training and got to have fellowships in that area, lots of people who specialise in that area and have actually had that exposure. A general plastic surgeon, whilst might be able to do a very good job of a rhinoseptoplasty, what you want to do is obviously go to an expert in that area.

Karen. “What’s the best for my daughter to get breast reduction. She’s 20 and a G cup, has neck… Our GP doesn’t think neck pain causes…” Oh, it does. It does. If your daughter, the key test of this is how she feels at the end of the day, so there’s two things I always ask my patients. Whether they’ve got big lines on their shoulders, the strap lines from the bra at the end of the day, and whether their neck and shoulder pain is worse if they … Often patients complain of shooting pains from the neck all the way up to the back and G cup size certainly would be something that does that, so I’ve … We regularly do reductions on younger ladies who’ve got large breasts who’s actually affecting their function and they’re getting into pain.

There’s a question from Louise, “What’s the best facial surgery for deep smile lines, frown lines. I’m in my forties…” It’s a little bit difficult without actually seeing you, Louise, but in general, the only thing that affects a deep smile line, so we’re talking about the nasolabial fold, if you look at my face, actually, you can see it, so I’m developing those lines. If you look at this part of my face, this is called the mid cheek, a mid cheek lift, whether it is part of an extended facelift, or just the mid cheek lift through the lower eyelid, is actually the thing that actually addresses this the best. Now, often, if this is the only area that affects patients, they end up with what’s called a mid face lift, where they get an incision under their eyelid, their mid face is lifted up and often requiring incision of some excess skin under their lower eyelid, and that resolves their nasolabial deep folds. If they also have looseness of the jowls and they’re developing loose skin in the neck, then that stands for the standard facelift incision with a high SMAS fixing, and in either case, you should consider getting advice from a plastic surgeon who does do facial aesthetic surgery and has had facial aesthetic training to do that, because that’s certainly tiger country.

Liz, “I had a tummy tuck and the surgeon has left me with a very deep belly button. It gets smelly and it’s very thin and long. Is this normal?” I don’t know, I haven’t seen a photograph before but it’s resetting of the umbilicus is, believe it or not, one of those areas that in plastic surgery you often talk about, there’s lots of papers about what would be the best looking umbilicus and there’s all sorts of schools of thoughts as to whether you make an incision which is a smile incision, so the umbilicus sits a bit more proudly or whether you make a deep umbilicus incision or whether you, in fact, just make a small circular incision. In either case, if you’ve got a deep, thin umbilicus, which is causing you concern, you might have to speak to your plastic surgeon. Might be something which is amenable to some local surgery with local anaesthetic, which wouldn’t be too intensive and it would just require a scar revision, that should hopefully address any concerns.

I’ll move down the question list a bit more, and “Is it simple surgery to have an implant put in a year after your breast lift?” In general, it’s not that difficult. So if you’ve had a breast lift, putting a new set of implants in, it’s not as straight forward as a primary breast augmentation, but in general, it’s not actually that difficult, so the incisions end up being very similar, the planes end up being similar, the main thing is the resetting the implants so that the nipple areola complex doesn’t either ride up too high or come too low.

“Is it best to do a body lift and a thighplasty together or separately?” Separately. Thighplasties in general, so thigh lifts in general, depending on whether they’re extensive thigh lifts with a vertical component or a limited thigh lifts, are prone to scar breakdown, so particularly in the bariatric patient population, there can be as high as 50%, so with these surgeries it’s actually, in my views, and I recommend this to all my patients, it’s more sensible to have them sit on the operating table for 6, 8, 10 hours, to actually divide them into two sets of surgery. The nuisance of this is obviously recovery, because you’re going through two recovery phases, but the recoveries of being less arduous, patients tend to find that they recover better and the risk of complications is a lot less.

“Do you think my lift and implant were done properly?” Very obviously different, Trish has sent you a picture, you have therefore seen the picture by now. Is it … Find it … This box. Ooh. I think that is trying my … I’m sorry I can’t find it right now. If you send me your photograph by email, I’ll be happy to reply. I’ll do that in the next 24 hours, if you just … The email address to our practise is [email protected] and if you send your photograph to us, I’ll be delighted to reply to you.

“Recommendation for keloid or red scarring. What do I think of laser treatment?” Keloid or hypertrophic scarring is part of the same spectrum. In general, it is related to genetics, so it’s more common in people from African or Asian, South East Asian, genetic backgrounds and in principle, a treatment involves immunomodulation, because this is just bodies over-exuberant reaction to scar formation, so we often end up injecting these things with steroids. Now, on top of that, laser can have a role in softening up the scar, but the definitive treatment is, in conservative terms, with scar management silicone gel, steroid injections and the definitive surgical management involves excising the scar and rejoining the scar with some form of immunomodulation injection at the time.

Question from Melbourne. “I’m hoping that I’m eligible for the Medicare rebate but I’ll have to discuss that with my plastic surgeon. I’m a little bit iffy on being eligible on skin irritation issue.” Well done, that’s well done. Yeah, look, the best thing … I trained in Melbourne but I’m not in Melbourne at the moment, obviously, it’s set in Sydney. You may well be eligible, there are Medicare conditions these days to these item numbers that are related to this kind of surgery and the easiest thing to do is, depending on whether … I don’t know if you’ve got private insurance, if you have private insurance it would be sensible to call the private insurance with the item number and depending on what insurer you have, you might be covered for your hospital stay, which is a significant proportion of the costs, so the operating theatre fee and the hospital stay might be covered, but if that’s not covered, then, unfortunately, you would have to foot that part of the bill as well. Yeah, that’s the thing with surgical fees often, even if it is covered by your insurers, is not really enough.

There’s a question from Karen. “I was born with a cleft lip and I had work done on my lip when I was … and am now due to breathing difficulties and self esteem issues because of it, my nose.” Yeah. It’s not unusual to develop the problem but … My left eye, yep. A different shape. This is affecting … I don’t know, actually. There’s a possibility that it might be considered a Medicare item so the best way to address this is probably to get a letter from your GP and consider going to your local tertiary referral hospital, so I don’t know which state you’re in but one of the big hospitals that deals with plastic surgery, with a lack of referral, and convey your concerns and if it is, in fact, rebatable under Medicare, because often you’d have to put some documentation through with Medicare, you can meanwhile be eligible for having that surgery done on the public setting.

Emmy, “I had an arm lift about seven months ago, I’m keen to get in some tattoos. How long do you recommend waiting?” How long is a piece of string? Ball park figure is considered to be 12 months, so at 12 months, but at six months, you’re fairly safe into it, so …

Ruth, “I have a droopy eyelid and have had several baths of Anti-wrinkle injections from different practitioners. Yep. But have twice experience drop eye, yep. This component problem has taken three months to revert back.” Yeah. Thread lifts is not even good surgery, so it’s not an option for anything. So whoever’s offering that, shouldn’t be. In regards to the droopy eyelid, it depends on whether you actually have a problem with the muscle that is elevating your eyelid, that is called blepharoptosis and some people have it and it can be unilateral or bilateral, and if it is that, that can be fixed by an incision, which is similar to the blepharoplasty eyelid lift incision and aponeurosis, which helps the eyelid, eye lift can be reset. The problem that happens, this is what most people think, if you think about it, if this is the muscle that lifts the forehead and you … And it is the only thing that is … That’s the muscle that’s closing your eye, you end up putting Anti-wrinkle injections here is exactly what will happen is that you will end up with more of a droopy eyelid than you had before.

The question often ends up in, particularly in ladies as they age, as to whether this is purely related to the eyelid or it is also related to the brow. So if you sort of look at my brow, because I’m in my forties, if I lift my brow a little bit, you can see that my eyelid becomes less prominent or the fold in my eyelid becomes less prominent, so there’s definitely a contribution from your brow and also your eyelid. The question ends up being how much of it is related to your brow, does that require surgery as well, or is it just enough to address your eyelid and that’s something that needs to be assessed by a plastic surgeon that does facial rejuvenation surgery.

Celeste. “I’ve lost weight … I had weight loss surgery in 2000, lost a hundred pounds.” Well done. It’s the best thing you’ve done for your health. Your cholesterol’s going to go down, your high blood … I mean, this is a brilliant, brilliant step that you’ve taken for your health. “I’m looking at having a tummy tuck and an arm lift. I suffer from pain very badly from surgery, it’s very hard to recover. Do you have any advice for me?” This is a difficult situation because this is something which cannot be cured, as you know, but it can be tempered, so often what happens in these settings, in combination of talking to your rheumatologist, patients end up having doses of steroids or other related medications that puts a disease into greater remission and then you have surgery. Obviously immunosuppression does affect rates of healing and does increase the risk of complications to surgery, that is something that you would need to work through with your plastic surgeon once you’ve seen them.

Oh, you haven’t quite finished your post. Sorry. I was a candidate for … Can you let me know what sort of costs and downtime. Look, I don’t do thread surgery and most plastic surgeons who do facial aesthetic surgery or have had facial aesthetic surgery training don’t feel that thread surgery is something which is … Withstood the test of time, I guess is the best way of describing is. Most people consider it to be a poor substitute for surgery and the issues are being that you end up having a procedure that then precludes you or makes secondary surgeries a lot more difficult and whilst the results in the short term, and this is the reason why lots of people, I suppose, promote thread surgery, is in the short term the results don’t look too bad, but in the long term, the results are not great and part of the reason why it’s promoted is because this is something that doesn’t require extra surgical training, their rates of complications are considered to be relatively minor, but, ultimately, what you want is surgery which is reliable, which is going to be long lasting and, unfortunately, thread surgery is not one of those.

Yes, I think you’re right. I think your … Ruth, I’ve just read your second post. I think … I can’t tell but it sounds like you actually required a brow lift as well, so one of the things, this is why I was asking you whether it’s unilateral or bilateral, so often what happens is your brow is a bit low and then you end up having some Anti-wrinkle injections there and then it becomes even more prominent, so there is … Often is a component of brow as well as a component of the upper eyelid, and this is the reason why it’s actually important to see somebody who does quite a lot of facial aesthetic surgery, to actually give that assessment. The brow lift has often either keyhole incisions here or smaller incisions here, and then lifts your brow up and that means once you’ve done that you can, if needs be, have a little bit of your upper eyelid incised as well.

Celeste. I’ve read about the arm lift that is basically under the arm pit, is that effective enough to move. Yeah. Arm lift surgery is effective in removing a lot of skin. It does leave you with some scar but if you’ve had large amounts of weight loss, it does actually work very well. The main thing for people who have had any sort of gastric sleeve or bariatric surgery in all studies is that the wall break down rates are much higher than the normal population, so it can be up to 50, 60%, so that is something to be mindful of. All of it heals, it just means it’s a bit of a nuisance.

Kimberly. Yeah, you’re right. Cosmetic injectors can give good brow lifts, non-surgically, and it depends, so if it’s enough to resolve it, and, in fact, a proportionate number of brow lifts that we can do these days are significantly reduced as a result of botulinum toxin, the key to that is to make sure that it is enough, it actually addresses your concerns, and if it isn’t enough to address your concerns, then that’s when surgery is required.

Yeah. Okay. I think … I feel the same about my lip fillers. I’ll just say something about this, Kimberly, because permanent fillers for the lip, the best permanent filler these days that we know of is your own body’s fat, so I use it in facial rejuvenation all the time and, in fact, most of my patients who have facelifts and neck lifts and things like that, they end up with having not just fat put in the rest of their face but in the lip and you’re right, the permanent fillers are perfect because, even though you might have one or two injections, often you can actually get away with just doing one time because some of the fat reabsorbs, but it’s a permanent filler without any of the complications that some of the other injections, like Restylane, do. So that’s something to consider and there are some people who offer that.

I’m going to pick your brain once more. Sure, Celeste. I had my appendix removed as a child. Will that scar be gone. Yes. Yes. After a tummy tuck. So all of the skin, with a standard tummy tuck, all of the skin and you, if you’ve lost a lot of weight, it will be even more, but all of the skin below your umbilicus and a little bit above your umbilicus, your belly button, is all taken out.

Okay. So, ladies, I might bid you farewell and go and put my newly born son to bed and hopefully see you next time. Thank you very much for your time and, Trish, thank you very much for setting this up. I am looking at what you’re saying but I can’t actually see an option to save here, it’s just a finish option, so I’ll do that. Goodnight.

For more information on Dr Ross Farhadieh check out his listing on the Plastic Surgery Hub website or you can phone his clinic on 1300 030 371.

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