What is the difference between plastic surgery, aesthetic surgery and cosmetic surgery?

'Cosmetic surgery' and 'Aesthetic surgery' have the same meaning. They refer specifically to surgery which enhances or beautifies the appearance of faces and bodies. The general public associate 'Plastic Surgery' most strongly with operations which enhance and beautifiy appearance but 'Plastic Surgery' also includes surgery to treat many other conditions: removing skin cancer, reconstructing breasts and other body parts affected by cancer, injury or infection, treatment of burns and scars, operating on painful or injured hands and treating birth anomalies.

Plastic Surgeons trained in the UK all have at least 8 years training experience treating these conditions before qualifying for specialist registration.
Mr Harley has more than 15 years of Plastic Surgery experience and gained GMC specialist registration in 2012. As part of his higher surgical training he did a cosmetic surgery fellowship at the McIndoe Surgical Centre.

What has plastic surgery got to do with treating hand and wrist conditions?

The field of 'Plastic Surgery' covers a wide range of conditions - the uniting theme is the use of meticulous surgical technique to restore or improve function and form to 'organs of expression' - the surface - skin, face, hands, breasts etc.

Hand and wrist surgery is a domain which is shared between 'Plastic' and 'Orthopaedic' surgeons. Clinicians who take a special interest in Hand and Wrist surgery usually spend a period of time gaining additional experience and training in this discipline. Having completed Higher Specialist Training in Plastic Surgery, Mr Harley gained additional Hand Surgery expertise in both Orthopaedic and Plastic Surgery departments.

What is 'Hand Therapy'?

This is specialised physiotherapy for the hand and arm. Hand therapists follow this specialisation having gained qualifications in physiotherapy or occupational therapy. Some conditions will require hand therapy as the initial choice of treatment (e.g. post injury joint stiffness, early arthritis) and in other cases (e.g. dupuytrens surgery or finger joint replacements) hand therapy is of minimal benefit on its own but will be essential after surgery to support and exercise the hand to achieve the best possible outcome. In many cases hand therapy will include a custom-made lightweight splint which can be removed where necessary for exercise and washing.

What is the difference between local anaesthetic and general anaesthetic?

Local anaesthetic - 'LA'

Local anaesthetic is a substance which stops nerves from conducting pain messages to the brain for several hours. It is injected in specific areas of the body to cause a zone or 'field' of numbness. Operations can then be conducted in the numb zone. Some pain is felt when the injections are administered but the local anaesthetic rapidly takes effect. The patient is fully conscious during this type of surgery and although it sounds like a daunting prospect, it is tolerated very well by patients. Patients are often aware of movement and 'things happening' but should not feel pain. Many patients relax to the point where they doze off during surgery and others find it reassuring to be able to talk to surgical staff during surgery or listen to music. You will not have to see the surgery happening although this can sometimes be arranged for patients who are more inquisitive.

Local anaesthetic is very safe even for people with relatively poor general health.

The surgeon typically administers the local anaesthetic (anaesthetist not required) and less hospital time is required so costs can be minimised as a result.

Very little preparation is required in advance of surgery and there is no need to be 'nil-by-mouth' before a local anesthetic operation (unless a regional block - see below - is to be used)

There is no 'hang-over' as there may be after a general anesthetic and no special observations are required after surgery - you can leave the hospital or clinic as soon as the surgery is finished in most circumstances.

Because of these significant advantages a large and increasing number of cosmetic and hand surgery procedures are carried out under LA.

Local anaesthetic surgery is not appropriate for more extensive procedures as there is a limit to the size of the zone which can be numbed.

Local anesthetic creams and pastes are also available and these can help to reduce the pain from injections for certain aesthetic treatments.

Sometimes the specialist skills of an anesthetist will be required to administer a specially targeted dose of local anaesthetic ('Regional Anaesthesia', 'RA' or 'Regional Block'). This allows a whole limb or limbs to be numbed by guiding the local anaesthetic to the roots of nerves which supply the limbs or other regions.  Anaesthetists may also administer 'sedation' during a local anaesthetic procedure if a patient is likely to be very anxious during local anaesthetic surgery.

General anaesthetic - 'GA'

Most patients are familiar with the idea of general anaesthesia where a specialist anaesthetist uses medical drugs to keep the patient unconscious and out of pain for the duration of surgery. This is essential for many larger operations or operations where local anaesthetic is difficult to administer easily and effectively.

General anaesthetic is very safe in the modern age and modern medical drugs and techniques provide a smoother and better tolerated anaesthetic than in the past. Despite this, health can, very occasionally, be damaged permanently by general anaesthetic. The risks of a serious problem increase with patient age, weight, poor physical fitness and pre-existing diseases.

Therefore a medical health check is essential before general anaesthetic. This is usually done by the clinic or the hospital. The guidelines vary amongst hospitals but for patients in middle or older age, and those with ongoing medical conditions or medications, blood tests, a heart trace and possibly a chest x-ray will be required. Existing medical conditions will require some further exploration or stabilisation before it is safe to have a GA and occasionally the health check will identify a previously undiagnosed health problem. Unfortunately, correction of any additional health problems which arise from the healthcheck will not be covered by the cost of surgery and are likely to result in postponement of your operation.

The commonest causes for patients failing a healthcheck are raised blood pressure, an abnormal heart rhythm, poorly controlled diabetes, patients on anticoagulant medication and excessive weight. If you have a bad cold on the day of your surgery, your operation will be postponed even if you have previously passed the pre-operative health check.

Local anaesthetic AND General anaesthetic together.

It is very usual for local anaesthetic to be administered during a general anaesthetic operation. This is done to minimise the amount of pain experienced on waking from anaesthesia.

How can I get the most from my consultation?

It is often difficult to be precise about recalling or summarising medical details but try to provide an accurate and concise account of your medical history when you come to your consultation.

It helps to consider your problem in the following order:

1. Current symptoms, difficulties or concerns you experience day-to-day.
2. How and when your symptoms / problem / condition started.
3. The approximate date and details of any treatments and tests you might previously have had for the same problem
4. Any other ongoing or previous medical conditions / operations / medication. Approximate dates helpful here also e.g. " i had a hip replacement in 1990"

Do bring copies of documents, test results and prescriptions which relate to ongoing or serious past medical conditions or surgery. If you have had X-rays or scans relating to your condition, you should bring CD-rom copy of the scan to clinic appointment and also a copy of the radiologist's report.

Get advice from your GP or treatment in advance for any undiagnosed symptoms or problems you may be suffering from, especially breathlessness, chest pain, heart flutters or high blood pressure.

How quickly can I get my surgery done?

Frequently people want to have surgery done in time for a special event, perhaps a wedding or a holiday.  For all but the most minor operations, surgeons strongly advise a couple of weeks between the first consultation and any operation as a 'cooling' off period because the results of surgery may be difficult to reverse.  There is usually flexibility with surgical bookings but at times of high demand there may be a wait.  If you have other medical problems or require further investigations before surgery this can add some weeks to your progress.  It is typically 3-6 months before the final results of surgery are fully achieved although most obvious signs of surgery are subsided within 1 month. There is potential to run into problems after surgery and these may be difficult or expensive to deal with if you are overseas so it is an additional risk if you want to be travelling overseas within a few weeks of surgery.  If you have a special date in mind, it is best to plan for your first consultation to be at least 4 and preferably 6 months in advance of your deadline.

How are surgical fees charged?

Self Pay

Clinic fees for consultations are payable in advance or on the day of appointment. These include the consultation only; additional treatments, laboratory tests, x-rays and scans will be additional costs.

Fees for surgery have 3 components: The surgeon's fee, the facility fee (associated with consumables, theatre resources, hospital stay, staff etc at the clinic or hospital) and the anaesthetist's fee (if applicable). Sometimes these will be billed as a single invoice and sometimes a different invoice will be raised for each component. Additional expenses may also be applied for laboratory tests and implants. Post-surgical garments and post-operative medication are usually but not always included in the fees.

Additional adjustments after the principle surgery are occasionally required and these are not typically included in the cost.

Fees for surgery are paid in advance and a deposit may be required to secure an operation date.

Each treatment is bespoke and there are many variations in facility fees and prices of consumables so it is impossible to provide a meaningful list of items and costs on the website. If you are not sure, you should ask what is included in costs when you receive a quote.

Multiple procedures: It is quite usual for patients to combine different procedures into a single operation. Surgical fees are calculated to take into account the time and resources required for these to be completed. The overall fees for combined procedures are significantly less than simply adding up costs for each individual procedure.
Follow up appointments and dressings are usually included in the surgeon's and facility fee for a reasonable period after any operation. Follow up appointments for further discussion and planning in advance of surgery are not usually chargeable. For ongoing conditions not iminently requiring surgery a clinic fee is payable for each visit.

Health Insurance

Again, fees for surgery have the same 3 components: Surgeon, Facility and Anaesthetist (if used). Some clinics and hospitals are able to bill insurance companies directly. Other clinics and locations ask the patient to pay and claim back from their insurance. There may be an 'excess' applied to your policy or short-fall in the surgical fees charged and the maximum amount that is payable by the insurer. You should obtain, in advance, a reference number from your insurance company prior to seeking an outpatient consultation. You should ask the insurance company and the clinic to clarify what the financial arrangements will be.

Insurers do NOT usually support surgical treatment on the day of your first consultation because they need to see the surgeon's clinic letter in order to approve (another reference number) the costs of ongoing treatment.

Am I fit enough for surgery? (by Dr Tim Vorster, Consultant Anaesthetist)

Surgery comes in many shapes and forms. Some may be urgent, necessary to maintain day-to-day function, or indeed be life saving. On the whole cosmetic surgery and hand surgery is non-urgent in nature. While the surgery can be life changing and often leads to profound psychological benefits, we need to weight up your fitness for this sort of surgery. 
From the start of your journey through any surgical procedure we take your health and overall safety seriously and will discuss frankly with you about any risks that your health status and /or the proposed operation may entail.
Most people are fit for surgery under General Anaesthetic. If you are fit and well, taking no regular drugs or medicines from your GP, then there is unlikely to be any problems – I will still council you about any risks, and will also be there to reassure you about any worries you might have.
If you do have any well-controlled medical issues, such as asthma, thyroid conditions, high blood pressure etc, the risks of most procedures are also very small. We may do extra tests to check you are fit enough and occasionally alter our techniques accordingly, but most people with stable medical conditions are completely fine to proceed with surgery.
Occasionally we will see patients with poorly controlled medical problems. Planned surgery is best delayed and your medical condition 'optimized' (brought under control) by your GP or other medical specialists – all patients should ideally be at their best before elective surgery, even if this is not necessarily back to 'normal'.
Even if you are medically quite unfit, or just would prefer not to have a general anaesthetic, many operations (though not all) can still be carried out safely using other techniques. For many small operations local anaesthetic injections can be appropriate. Regional anaesthetics, where we numb an arm or leg, but keep you awake, are good for surgery at these sites. These can sometimes be done with the addition of some gentle sedation – this can be discussed and planned with your Surgeon and Anaesthetist.
Very occasionally I will tell people frankly that they are not fit enough to have Plastic Surgery – this does not mean you are not fit for lifesaving surgery, but rather that it would not be appropriate to put you through an unnecessary risk for more trivial gain.
Smoking – all surgery is more successful in non-smokers. Smoking decreases the blood flow to all wounds, including post-surgical wounds. This delays healing and increases the risk of infection and leads to more unsightly scars. There are also some increased risks of general anaesthetics including a higher risk of postoperative chest infections and pneumonia. While we all know it is hard to give up smoking, to gain the best result from your surgery, this is the best thing you can do. To gain maximum benefit you should give up completely for at least six weeks pre-operatively until you wounds are healed. Giving up on the day of surgery is of little value and may actually make things worse – your airways are more irritable, as is the rest of you!
In all patients we would like to know if your health status changes. If you are unlucky enough to develop a common cold just prior to your admission we would like to know – on the whole this usually is OK – the standard test is 'were you bed-bound or unwell enough to take time off work'. A minor irritating snuffle does not alter your fitness for surgery – this is especially true in kids who often spend the winter 'well' but snotty!
As above, my aim is to provide safe treatment to all our patients, and we I make a thorough assessment of your general health prior to any surgery.
We will start assessing your fitness for surgery when you first meet your Consultant Surgeon. Prior to your surgery you will also be asked to fill out a more detailed medical questionnaire. If there are any concerns raised by this, you will be contacted by one of our pre-assessment nurses who may need to clarify any worries highlighted.  An appointment will often be made to see the nurse in person – this may be to go through things in more detail, but is often just to give you a check-up and do any blood tests that are needed prior to surgery..
If you have any concerns about the anaesthetic or your fitness to go through a procedure, you can ask for an appointment with a Consultant Anaesthetist – I will always gladly see patients if it is required. I will also make appointments if the Surgeon or Pre-assessment nurses have any concerns.