Plastic, Reconstructive, and Cosmetic Surgery

Plastic, reconstructive, and cosmetic surgery refers to a variety of operations performed in order to repair or restore body parts to look normal, or to change a body part to look better. These types of surgery are highly specialized. They are characterized by careful preparation of a person's skin and tissues, by precise cutting and suturing techniques, and by care taken to minimize scarring. Recent advances in the development of miniaturized instruments, new materials for artificial limbs and body parts, and improved surgical techniques have expanded the range of plastic surgery procedures that can be performed.

Purpose

Although these three types of surgery share some common techniques and approaches, they have somewhat different emphases. Plastic surgery is usually performed to treat birth defects and to remove skin blemishes such as warts, acne scars, or birthmarks. Cosmetic surgery procedures are performed to make persons look younger or enhance their appearance in other ways. Reconstructive surgery is used to reattach body parts severed in combat or accidents, to perform skin grafts after severe burns, or to reconstruct parts of person's body that were missing at birth or removed by surgery. Reconstructive surgery is the oldest form of plastic surgery, having developed out of the need to treat wounded soldiers in wartime.

Demographics

The top 10 most commonly performed elective cosmetic surgeries in the United States include the following:

• liposuction
• breast augmentation
• eyelid surgery
• face lift
• tummy tuck
• collagen injections
• chemical peel
• laser skin resurfacing
• rhinoplasty
• forehead lift

There were approximately 29 million surgical procedures performed in the United States in 2001. Because many plastic and reconstructive surgical procedures are performed in private professional offices or as outpatient procedures, accurate statistics concerning the number of procedures performed are not available.

Description

Plastic surgery

Plastic surgery includes a number of different procedures that usually involve skin. Operations to remove excess fat from the abdomen ("tummy tucks"), dermabrasion to remove acne scars or tattoos, and reshaping the cartilage in children's ears (otoplasty) are common applications of plastic surgery.

Cosmetic surgery

Most cosmetic surgery is done on the face. It is intended either to correct disfigurement or to enhance a person's features. The most common cosmetic procedure for children is correction of a cleft lip or palate. In adults, the most common procedures are remodeling of the nose (rhinoplasty), removal of baggy skin around the eyelids (blepharoplasty), face lifts (rhytidectomy), or changing the size or shape of the breasts (mammoplasty). Although many people still think of cosmetic surgery as only for women, growing numbers of men are choosing to have facelifts and eyelid surgery, as well as hair transplants and "tummy tucks."

Reconstructive surgery

Reconstructive surgery is often performed on burn and accident victims. It may involve the rebuilding of severely fractured bones, as well as skin grafting. Reconstructive surgery includes such procedures as the reattachment of an amputated finger or toe, or implanting a prosthesis. Prostheses are artificial structures and materials that are used to replace missing limbs or teeth, or arthritic hip and knee joints.

Diagnosis/Preparation

General preparation

Preparation for nonemergency plastic or reconstructive surgery includes individual education, as well as medical considerations. Some operations, such as nose reshaping or the removal of warts, small birthmarks, and tattoos can be done as outpatient procedures under local anesthesia. Most plastic and reconstructive surgery, however, involves a stay in the hospital and general anesthesia.

Medical preparation

Preparation for plastic surgery includes the surgeon's detailed assessment of the parts of an individual's body that will be involved. Skin grafts require evaluating suitable areas of skin for the right color and texture to match the skin at the graft site. Face lifts and cosmetic surgery in the eye area require very close attention to the texture of the skin and the placement of surgical cuts (incisions).

Persons scheduled for plastic surgery under general anesthesia will be given a physical examination, blood and urine tests, and other tests to make sure that they do not have any previously undetected health problems or blood clotting disorders. The surgeon will check the list of prescription medications that the prospective patient may be taking to make sure that none of them will interfere with normal blood clotting or interact with the anesthetic.

Individuals are asked to avoid using aspirin or medications containing aspirin for a week to two weeks before surgery, because these drugs lengthen the time of blood clotting. Smokers are asked to stop smoking two weeks before surgery because smoking interferes with the healing process. For some types of plastic surgery, individuals may be asked to donate several units of their own blood before the procedure, in case a transfusion is needed during the operation. The prospective patient will be asked to sign a consent form before the operation.

Personal education

The surgeon will meet with the prospective patient before the operation is scheduled, in order to explain the procedure and to be sure that the individual is realistic about the expected results. This consideration is particularly important for people undergoing cosmetic surgery.

Medical considerations

Some people should not have plastic surgery because of certain medical risks. These groups include:

• persons recovering from a heart attack, severe infection (for example, pneumonia), or other serious illnesses
• people with infectious hepatitis or HIV infections
• individuals with cancer whose cancer might spread (metastasize)
• people who are extremely overweight (Individuals who are more than 30% overweight should not have liposuction.)
• persons with blood clotting disorders

Psychological

Plastic, cosmetic, and reconstructive surgeries have an important psychological dimension because of the high value placed on outward appearance in Western society. Many people who are born with visible deformities or disfigured by accidents later in life develop emotional problems related to social rejection. Other people work in fields such as acting, modeling, media journalism, and even politics, where their employment depends on how they look. Some people have unrealistic expectations of cosmetic surgery and think that it will solve all their life problems. It is important for anyone considering nonemergency plastic or cosmetic surgery to be realistic about its results. One type of psychiatric disorder, called body dysmorphic disorder, is characterized by an excessive preoccupation with imaginary or minor flaws in appearance. Persons with this disorder frequently seek unnecessary plastic surgery.

Aftercare

Medical

Medical aftercare following plastic surgery under general anesthesia includes bringing patients to a recovery room, monitoring their vital signs, and giving medications to relieve pain as necessary. Persons who have had fat removed from the abdomen may be kept in bed for as long as two weeks. Individuals who have had mammoplasties, breast reconstruction, and some types of facial surgery typically remain in the hospital for a week after the operation. Those who have had liposuction or eyelid surgery are usually sent home in a day or two.

People who have had outpatient procedures are usually given antibiotics to prevent infection and are sent home as soon as their vital signs are normal.

Psychological

Some individuals may need follow-up psychotherapy or counseling after plastic or reconstructive surgery. These people typically include children whose schooling and social relationships have been affected by birth defects, as well as persons of any age whose deformities or disfigurements were caused by trauma from accidents, war injuries, or violent crimes.

Risks

The risks associated with plastic, cosmetic, and reconstructive surgery include the postoperative complications that can occur with any surgical operation under anesthesia. These complications include wound infection, internal bleeding, pneumonia, and reactions to the anesthesia.

In addition to these general risks, some plastic, cosmetic, and reconstructive surgical procedures carry specific risks:

• formation of undesirable scar tissue
• development of persistent pain, redness, or swelling in the area of the surgery
• infection inside the body related to inserting a prosthesis (These infections can result from contamination at the time of surgery or from bacteria migrating into the area around the prosthesis at a later time.)
• anemia or fat embolisms from liposuction
• rejection of skin grafts or tissue transplants
• loss of normal feeling or function in the area of the operation (For example, it is not unusual for women who have had mammoplasties to lose sensation in their nipples.)
• complications resulting from unforeseen technological problems (The best-known example of this problem was the discovery in the mid-1990s that breast implants made with silicone gel could leak into the recipient's body.)

Normal results

Normal results include an individual's recovery from the surgery with satisfactory results and without complications.

Morbidity and mortality rates

Morbidity and mortality rates vary with the complexity and severity of different procedures. Mortality is similar to that associated with all surgical procedures. Morbidity is influenced by personal expectations. From a surgical perspective, most morbidity is due to errors associated with anesthesia, procedure, pain medications, and after care. From an individual's perspective, morbidity involves the degree to which actual results compared to expected outcomes. The latter distinction is very subjective.

Alternatives

Alternatives to plastic, reconstructive, and cosmetic surgical procedures include using various products that may be affixed to articles of clothing or the surface of the body.

See alsoCleft lip repair; Face lift.

Resources

BOOKS

Kaminer, Michael S., Jeffrey S. Dover, and Kenneth A. Arndt.Atlas of Cosmetic Surgery. Philadelphia: Saunders, 2002.

Loftus, Jean M. The Smart Woman's Guide to Plastic Surgery:Essential Information from a Female Plastic Surgeon. New York: McGraw Hill, 2000.

Mason, Aaron C. Handbook of Plastic Surgery. St. Louis:Mosby, 2001.

Narins, Rhoda S. Cosmetic Surgery: An Interdisciplinary Approach. New York: Marcel Dekker, 2001.

PERIODICALS

Butler, P. E., and M. Khan. "Assessing Technical Skills of Plastic Surgeons."Plastic and Reconstructive Surgery 111 (2003): 491–492.

Cockerill, J. W. "Improving Digital Imaging."Plastic and Reconstructive Surgery 111 (2003): 503–504.

Goldwyn, R. M. "Get a Life or Two or More!"Plastic and Reconstructive Surgery 111 (2003): 934–936.

Melmed, E. P. "Who Decides the Criteria?"Plastic and Reconstructive Surgery 111 (2003): 513–514.

ORGANIZATIONS

American Academy of Facial Plastic and ReconstructiveSurgery. 310 S. Henry Street, Alexandria, VA 22314. (703) 299-9291. .

American Board of Plastic Surgery. Seven Penn Center, Suite400, 1635 Market Street, Philadelphia, PA 19103-2204. (215) 587-9322. .

American College of Plastic and Reconstructive Surgery. .

American College of Surgeons. 633 North Saint Claire Street,Chicago, IL, 60611. (312) 202-5000. .

American Society for Aesthetic Plastic Surgery. 11081 WinnersCircle, Los Alamitos, California 90720. (800) 364-2147. (562) 799-2356. .

American Society of Plastic Surgeons. 444 E. Algonquin Rd.,Arlington Heights, IL 60005. (888) 475-2784. .

OTHER

Johns Hopkins University. [cited March 2, 2003]. .

National Library of Medicine. [cited March 2, 2003]. .

University of Iowa. [cited March 2, 2003]. .

L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Plastic, reconstructive, and cosmetic surgical procedures are performed by surgeons with specialized training in plastic and reconstructive surgery. Depending on the complexity of the procedures, they may be performed in hospitals as an inpatient, in outpatient facilities, or in private professional offices.

QUESTIONS TO ASK THE DOCTOR

• Will insurance cover the surgery?
• How long will the recovery be?
• What will be the resulting appearance?
• Is the surgeon board certified in plastic and reconstructive surgery?
• How many similar procedures has the surgeon performed?
• What is the surgeon's complication rate?