Cosmetic surgery

Cosmetic Surgery (Aesthetic Surgery) is surgery intended to improve appearance, rather than to cure disease. As one expert explains: "Aesthetic surgeons, in the normal practice of their specialty, routinely alter the otherwise acceptable physical form of the patient toward the arbitrary and stylized visages thought desirable either by the patient or by the community in general." In other words, cosmetic surgery is surgery in the pursuit of human beauty, according to standards agreed upon by patient and surgeon. Plastic surgery encompasses both cosmetic and reconstructive surgery. Currently, Cosmetic Surgery is an umbrella term for the professional knowledge that lies behind a gamut of medical techniques, like skin resurfacing ("peels") and laser ablation of facial capillaries, that are outside the traditional boundaries of operative surgery, along with the traditional operative procedures of plastic and reconstructive surgery, like face lift and nose surgery, that can be used to enhance appearance.

All surgery is accompanied by some risk of harm, even of death, but there is general agreement (among patients, health care professionals, and society) that an operation is indicated when the benefit of the procedure outweighs the potential harm. Cosmetic surgery presents a special situation in elective surgery. How can a surgical treatment ever be justified when no illness is present? Although cosmetic procedures do not remedy disease, they can improve the quality of life, and that benefit justifies their performance. In cosmetic surgery, however, the ceiling for acceptable risk of harm to the patient is low compared to operations designed to eradicate disease. Higher risk procedures to improve appearance are usually only contemplated when a person's appearance is so abnormal that it severely impairs his or her ability to interact normally with other people, or when the deformity is the result of a trauma or disease. In these cases, corrective surgery is considered to be reconstructive rather than cosmetic.

Choosing cosmetic surgery

One important way that surgeons seek to ensure that the harm of cosmetic surgery does not outweigh its benefits is by patient selection. That topic is covered in every surgical textbook and every training program, because the ultimate success or failure of cosmetic surgery is as dependant on proper patient selection for a given operation as are the technical considerations of the operation. The common teachings of surgical training programs are summarized below:

If the expectations of a patient seem reasonable and if it seems probable that surgery will produce a satisfactory result at a reasonable risk; cosmetic surgery is said to be "indicated". If not, the patient may be well suited for a different procedure, or may not be a candidate for any elective cosmetic surgery at all. When an individual has physical attributes that make a good technical result unlikely, or psychological attributes that make the result unlikely to satisfy the patient's wants, then surgery is not offered.

Well-trained ethical cosmetic surgeons are expected to carefully consider why their patients want surgery, and to try to dissuade a patient with unreasonable expectations from having surgery, no matter what financial reward is offered. This is not entirely altruistic, as it has been said that “a plastic surgeon makes his money from operating and his reputation from refusing to operate.”. Additionally, undertaking the surgical transformation of a patient who perceives this change as one of identity, or has demands that cannot be met by surgery because of such underlying disorders as Body Dysmorphism Syndrome, can result in harm to the surgeon. Apart from legal suits lodged as a punitive action, there have been cases of assault and even homicide of plastic surgeons by troubled patients after cosmetic surgery.

Benefits of Cosmetic Surgery

In some cases, cosmetic surgery is performed to help increase self-esteem. For example, removing gang-related tattoos, reducing scars, straightening nasal deviations and correcting physical mementoes of assaults can help facilitate rehabilitation. Some individuals have experienced a tremendous benefit by being freed of these stigmata. Such surgery has even been viewed as having social worth, and been financed by charitable organizations and surgical training programs in some cases.

In other cases, surgical modification of an unusual feature present since childhood, like a prominent nose, a receding chin, or a fat pad under the chin, can be a expedient alternative to a continuing struggle to accept the presence of these features. Self-consciousness over lack of the desired amount of breast development, or overdevelopment, in girls may also cause them to seek cosmetic surgery in adolescence or adulthood. There is evidence that most patients who undergo these procedures are satisfied with the results.

With ageing, soft tissues tend to "droop", and a sense of rejuvenation can often be experienced when the appearance of this droop is reduced. When livelihood depends on personal appearance or photogenicity, the financial cost may be regarded by the patient as a business expense, - and the time and discomfort as a career investment. If the desired change in appearance is one that is likely to be technically achieved, then that patient is usually considered a good candidate for cosmetic surgery.

Risks of Cosmetic Surgery

see also Surgery, for risks of surgery

All surgery is accompanied by some risk of harm, even of death, but there is general agreement (among patients, health care professionals, and society) that an operation is indicated when the benefit of the procedure outweighs the potential harm. In cosmetic surgery, the ceiling for acceptable risk of harm to the patient is low compared to tumor surgery or other operations designed to eradicate disease. Higher risk procedures to improve appearance are usually only contemplated when a person's appearance is so abnormal that it severely impairs his or her ability to interact normally with other people, or when the deformity is the result of a trauma or disease. In these cases, corrective surgery is considered to be reconstructive rather than cosmetic.

If a patient is in poor health, cosmetic procedures as a whole may be contraindicated, but in most cases of ill health, only some procedures are contraindicated. Prolonged operations requiring general anesthesia or injections of local anesthesia with vasoconstrictors (such as epinephrine), are of low risk to healthy individuals, but of unacceptably high risk to people with severe cardiac disease, for example. Although a patient with such medical problems may not be a candidate for a full rhytidectomy (facelift), alternative procedures, such as dermatological treatments, can offer cosmetic improvement at lower risk.

In some cases, preoperative planning for special care before, during, or after the procedure can reduce the risk of the surgery. For example, the use of medications and plasma may counteract an inherited tendency towards excessive bleeding, and allow surgery to be uncomplicated. Still, in such situations, the patient must accept the increased possibility of a problematic outcome, and not every patient will proceed knowing there is higher risk. .

Cigarette smoking impairs the circulation in tissue flaps and interferes with optimal wound healing. Many cosmetic surgeons insist that patients who desire procedures like face lift surgery (rhytidectomy) that involve tissue flaps stop smoking well before surgery is scheduled. Similarly, the use of aspirin or other drugs that can increase bleeding time is usually discouraged before surgery involving extensive soft tissue dissection. Patients who will or can not comply with preoperative cessation of smoking or the use of medications that promote bleeding, may not be optimal candidates for soft tissue surgery, but undergo less invasive procedures at very low risk.

The chance of a poor outcome is higher in some patients because of specific aspects of skin quality or other physical characteristics. In patients with a history of keloid formation or hypertrophic scarring, skin incisions are less likely to heal unobtrusively. Although there are methods to decrease the chance of excessive scarring, the risk of a poor result may make such procedures as body contouring (that require long skin incisions), inappropriate. Individuals with very fair, thin skin, on the other hand, have an increased risk of underlying implants or fracture lines (such as are made on either side of the nose in rhinoplasty) being evident after cosmetic surgery, and modifications of surgical technique or choice of implants may be required. These individual factors are ideally taken into consideration by the cosmetic surgeon when planning which procedures will best achieve the long term result desired by the patient.

"Addiction" to cosmetic surgery

(Muhlbauer W et al. (2001) The thersites complex in plastic surgical patients. Plastic & Reconstructive Surgery 107:319-26 PMID 11214044)

Paying for cosmetic surgery

Although the personal benefits of cosmetic procedures justify them to the patients that choose to undergo them, and allow them to be accepted as legal and legitimate in most societies; the fact that illness is not present changes how the surgery is financed, as well as the general social support offered to the patient. Whereas private insurance and government health care plans are likely to partially or completely cover the cost of procedures required to treat disease, especially when they are life-threatening, the cost of cosmetic surgery is seldom subsidized by either.

Although there are subcultures in which social networks provide abundant support to patients recovering from cosmetic surgery, generally, employer "sick time" and other institutional allowances are not automatically extended to patients when the surgery is cosmetic.

Surgeon selection by patients

Patients considering cosmetic surgery are usually advised to choose a surgeon carefully, taking the time to investigate the training and qualifications of any physician consulted. This is important, but difficult for a lay person to do successfully. That's because the credentialing of cosmetic surgeons is so variable, even within a single geographic region, and few practitioners are equally qualified in every aspect of each cosmetic procedure. The patient seeking consultation for a desired change in appearance does not necessarily know in advance which cosmetic procedure is preferred or optimal to effect that change.

Credentialing of the cosmetic surgeon

Cosmetic surgeons come from a variety of backgrounds in surgical, and even dermatological, training. In most countries, a licensed physician can claim expertise in "cosmetics" without training or Board Certification in any of the specialties that are recognized by the medical profession as being part of plastic and cosmetic surgery. A physician may legally advertise cosmetic services even when his or her training and experience is not sufficient to be recognized as adequately qualified in cosmetic surgery by experts in the field. The fact that those experts have more than one possible Board Certified Specialty and course of training, complicates the patient's ability to recognize which physicians are adequately trained in cosmetic surgery. An understanding of which specialties are qualified to perform cosmetic procedures, and which procedures are performed by each is important in evaluating a potential provider of cosmetic surgery.

General Plastic Surgeons

(US) [1](North America) [2] (International) [3]

Facial Plastic Surgeons

"Most facial plastic surgeons do their residency training in Otolaryngology-Head-and-Neck Surgery". (US based, International Membership) [4]

Ophthalmologic Plastic Surgeons (Oculoplastic Surgery)

Oculoplastic Surgery includes cosmetic surgery of the forehead, eyebrows, eyelids and mid-face. Surgeons are usually board-certified ophthalmologists with fellowship training in ophthalmologic plastic surgery. (Training in UK)[ http://www.oculo-plastics.org.uk/]

Dermatologists

"Dermasurgeons (dermatologists) play an ever-expanding role in the management of cosmetic patient concerns. As a specialty, they have advanced and pioneered safe liposuction, noninvasive endovascular venous technologies, ablative and nonablative laser approaches, and minimally invasive suture-based lifting procedures".(Advanced Cosmetic Surgery Sadick NS - Dermatol Clin - 2005 Jul; 23(3); xi)

(US)[5]

Oral and maxillofacial surgeons

One group of professionals who are generally recognized as having expertise in cosmetic surgery are not physicians at all, but dentists. Graduates of Dental School who go on to post-graduate residency training in Oral Surgery with adequate experience in facial cosmetic surgery may practice cosmetic facial surgery. "Because of their surgical and dental background, oral and maxillofacial surgeons are uniquely qualified to perform cosmetic procedures that involve the functional and aesthetic aspects of the face, mouth, teeth and jaws." [6]

Interdisciplinary organizations

Some professional organizations dedicated to Cosmetic Surgery now include members of various disciplines [7]

Cosmetic procedures by other specialists (General Surgeons, Vascular Surgeons, and others)

Certain types of procedures are usually performed by specialists whose training and practice is not typically in cosmetic or reconstructive surgery. Vascular surgeons have special expertise in the removal of varicose veins and general surgeons, gynecologists, and urologists have expertise in performing cosmetic procedures of the genitals, anus, and perineum.

Meeting with the surgeon

The ethical surgeon uses techniques of Shared Decision-making, which include undertaking a frank discussion of the risks and benefits of cosmetic surgery with the patient, and then helping the patient to make a decision that is in the patient's best interests. However, every specialist is somewhat limited by his or her particular training and experience, and will not be equally familiar with all of the operations and procedures available. Patient advocates usually recommend that anyone who is considering elective surgery should try to find out about the background and reputation of a specialist, and if possible obtain a second opinion before going ahead with an operation.

Human beauty : universal attributes

Michaelangelo's statue of David embodies an idealized form of masculine beauty.

Symmetry, sexual dimorphism, skin

Cultural & ethnic considerations

Whereas certain attributes, like symmetry, seem to be valued by all peoples, there are many preferences that are not uniform - but held by certain people and not by others. The medical literature in cosmetic surgery analyses these preferences, because a good result depends on what the patient, and his peers, see as attractive, and that is not necessarily the same as what the surgeon sees as attractive.

For example, what does the ideal female eyebrow look like? There were a series of ideal positions and shapes of the female eyebrow in European culture over the first three-quarters of the 20th century. A study by German plastic surgeons in 1976 indicated that the age of the patient was a primary determinant of which eyebrow shape and position was seen as more beautiful; older patients preferred the high, arched brow, popular in the earlier part of the era, and younger patients preferred a lower eyebrow without a definite arch. The surgeons concluded that, for beautiful eyebrows, "there is not one single choice, but at least three".

Facial cosmetic surgery

Forehead and brow

"The eyebrow is an integral aesthetic part of the upper facial anatomy. Its location and contour convey a degree of emotion and feeling in both men and women." (reference for quote:Goldstein SM. Katowitz JA. The male eyebrow: a topographic anatomic analysis. [Journal Article] Ophthalmic Plastic & Reconstructive Surgery. 21(4):285-91, 2005 Jul. UI: 16052142)

Cheekbones

In the west, high prominent cheekbones are generally thought to be beautiful, and many patients undergo the placement of various types of implants in malar augmentation procedures.

In the east, malar reduction procedure are described. "Young Korean women with prominent zygoma may experience stress in daily life because the Oriental physiognomy often associates prominent zygoma with bad luck. Moreover, prominent zygoma in a wide Oriental face has the effect of making a person appear older and stubborn. Zygomatic reduction is often necessary to relieve stress from self-consciousness about facial appearance and to obtain younger and softer features." (reference for quote: Lee JG. Park YW. Intraoral approach for reduction malarplasty: a simple method. [Journal Article] Plastic & Reconstructive Surgery. 111(1):453-60, 2003 Jan. UI: 12496618)

Noses

Rhinoplasty

In the 19th and in part of the 20th century, a slim Northern European Caucasian nose of very refined proportions was the aesthetic ideal in the western world. Noses with shapes and underlying structures typical of most other ethnic groups were considered less attractive. In the earlier portion of that period, the unattractiveness of nose shapes identified as "semitic" or "negro" was openly discussed in both lay and professional publications. Later in the 20th century, wide and hooked noses were no longer overtly labeled as a detrimental mark of ethnic origin, but still, such features were routinely described as showing "deformities". Some surgeons have were willing to surgically modify these features. For example, a 1996 manual describes "correction" of the "Jewish nose", while another manual notes that two patients with noses that "have acute nasolabial angles, plunging tips, or foreshortened nasal tip pyramids" were "of Jewish ancestry" or of "Jewish descent."

The recognition of beauty can change over time, and some ethnic characteristics once seen as "ugly" have become widely appreciated as intolerance dissipates. For example, the actress Jennifer Grey experienced a set-back in her career when she had a cosmetic rhinoplasty that changed her distinctive natural nose (with a delicate downward hook) into a more generic nose with a diminutive button tip.

Until surgical techniques advanced over the last few decades, cosmetic rhinoplasties tended to "overskeletonize" the nose, and such technical complications as pinched appearing nostrils, and collapse of the bridge of the nose ("saddle nose deformity") were fairly common. Especially in fair skinned patients whose skin was also thin, aggressive narrowing of the bony nose by the creation of fracture lines resulted in unsightly long-term results. Years after rhinoplasty, as these patients passed into and past middle age, additional age-related thinning of the skin exposed the irregular contour of these fracture lines.

The initial use of silicone implants, and other materials used to raise the bridge of the nose, was complicated by a relatively high rate of infection, and erosion of the skin and soft tissues of the nasal tip. Poor results were especially frequent when oversize implants were used in an effort to raise the profiles of black and Asian noses, which naturally tend to have a bony pyramid of wider width and more diminutive height.

Changing ideals and improved techniques

Rhinoplasty currently strives to enhance the appearance of the nose according to the individual face. Straightness and refinement of the nasal tip are universal ideals, but modern cosmetic rhinoplasty aims to preserve ethnic and individual nasal characteristics rather than produce a uniform result.

Less aggressive removal of cartilage and bone tends not only to give a more natural result, but to decrease the incidence of collapse from loss of supporting structure.

Lips

In the 21st century, very full lips are considered to be so attractive that procedures to "fill out" the lips are among the most popular procedures requested of aesthetic surgeons. Not only are various fillers injected into the lips, but traditional "cold knife' plastic surgery is used to give more lasting results than the fillers can currently provide. . Interestingly, there was little demand for lip augmentation a generation ago, because the fashionable face was different then.

Whereas the actress Angelina Jolie (pictured left) is thought by many to have nearly perfect feminine lips in 2007, the actress Grace Kelly was much closer to that ideal in 1967, when the picture to the right was taken. Both women are generally considered to be great beauties, yet each of them, as pictured in these photographs, might also be considered legitimate candidates for cosmetic surgery.

Forty years ago, what are now considered beautifully full lips were then viewed as excessively thick. Rather than lip augmentations, surgeons concentrated on "lip thinning" operations to make the mouth appear smaller and more delicate. Lip reduction operations were a standard part of the facial plastic surgeons repertoire in the 1960's and 1970's, and were the cosmetic lip surgery featured in the plastic surgical textbooks of those times. Currently, as demand has changed, such procedures receive scant mention in the medical literature.

One could speculate that if Angelina Jolie could be brought back in time to be examined by a cosmetic surgeon in Grace Kelly's era, she might be offered a lip reduction to improve her appearance. On the other hand, Grace Kelly, at the peak of her beauty, might be seen as a candidate for lip augmentation by a contemporary cosmetic surgeon. An awareness of how opinions change over time about what constitutes beauty is important for both the surgeons and the patients involved in cosmetic surgery, as permanent changes in the face and body made to accommodate a preference that is temporary is liable to eventually be regretted by each.

Jaw

Whereas a square angle of the jaw is a mark of great beauty in both men and women of all races in the West, in Asia, in women, the opposite is true. A strong jaw, with a square angle, is traditionally viewed as unsightly.

"Rejuvenation" of the aging face

Removing lax skin, resurfacing of sun-damaged skin, and tightening of subcutaneous tissues and facial muscles can reduce some of the superficial signs of aging, especially when due to sun damage. This type of surgery is often combined with various types of skin resurfacing or dermal fillers. Reversal of some of the signs of ageingin the face can raise self-esteem. . Some patients also benefit from the modification of lowered brows, hooded eyes, or frown lines that give the appearance of a negative expression to the face.

Botulinum toxin

"What is so different about the injection of cosmetic botulinum toxin from other injections? Simply stated, neurotoxin injections are a surgical procedure—because the results depend entirely on the injector's knowledge of the underlying muscular anatomy and pharmacology as well as the principles of aesthetics."

Skin

Beauty is only skin deep, or so it is said. From a cosmetic point of view, human skin consists of three layers: epidermis, dermis, and subcutaneous fat.

Dermal fillers

The natural matrix of skin lies below the epidermis in the dermis. The main fiber filling the bulk of the dermis is collagen, and the main types of collagen in human skin are I, and III. With aging there is collagen loss, and a change in the abundance of the types of collagen, a relative loss of I and gain of III.

Hyaluronic acid

Hyaluronic acid is non-allergic, but in pure form, lasts only for a couple of days.

The Neck

Cosmetic operations on the neck are usually focused either on removing a fat pad, or in rejuvenation surgery. (Rohrich RJ. Rios JL. Smith PD. Gutowski KA. Neck rejuvenation revisited. [Review] [30 refs] [Case Reports. Journal Article. Review] Plastic & Reconstructive Surgery. 118(5):1251-63, 2006 Oct. UI: 17016198). The appearance of the aged neck is primarily due to excess skin as well as laxity of the thin sheet of muscle called the platysma. Various surgical methods of removing the excess skin and "tightening" the underlying muscle are employed. (Rohrich RJ. Rios JL. Smith PD. Gutowski KA. Neck rejuvenation revisited. [Review] [30 refs] [Case Reports. Journal Article. Review] Plastic & Reconstructive Surgery. 118(5):1251-63, 2006 Oct. UI: 17016198)

Body Recontouring

Jean Paul Ruben's painting of the "Judgement of Paris" shows three of the most beautiful mythologic goddesses. This is an example of the idealized female form in 17th century European culture.

There are multiple procedures to change the contour of the body for cosmetic enhancement. Generally, the contours sought have at least two ideal forms: male and female, and so the goal of a given procedure, and even the type of procedure, are frequently different for men and women.

All body recontouring procedures require a skin incision, and every skin incision leaves a scar. Plastic techniques can minimize the appearance of a scar, but except when surgery is performed in a fetus (which, to date, has never been done for purely cosmetic reasons) no surgical technique, including the use of the laser, can part the full thickness of the skin and not result in a scar.

Since a long thin cannula is placed through a small skin incision in liposuction procedures, the contour of large areas of the body can be modified by the suction removal of fat without the need for long skin incisions. Placing a small incision in natural skin creases tend to help camoflauge them. However, when the skin is left intact, but the underlying contour is reduced, the appearance may be compromised by lax, hanging skin.

In traditional body contouring surgery, relatively long skin incisions are made, and, not only is underlying fat removed, but closure of the skin and subcutaneous tissue is done in a manner that shapes the body part. Sometimes, for example after massive weight loss, the aim of this surgery is to remove excess skin and effect a "redraping". In other cases, such as breast lift, the emphasis on recontouring is mainly on the underlying tissues, rather than the skin, although skin may be trimmed as part of the procedure.

Because body recontouring by means of open surgical techniques always leaves relatively long scars, cosmetic surgeons concentrate on effecting the most improvement with the least apparent scarring. That means that body recontouring procedures are sometimes combined to allow access to more than one area through the same opening. For example, "women who seek consultation for abdominal recontouring to reverse the effects of childbearing, weight loss, or aging often wish to combine the procedure with breast augmentation or mastopexy. Performing breast augmentation through the abdominoplasty incision allows correction of both problem areas with one operation and one anesthetic while avoiding incisions on the breasts." (

Breast augmentation and mammapexy ("lift")

Schwarzman E. Goldan S. Wilflingseder P. The classic reprint. Die Technik der Mammaplastik (the technique of mammaplasty). Plastic & Reconstructive Surgery. 59(1):107-12, 1977 Jan. UI: 318746

Breast augmentation techniques and resultant shapes have been revised since the invention of the procedure in the 1960s.

"Belly tuck"

Abdominoplasty

A 2003 study of abdominoplasty patients indicated significant improvements in body image, as measured by several different outcomes. There were no changes reported in self-esteem or other psychological components.

Liposuction

"Since 1980 and after its presentation in the medical literature, traditional suction-assisted lipoplasty has today become the most commonly performed aesthetic surgical procedure". Prado A. Andrades P. Danilla S. Leniz P. Castillo P. Gaete F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. [Comparative Study. Journal Article. Randomized Controlled Trial] Plastic & Reconstructive Surgery. 118(4):1032-45, 2006 Sep 15. UI: 16980867. Liposuction has become so popular that even the FDA, a US government health agency, maintains information on the web as a public service. [8]. In the US, any licensed physician can perform liposuction.

Further reading

Consumer guides

Allen D. Rosen, Valerie J. Ablaza: Beauty in Balance: A Common Sense Approach to Plastic Surgery & Treatments-Less Is More. ISBN 0-9748997-4-7

Classic and contemporary professional texts

Thomas D Rees MD, FACS: Aesthetic Plastic Surgery. Volumes I and II. WB Saunders Company 1980 ISBN 0-7216-7522-0