Plastic surgery

• ANATOMY OR SYSTEM AFFECTED: All

DEFINITION: Plastic surgery uses such procedures as grafting and the implantation of prostheses to treat congenital defects and tissue or limb damage resulting from trauma; reconstructive surgery uses the techniques of plastic surgery to repair injured tissues or reattach severed body parts; and cosmetic surgery employs these same methods to alter body shape or appearance for aesthetic purposes.

Indications and Procedures

The intent of plastic, reconstructive, and cosmetic surgery is to restore a body part to normal appearance or to enhance or cosmetically alter a body part. The techniques and procedures of all three surgical applications are similar: extremely careful skin preparation, the use of delicate instrumentation and handling techniques, and precise suturing with extremely fine materials to minimize scarring.

Plastic surgery. Plastic surgery consists of a variety of techniques and applications, often dealing with skin. Some common procedures that primarily involve skin are undertaken to remove unwanted wrinkles or folds. Folds in skin are caused by a loss of skin turgor and excessive stretching of the skin beyond which it cannot recover. Common contributors to loss of skin turgor in the abdomen include pregnancy and significant weight loss after years of obesity.

Both women and men may undergo a procedure known as abdominoplasty (commonly called a “tummy tuck”). The skin that lies over the abdominal muscles is carefully separated from underlying tissue. Portions of the skin are removed; frequently, some underlying adipose (fat) tissue is also removed or relocated. The remaining skin is sutured to the underlying muscle as well as to adjacent, undisturbed skin. A major problem with this procedure is scar formation because large portions of skin must be removed or relocated. The plastic surgeon must plan the placement of incisions carefully to avoid undesirable scars.

Plastic surgery is also used to reduce the prominence of ears, a procedure called otoplasty. In some children, the posterior (back) portion of the external ear develops more than the rest of the ear, pushing the ears outward and making them prominent. By reducing the bulk of cartilage in the posterior ear and suturing the remaining external portion to the base of the ear, the plastic surgeon can create a more normal ear contour. The optimal time to perform this procedure on children is just prior to the time that they enter school, or at about five years of age.

Reconstructive surgery. Notable examples of reconstructive surgery involve the reattachment of limbs or extremities that have been traumatically severed. As soon as a part is separated from the body, it loses its blood supply; this leads to ischemia (lack of oxygen) of tissues, which in turn leads to cell death. When an individual cell dies, it cannot be resuscitated and will soon start to decompose. This process can be greatly slowed by lowering the temperature of the severed body part. Packing the part in ice for transport to a hospital is a prudent initial step.

An important consideration in any reconstructive procedure is site preparation. The edges, or margins, of the final wound must be clean and free of contamination. Torn skin is removed through a process called debridement. A sharp scalpel is used gently to cut away tissue that has been crushed or torn. All bacterial contamination must be removed from the site prior to closure to prevent postoperative contamination. Foreign material, such as dirt, glass, gunpowder, metals, or chemicals, must be completely removed. The margins of the wound must also be sharply defined. Superficially, this is done for aesthetic reasons. Internally, sharply defined margins will reduce the chances for adhesions to form. Adhesions are bands of scar tissue that bind adjacent structures together and restrict normal movement and function. Therefore, both the body site and the margins of the severed part must be debrided and defined. Reconstruction consists of the painstaking reattachment of nerves, tendons, muscles, and skin; these are held in place primarily by sutures, although staples, wires, and other materials are occasionally used. Precise alignment of the skin to be closed is accomplished by joining opposing margins. Postoperative procedures include careful handling of the wound site, adequate nutrition, and rest to maximize healing. Abnormalities in the healing process can lead to undesirable scarring from the sites of sutures. Such marks can be avoided with careful attention to correct techniques.

Bones are reconstructed in cases of severe fractures. The pieces are set in their proper positions, and the area is immobilized. Where immobilization is not possible, a surface is provided on which new bone can grow. These temporary surfaces are made of polymeric materials that will dissolve over time.

Congenital anomalies, such as a deformed external ear or missing digit, can be corrected using reconstructive techniques. In the case of a missing thumb, a finger can be removed, rotated, and attached on the site where the thumb should have been. This allows an affected individual to write, hold objects, such as eating utensils, and generally lead a more typical life. Similar procedures can be applied to replace a missing or amputated great or big toe. The presence of the great toe contributes significantly to balance and coordination when walking.

Prosthetic materials are implanted in a growing variety of applications. There are two basic types of materials used in prostheses, classified according to their surface characteristics. One type is totally smooth and inert; examples include Teflon and silicone. The body usually encloses these materials in a membrane, which has the effect of creating a wall or barrier to the surface of the prosthesis. From the body’s perspective, the prosthesis has thus been removed. With any prosthesis, the problem most likely to be encountered is infection, usually caused by contamination of the operative site or the prosthesis. Infection can also occur at a later, postoperative date because of the migration of bacteria into the cavity formed by the membrane. This is a potentially serious complication. A smooth prosthesis can also be used to create channels into which tissue can later be inserted. In such an application, the prosthesis may be surgically removed at some time in the future. The second type of prosthesis does not have a smooth surface; rather, it has microscopic fibers similar to those found on a towel. This type of surface prevents membranes from forming, contributing to a longer life for the prosthesis by reducing postoperative infections.

An important procedure in reconstructive surgery is skin grafting. A graft consists of skin that is completely removed from a donor site and transferred to another site on the body. The graft is usually taken from the patient’s own body because skin taken from another individual will be rejected by the recipient’s immune system. (Nevertheless, fetal pig skin is sometimes used successfully.) Skin grafting is useful for covering open wounds, and it is widely used in serious burn cases. When only a portion of the uppermost layer of the skin is removed, the process is called a split-thickness graft. When all the upper layers of the skin are removed, the result is a full-thickness graft. Whenever possible, the donor site is selected to match the color and texture characteristics of the recipient site.

A skin flap is sometimes created. This differs from a graft in that the skin of a flap is not completely severed from its original site but simply moved to an adjacent location. Some blood vessels remain to support the flap. This procedure is nearly always successful, but it is limited to immediately adjacent skin.

A wide variety of flaps have been developed. A flap may be stretched and sutured to cover both a wound and the donor site. Flaps may be created from skin that is distant to the site where it is needed and then sutured in place over the donor site. Only after the flap has become established at the new site is it cut free from the donor site. Thus, skin from the abdomen or upper chest may be used to cover the back of a burned hand, or skin from one finger may be used to cover a finger on the other hand. This two-stage flap process requires more time than a skin graft, but it also has a greater probability of success.

One example of a reconstructive surgery is closure of a cleft lip or palate. The correction of a cleft lip is usually done early, ideally in the first three months of life. Closure of a cleft palate (the bone that forms the roof of the mouth) is delayed slightly, until the patient is twelve to eighteen months old. These procedures allow affected individuals to acquire normal patterns of speech and language.

Cosmetic surgery. Unlike reconstructive surgery and some other plastic surgery, cosmetic surgery is for aesthetic purposes only. One of the most common sites for such procedures is the face. Procedures may range from major surgery to minimally invasive techniques, such as laser treatments or injections. Among the latter, a well-known and highly popular procedure is botulinum toxin type A (Botox) injections for the purpose of facial rejuvenation. According to data from the American Society of Plastic Surgeons, the annual number of such injections increased steadily throughout the early twenty-first century, from just 786,911 in 2000 to more than 5.37 million in 2010 and more than 9.48 million in 2023. Between 2000 and 2020, the number of Botox injections received increased 459 percent. The US market was valued at $4.4 billion in 2022.

Other common facial procedures include blepharoplasty and rhinoplasty. The former refers to the removal of excess skin around the eyelids, while the latter refers to a change, usually a reduction, in the shape of the nose. Both procedures may be included in the more general term "face-lift." The effects of aging, excessive solar radiation, and gravity combine to produce fine lines in the face as individuals get older. These fine lines gradually develop into the wrinkles characteristic of older persons. For some, these wrinkles are objectionable. To reduce them—or, more correctly, to stretch them out—a plastic surgeon removes a section of skin containing the wrinkles or lines and stretches the edges of the remaining epidermis until they are touching. These incisions are placed to coincide with the curved lines that exist in normal skin. Thus, when the edges are sutured together, the resultant scar is minimized. Rhinoplasty often involves the removal of a portion of the bone or cartilage that forms the nose. The bulk of the remaining tissue is also reduced to maintain the desired proportions of the patient’s nose. As with any plastic surgical procedure, small sutures are carefully placed to minimize scarring.

Another body area that is commonly subjected to cosmetic procedures is the breast. A woman who is unhappy with the appearance of her breasts may seek to either reduce or augment existing tissue. Breast reduction (which may be considered reconstructive rather than cosmetic if done for health reasons) is accomplished by careful incision and the judicious removal of both skin and underlying breast tissue. Often the nipples must be repositioned to maintain their proper locations. A flap that includes the nipple is created from each breast. After the desired amount of underlying tissue is removed, the nipples are repositioned, and the skin is recontoured around the remaining breast masses.

One of the most popular cosmetic procedures is breast enlargement. Annually, about 400,000 individuals receive breast augmentation surgeries in the United States—approximately 300,000 for cosmetic reasons and 100,000 for reconstruction. In 2023, over 304,000 people had cosmetic breast augmentation procedures. The total number of women with breast implants in the United States is in the millions.

Other popular cosmetic surgical procedures include liposuction and cosmetic abdominoplasty ("tummy tuck"). Popular minimally invasive cosmetic procedures include soft tissue fillers, chemical peels, laser hair removal, and microdermabrasion.

Uses and Complications

Plastic, reconstructive, and cosmetic surgeries all have their complications, ranging from severe, such as the rejection of transplanted tissue, to minor but unpleasant, such as noticeable scars. In addition, there is an inherent risk in any procedure that requires the patient to undergo general anesthesia. With reconstruction, which involves the repair of damaged tissues and structures, the initial injuries sustained by the patient present further obstacles and dangers. The following examples from each type of surgery illustrate the risks involved.

A surgeon who must perform a skin graft can choose between a split- or a full-thickness graft. A split-thickness graft site will heal with relatively normal skin, thus providing opportunities for additional grafting at a later date. It also produces less pronounced scarring. However, there is an increased likelihood that the graft will fail. Full-thickness grafts are stronger and more likely to be successful, but they lead to more extensive scarring, which is aesthetically undesirable and renders the site unsuitable for later grafts. The surgeon’s decision is based on the needs of the patient and the severity of the injury.

The minimization of scarring is a major concern for many patients undergoing plastic surgery. Preventing noticeable scars requires an understanding of the natural lines of the skin. All areas of the body have lines of significant skin tension and lines of relatively little skin tension. It is along the lines of minimal tension that wrinkles and folds develop over time. These lines are curved and follow body contours. As a rule of thumb, they are generally perpendicular to the fibers of underlying muscle. The plastic surgeon seeks to place incisions along the lines of minimal tension. When scars form after healing, they will blend into the line of minimal tension and become less noticeable, and the scar tissue is less likely to become apparent when the underlying muscles or body part is moved. Undesirable scarring is a greater problem in large procedures, such as abdominoplasty, than in procedures confined to a small area, such as rhytidectomy (face-lift), because of the difficulty in following lines of minimum tension when making incisions.

Some of the most popular cosmetic procedures have earned considerable media attention for their risks, especially considering the elective nature of the procedures. Controversy over breast implants is one prominent example. Initially, the most commonly used breast implant was made of silicone. In some cases, silicone leaked out, causing the formation of granulomatous tissue. Such complications led to a voluntary suspension of the production of silicone prostheses by manufacturers and of their usage by surgeons. Different materials, such as polyethylene bags filled with saline solution or solid polyurethane implants, were soon substituted. Silicone implants made a comeback in 2006 when the US Food and Drug Administration began approving them for use in women aged twenty-two years or older. However, concerns over health complications caused by breast implants, including links to certain types of cancer, continued to make headlines, and certain products have been removed from the market.

Perspective and Prospects

The origins of plastic, reconstructive, and cosmetic surgeries are fundamental to the earliest surgical procedures, which were developed to correct superficial deformities. Without any viable methods of anesthesia, surgical interventions and corrections were limited to the skin. Present-day nose reconstructions (rhinoplasty) are essentially similar to procedures developed four thousand years ago. Hindu surgeons developed the technique of moving a piece of skin from the adjacent cheek onto the nose to cover a wound; similar procedures were developed by Italian surgeons, using skin that was transferred from the arm or forehead to repair lips and ears as well as noses. Wars have provided opportunities to advance reconstructive techniques. As field hospitals and surgical facilities became more widely available and wounded soldiers could be stabilized during transport, techniques to repair serious wounds evolved.

Skin grafts have been used since Roman times. Celsus described the possibility of skin grafts in conjunction with eye surgery. References were made to skin grafts in the Middle Ages. The evolution of modern techniques can be traced to the early nineteenth century, when Cesare Baronio conducted systematic grafting experiments with animals. The modern guidelines for grafting were formulated in 1870. Instruments for creating split-thickness grafts were developed in the 1930s, and applications of this procedure evolved during World War II.

Plastic, reconstructive, and cosmetic procedures have all become important in contemporary surgical practice. Reconstructive surgery allows the repair of serious injuries and contributes greatly to the rehabilitation of affected individuals. Cosmetic surgery can help individuals feel better about themselves and their bodies. Both use techniques developed in the broader field of plastic surgery.

There are positive and negative aspects of plastic surgery. Positively, many individuals who sustain serious and potentially devastating injuries are able to return to relatively normal lives. Burn victims and accident victims are more likely to return to normal activities and resume their occupations than at any time in the past. Miniaturization and new materials have extended the range of a plastic surgeon’s skills. Negatively, there is growing criticism concerning the number of elective procedures undertaken for the repair of cosmetic defects. The American Society of Plastic Surgeons reported a total of 17.7 million cosmetic procedures performed in 2018 alone—a 163 percent increase from 2000. Spending on cosmetic procedures reached more than $16.5 billion in 2018. Following the COVID-19 pandemic, 76 percent of practicing plastic surgeons reported an increase in demand for their services. This trend continued into the 2020s, with the global market totaling $57.67 billion in 2023.

The quest for perfection and physical beauty has prompted some critics to question the correctness of some unnecessary procedures. Although such procedures are not usually covered by insurance policies, their utilization has increased. The continuation of such activities invokes both ethical and personal considerations; there is no clearly defined, logical endpoint. Clearly, while plastic surgical techniques have benefited millions, there are opportunities for abuse. Society must decide if any limitations are to be placed on plastic surgical procedures and what they should be.

Further debate over the abundance of elective cosmetic procedures and their possibly dangerous ties to self-expression has only increased as the kinds of modifications have managed to grow. Some of the more unique but notable trends included hand lifts, forked tongues, "Cinderella surgery" (reshaping of the foot or toes), and iris implants. Meanwhile, media reports pointed to the influence of social media on body image and, consequently, on cosmetic surgery trends, including examples of patients seeking to replicate looks created by appearance-altering camera filters on various mobile device apps. Other apps directly sought to provide a preview of how various procedures would look on the user, while games involving virtual plastic surgery—including ones aimed at children—also proliferated. Many health advocates argued such cultural obsession over physical looks could have serious negative impacts on mental health and well-being.

Additionally, as the popularity of plastic surgery grew, medical experts emphasized the importance of researching prospective surgeons carefully when considering any plastic surgery procedures. Because most insurance plans do not cover plastic surgery, many doctors have branched out beyond their specialties to attempt to take part in this consistently lucrative field, leading to several cases where patients are forced to have more surgeries to remedy mistakes or are left with serious scars or injuries.

In the meantime, advances in materials, instruments, and techniques will benefit plastic, reconstructive, and cosmetic surgery. For example, the advent of magnification and miniaturization and the development of tiny instruments and new suture materials have allowed the reconstruction of many injury sites. Blood vessels and nerves are now routinely reattached, and a mere nine individual sutures are required to join the severed portions of a blood vessel one millimeter in diameter. Additionally, in the area of facial cosmetic surgery, modern tools such as ultrasound to apply heat and a wide range of quality fillers have reduced the need for cutting. Similar, less invasive methods are advancing in other areas as well.

Bibliography

Grazer, Frederick M., and Jerome R. Klingbeil. Body Image: A Surgical Perspective. Mosby, 1980.

Janis, Jeffrey E., ed. Essentials of Plastic Surgery. 2nd ed., CRC, 2018.

Loftus, Jean M. The Smart Woman’s Guide to Plastic Surgery. Updated 2nd ed., McGraw, 2008.

Narins, Rhoda S., and Paul Jarrod Frank. Turn Back the Clock without Losing Time: A Complete Guide to Quick and Easy Cosmetic Rejuvenation. Three Rivers, 2002.

"Plastic and Cosmetic Surgery." MedlinePlus, medlineplus.gov/plasticandcosmeticsurgery.html. Accessed 30 July 2023.

Plaugic, Lizzie. "Inside the Surreal, Probably Inevitable World of Plastic Surgery Apps." The Verge, 6 Apr. 2018, www.theverge.com/2018/4/6/17205718/plastic-surgery-apps-why-cosmetic-surgeons-insecurity. Accessed 7 Apr. 2020.

Rutkow, Ira M. American Surgery: An Illustrated History. Lippincott, 1998.

Thorne, Charles H., et al., eds. Grabb and Smith's Plastic Surgery. 7th ed., Lippincott, 2014.

Townsend, Courtney M., Jr., et al., eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st ed., Saunders, 2022.

2020 Plastic Surgery Statistics Report. American Society of Plastic Surgeons, 2020, www.plasticsurgery.org/documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf. Accessed 20 July 2023.

2023 ASPS Procedural Statistics Release. American Society of Plastic Surgeons, 2023, www.plasticsurgery.org/documents/news/statistics/2023/plastic-surgery-statistics-report-2023.pdf. Accessed 17 Oct. 2024.