Plastic, Cosmetic, and Reconstructive Surgery

Definition

Plastic, cosmetic, and reconstructive 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 the patient'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 operations 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 the patient look younger or enhance his or her 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 the patient'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.

Precautions

Medical

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

• patients recovering from a heart attack, severe infection (for example, pneumonia ), or other serious illness
• patients with infectious hepatitis or HIV infection
• cancer patients whose cancer might spread (metastasize)
• patients who are extremely overweight. Patients who are more than 30% overweight should not have liposuction
• patients 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. Patients with this disorder frequently seek unnecessary plastic surgery.

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 the patient'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 ), facelifts (rhytidectomy), or changing the size 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 cancer patients as well as 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.

In cancer patients, reconstructive surgery is done to restore the function as well as the appearance of the face and other parts of the body. The most commonly performed reconstructive surgeries of cancer patients are breast reconstruction, laceration repair, scar revision, and tumor removal.

The most challenging area of reconstructive surgery involves the structures of the face, neck, and jaw because trauma or cancer treatments often affect the patient's ability to see, eat, taste, swallow, speak, and hear as well as his or her external appearance. The surgeon must try to retain as much sensation as possible when performing skin or bone grafts in the head and neck as well as recreate a reasonably normal appearance.

Preparation

Preparation for nonemergency plastic or reconstructive surgery includes patient 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. Patients are typically asked to stop taking certain prescription medications that affect bleeding for about two weeks before the procedure and to stop smoking for at least a week before the operation.

Preparation for reconstructive surgery following cancer treatment may require much more extensive counseling and discussion of possible alternatives to the surgery.

Medical preparation

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

Patients 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 doctor will check the list of prescription medications that the patient may be taking to make sure that none of them will interfere with normal blood clotting or interact with the anesthetic.

Patients 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, the patient may be asked to donate several units of his or her own blood before the procedure, in case a transfusion is needed during the operation. The patient will be asked to sign a consent form before the operation.

Patient education

The doctor will meet with the patient before the operation is scheduled, in order to explain the procedure and to be sure that the patient is realistic about the expected results. This consideration is particularly important if the patient is having cosmetic surgery.

Aftercare

Medical

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

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

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, plastic, cosmetic, and reconstructive surgery carry specific risks:

• formation of undesirable scar tissue
• 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 patient's body).

Normal results

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

KEY TERMS

Blepharoplasty— Surgical reshaping of the eyelid.

Dermabrasion— A technique for removing the upper layers of skin with planing wheels powered by compressed air.

Facelift— Plastic surgery performed to remove sagging skin and wrinkles from the patient's face.

Liposuction— A surgical technique for removing fat from under the skin by vacuum suctioning.

Mammoplasty— Surgery performed to change the size of breasts.

Rhinoplasty— Surgery performed to change the shape of the nose.

Resources

PERIODICALS

Cordeiro, P. G., A. L. Pusic, J. J. Disa, et al. "Irradiation after Immediate Tissue Expander/Implant Breast Reconstruction: Outcomes, Complications, Aesthetic Results, and Satisfaction among 156 Patients." Plastic and Reconstructive Surgery 113 (March 2004): 877-881.

Dupin, C., S. Metzinger, and R. Rizzuto. "Lip Reconstruction after Ablation for Skin Malignancies." Clinics in Plastic Surgery 31 (January 2004): 69-85.

Guerra, A. B., S. E. Metzinger, R. S. Bidros, et al. "Bilateral Breast Reconstruction with the Deep Inferior Epigastric Perforator (DIEP) Flap: An Experience with 280 Flaps." Annals of Plastic Surgery 52 (March 2004): 246-252.

Hofstra, E. I., S. O. Hofer, J. M. Nauta et al. "Oral Functional Outcome after Intraoral Reconstruction with Nasolabial Flaps." British Journal of Plastic Surgery 57 (March 2004): 150-155.

Losken, A., G. W. Carlson, M. B. Schoemann, et al. "Factors That Influence the Completion of Breast Reconstruction." Annals of Plastic Surgery 52 (March 2004): 258-261.

Patrick, C. W. "Breast Tissue Engineering." Annual Review of Biomedical Engineering 6 (2004): 109-130.

ORGANIZATIONS

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). 310 South Henry Street, Alexandria, VA 22314. (703) 299-9291. 〈http://www.facemd.org〉.

American Medical Association. 515 N. State St., Chicago, IL 60612. (312) 464-5000. 〈http://www.amaassn.org〉.

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. 〈www.plasticsurgery.org〉.