Plastic, cosmetic, and reconstructive surgery

Plastic, cosmetic, and reconstructive surgery refers to a variety of operations performed in order to repair or restore body parts to look "normal," or tochange a body part to look better. These highly-specialized types of surgerybegin with careful preparation of the patient's skin and tissues, followed by precise cutting and suturing techniques and care to minimize scarring. Recent advances in the development of miniaturized instruments, new materials forartificial limbs and body parts, and improved surgical techniques have expanded the range of plastic surgery operations that can be performed.

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. It includes a number of different procedures, such as laser resurfacing, collagen injections, and dermabrasion. Procedures toremove excess fat from the abdomen ("tummy tucks"), to remove acne scars ortattoos, or to reshape the cartilage in children's ears (otoplasty) are all common applications of plastic surgery.

Cosmetic surgery procedures are performed to make the patient look younger orenhance appearance in other ways, and is usually focused on the face. The most common cosmetic procedure for children is correcting 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 manypeople still think of cosmetic surgery as only for women, growing numbers ofmen are choosing to have facelifts and eyelid surgery, as well as hair transplants and "tummy tucks."

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, developed out of theneed to treat wounded soldiers in wartime. It may involve the rebuilding of severely fractured bones, as well as the reattachment of an amputated finger or toe, or implanting a prosthesis (an artificial structure used to replace missing limbs, joints or teeth).

Plastic, cosmetic, and reconstructive surgeries have an important psychological component because of the high value placed on appearance in Western society. Many people who are born with visible deformities or who have been disfigured by accidents later in life develop emotional problems related to social rejection. Other people who work in fields such as acting, modeling, the mediaor politics, find that personal attractiveness is crucial to successful jobperformance.

Some people have unrealistic expectations of cosmetic surgery and think the surgery will solve all their problems. It's 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.

Once a patient decides to have plastic, cosmetic or reconstructive surgery, it's important to find a well-qualified surgeon. Since any doctor can call himself or herself a "cosmetic" (or plastic) surgeon after obtaining a license to practice medicine, it's important to evaluate the person's credentials by:

  • asking about board certification, training, qualifications and the hospital where the doctor has admitting privileges
  • checking for certification by the American Board of Plastic Surgery (all board-certified specialists are listed in the "Official ABMS Directory of Board-Certified Medical Specialists" in the library)
  • checking for membership in the American Society for Plastic and Reconstructive Surgeons and the American Society for Aesthetic Plastic Surgery
  • asking to see "before and after" photos
  • discussing the doctor's fees and costs, which will probably not be covered by health insurance

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.

Preparation for plastic surgery begins with a surgeon's detailed assessment of the parts of the patient's body that will be involved. A surgeon planning askin graft must evaluate suitable areas of the patient's skin for the rightcolor and texture to match the skin at the graft site. Facelifts and cosmeticsurgery in the eye area require very close attention to the texture of the skin and the placement of surgical incisions.

Facelifts, eyelid and eyebrow lifts can usually be performed as "day surgery"so the patient can go home the same day. Many surgeons prefer to use "twilight" anesthesia (or twilight sleep)--local anesthesia with intravenous sedation whenever possible.

Patients scheduled for plastic surgery under general anesthesia will be givena physical examination, blood and urine tests, and other tests to make surethat they don't have any undetected health problems or blood clotting disorders. The doctor will check the list of other prescription drugs 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 timeof blood clotting. Smokers are asked to stop smoking two weeks before surgerybecause smoking interferes with the healing process. Many anesthesiologistsalso advise patients to stop using certain other drugs and herbs, such as St.John's wort or a class of antidepressants known as MAO inhibitors. For sometypes of plastic surgery, the patient may be asked to donate several units ofhis or her own blood before the procedure, in case a transfusion is needed during the operation.

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 thepatient is having cosmetic surgery.

How much younger a person looks afterward, and the rate at which facial agingoccurs after surgery, depends on the person's age and lifestyle. However, even many years after surgery, most patients look better than if they had neverundergone surgery.

After surgery on the face, there is usually bruising and some discomfort (usually controlled with painkillers); within a few weeks, however, the face should begin to show improvement. Stitches are removed a few days after surgery and the scars are usually hidden by natural crease lines and hair. The patientmay be back to work within two weeks, although bruises may still be apparentfor several more weeks.

After surgery under general anesthesia, the patient wakes up in the recoveryroom and is given medications to relieve pain as necessary. Patients who havehad 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 typesof 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 toprevent infection and are sent home as soon as their vital signs are normal.

There may be scarring, but plastic surgeons are trained to close incisions ina way as to make the scars as inconspicuous as possible. Some scars eventually become a faintly-visible fine line. Scars from these procedures are in most cases quite acceptable, since they are usually placed within normal creasesand folds whenever possible. As with all surgery, the type of procedure andthe patient's personal healing ability play a large role in any scars that develop.

As with all surgery, complications are possible, but they are usually infrequent and minor when performed by a competent plastic surgeon. All patients experience some bruising and swelling for several days after cosmetic surgery, depending on the extent of the procedure. As with all elective surgery, the patient should carefully consider risks and potential complications before theprocedure.

The risks associated with plastic, cosmetic, and reconstructive surgery include the postoperative complications that can occur with any surgical operationunder 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 as a result of contamination during surgery or from bacteria that moves into the area around theprosthesis later on
  • 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.

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

  • recovering from a heart attack or severe infection (such as pneumonia)
  • with infectious hepatitis or HIV infection
  • with cancer whose disease might spread (metastasize)
  • who are extremely overweight (patients who are more than 30% overweight should not have liposuction
  • with blood clotting disorders

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