Surgical body sculpting

For most of human history, we have used surgery to try to save lives and improve health. However, as our medical techniques and knowledge improved over the centuries, surgery became a means not just to cheat death, but also to repair congenital or acquired deformities such has cleft palate or clubfoot. Overthe last 100 years, accompanying a general rise in levels of health and financial stability, people have begun using surgery to "fix" even their smallestfacial and other irregularities or enhance the physical characteristics withwhich they were born. This modern use of surgery, known as surgical body sculpting, has become a multibillion-dollar industry. It has also raised many complex ethical questions.

Plastic versus Cosmetic Surgery

Over the last century or so, the field of plastic surgery has spawned a subdivision of itself known as cosmetic surgery. Plastic surgery is mainly concerned with the reconstruction and repair of deformities or damaged tissues, andas such has an important place in surgical medicine. Cosmetic surgery stems from the gradual introduction, as surgical techniques improved, of less and less necessary procedures. For example, while plastic surgery often treats nonlife-threatening problems, such as using skin and plastic inserts to constructand replace a severed ear, cosmetic surgery might be especially concerned with the angle at which that new ear protrudes from the patient's head. Thus, although the two surgical areas are similar, one--cosmetic surgery--deals exclusively in nonessential, appearance-oriented improvements. However, some cosmetic surgeons (sensitive to the somewhat shady reputation of their field) make the argument that for a woman whose persistent obesity is driving her to thoughts of suicide, surgical intervention is quite necessary and perhaps evenlifesaving. This is where the subject's complexity reveals itself, because other experts believe that the obese woman has been programmed by society to think that she should look like a supermodel despite the unattainability of that goal for her and the vast majority of people. Such arguments make the distinction between plastic and cosmetic, necessary and unnecessary, even harder to make.

One way of defining the distinction between plastic and cosmetic surgery is to point out that plastic surgery usually treats birth defects and skin blemishes, including acne scars, warts, and birthmarks, while cosmetic surgery concentrates on procedures designed to enhance appearance or make the patient look younger. However, there is a great deal of blurring that occurs between these two areas. Reconstructive surgery, often lumped into the category of plastic surgery, is actually the older discipline. Reconstructive surgeons specialize in reattaching severed body parts, performing skin grafts on burn victims, and using technology to recreate surgically removed or congenitally missingbody parts.

Cosmetic Surgery in History

The history of surgical body sculpting might be said to have started in Indiain the late 1700s. There, a man whose nose was cut off as a form of punishment sought someone to help him reconstruct his ghastly face. Although the noseless man was not in immediate danger of dying from his wound, his extreme discomfiture at his appearance was sufficient reason for an amateur physician tohelp him return to normal. In a procedure now known as the "Hindu method," the physician cut a triangle of skin from the man's forehead, peeling it downward until only a single point of the triangle remained attached at the bridgeof the man's nose. By carefully shaping the skin into a nose-like protrusion, the physician gave the man at least a semblance of a normal nose. Several British surgeons witnessed this elegant, minimally invasive procedure and reported its success to their colleagues in Britain and Europe, thus changing thecourse of plastic surgery.

Unfortunately for the reputation of cosmetic surgery, unscrupulous physicianshave often targeted uneducated and/or desperate people with promises of renewed, permanent health and beauty. Of course, other physicians were merely illinformed. Perhaps such was the case of doctors in the late 1800s who x-rayedtheir patients' abdominal cavities, often found their organs to be "misplaced," and recommended that they undergo a procedure called "hitching up the kidneys." Likewise, between 1920 and 1950, many doctors performed tonsillectomies as a matter of course, although there was no reason for the "preventative"surgery, while hysterectomies were also quite popular for a time.

World Wars I and II were important stimulators of growth and innovation in the field of cosmetic surgery. Injuries occurred on an unprecedented scale andin formerly unimaginable ways, spurring doctors to find methods of helping survivors live the most normal lives they could despite missing limbs, disfigured faces, and other handicaps. In fact, some medical historians believe thatWorld War I actually led to the development of reconstructive and plastic surgery (and, by extension, cosmetic surgery).

Types of Cosmetic Surgery

The majority of cosmetic surgery concerns the face, since it is most visibleto other people. In children, the most common cosmetic surgery is correctionof a cleft lip (harelip) or cleft palate, congenital conditions that can cause disfiguring facial abnormalities. Most adults who have cosmetic surgery want to have baggy tissue around the eyelids removed (blepharoplasty); have their nose made smaller, more "normal," or otherwise different (rhinoplasty); have wrinkles removed or sagging skin on the neck, cheeks, forehead, or jawline"lifted" (rhytidectomy); have their breasts lifted or changed in size (mammoplasty); or have their stomachs "tucked" (abdominoplasty).

Traditionally, cosmetic surgery has been the domain of women. Even as of 1996, breast augmentation was second after liposuction as the most common form ofcosmetic surgery. However, men are making rapid incursions into this specialized medical area. For instance, one of the most popular operations in the late 1990s was "ab etching," in which surgeons would enhance the prominence ofa man's abdominal musculature by carefully removing fat from between the muscles. A related procedure is known as "ab sculpting," in which the surgeon leaves blocks of fat in selected locations to give the appearance of a "washboard stomach." With ab sculpting especially, however, turning or twisting the body can distort the remaining fat, giving an unnatural look. Most men, and thefew women, who request these types of procedures are amateur or professionalbodybuilders whose rankings depend on such details as degree of muscle definition. Such athletes might also have cosmetic surgery to increase the look ofseparation in the deltoid and biceps muscles.

More common in the average person is a procedure in which a silicone implantis inserted under the skin (although it is more likely to slip here) or intothe fascial compartment over the heads of the gastrocnemius. This operation is designed to create the appearance of larger, more defined calf muscles. Many men have also received pectoral implants to create or enhance the impression of a muscular chest. In this operation, the surgeon inserts silicone implants under the skin, where it may later become displaced, or between the pectoris major and pectoris minor muscles, causing the entire structure to bulge outward. As of 1999, most of these implant operations cost between $5,000 and $7,000.

Less common cosmetic surgery procedures include placing special surgical inserts inside the facial skin to create the appearance of pronounced or "high" cheekbones, using implants to create more rounded buttocks, and removing all or part of the bottom sets of ribs to narrow the waist. Perhaps the least-discussed surgery, though, involves the genitals.

Occasionally, a person will be born who has both male and female genitalia orgenitals that do not appear to be clearly male or female. This unusual condition, although typically hidden from sight, often causes strong feelings of shame in the afflicted person and a sense that through this one physical trait, he or she is fundamentally different from everyone else. These people sometimes seek aid from cosmetic surgeons to help them feel "normal." Other peoplewhose genitals are clearly male or female may wish so fervently to become amember of the other sex that he or she will employ a cosmetic surgeon to create a new set of genitals. For example, in a woman who wishes to have male genitals, the surgeon can perform a metoidioplasty, which consists of transforming the clitoris into a penis that functions normally except for urination purposes. In a man who wishes to have female genitals, the tissue of the penis itself is used to create a vagina-like opening.

Still other people use cosmetic surgery to change the appearance of the theirgenitals. Some women seek the aid of a cosmetic surgeon to reduce the size or change the appearance of the labia, while some men might have cosmetic surgery to straighten a congenitally "bent" penis or reposition the urethral opening to the usual location.

The Breast Implant Debate

Breast reshaping, reduction, or augmentation accounts for a large portion ofcosmetic surgery procedures, and is performed under general or local anesthesia. To reshape smaller breasts and to increase the size of any breasts, cosmetic surgeons insert a preformed, saline-filled, silicone-shell implant into asmall incision near the nipple. The surgeon places the implant into a pocketof skin and either behind or in front of the pectoral muscles (submuscular or submammary, respectively). The operation sometimes causes permanent loss ofsensation in the nipple because it severs the nerves in the area. In addition, women who have this surgery should expect to have other operations over the years, since the implants age and need to be replaced. One 1994 study reported in the Annals of Plastic Surgery suggested that eight years is themaximum length of time an implant should remain in the body.

Because leaking silicone breast implants have been found to cause health problems, they are no longer available to the general public. Only women with special medical needs, such as mastectomy (breast removal), severe injury or abnormality, or birth defects and who are willing to participate in a clinical trial approved by the U.S. Food and Drug Administration may use them for reconstructive surgery. As of 1998, saline implants remained on the market pendingthe manufacturers' compilation of data that their products are safe. Most experts believe these to be safer than silicone implants, since a rupture in asaline implant would result only in the leakage of saltwater into the body. Asmall number of women have polyurethane foam-covered implants, but these were taken off the market in 1991 when researchers showed that the implants release a carcinogenic chemical known as 2 TDA. No studies since then have demonstrated an increased risk of cancer in those women, although TDA was found intheir urine in small amounts.

The Search for a Surgeon

There are many guidelines available on how to choose a skilled, responsible cosmetic surgeon. The majority of the surgeons are well qualified and skillful. However, because there are some fly-by-night, unscrupulous ones in a business that tends to draw people desperate for quick, dramatic changes and thoseeager to make money by exploiting them, it is prudent to be wary. Experts advise that when searching for a cosmetic surgeon, the prospective client shouldask the following questions: What is your specialty and what training do youhave? How many of your patients have needed additional surgery? Where do youhave hospital privileges? How many operations like mine have you done? Willyou perform the operation yourself? May I contact your former patients?

Qualifying for Surgery

Candidates for cosmetic surgery must usually undergo a physical and psychological examination to determine if they are fit enough to withstand the stressof an operation. In terms of physical requirements, people who are recoveringfrom a heart attack, severe infection, or other serious problem are not goodcandidates for cosmetic surgery. Likewise, neither are people suffering fromHIV or AIDS, infectious hepatitis, cancer, or blood-clotting disorders. Patients more than 30 percent overweight are not good candidates for liposuction,although the myth persists that this suction-aided surgery is a permanent treatment for excess fat. (In reality, patients close to their ideal body weight benefit most from liposuction.) In terms of a patient's psychological status, most physicians will remind their clients that changing their body shape or size will not make all their life problems vanish and that they must be realistic about the surgery's results. Cosmetic surgeons frequently see patientswith body dysmorphic disorder, which causes obsession with minor or altogether imagined physical flaws. After approving a client, the surgeon should carefully review plans with him or her, sometimes drawing on a computer image ofthe client to show what changes the proposed surgery will produce

Considering the Risks

As with any type of surgery that requires anesthesia, cosmetic surgery has inherent risks. The first sort of risk can be considered "postoperative complications." These mainly include internal bleeding, infection, adverse reactionsto anesthesia, and pneumonia. Some cosmetic surgery, such as wart removal ornose reshaping, can be done on an outpatient basis with a minimum of anesthesia, however. The second group of risks occurs more often and is specific tocosmetic, plastic, and reconstructive surgery. These include chronic pain, swelling, or redness in the area of the surgery; formation of unattractive scartissue; rejection of transplants or skin grafts; infection caused by an implant; loss of normal nerve function in the area of the surgery; and subsequentdiscovery that some aspect of the surgery or the devices used were unsafe.

Although most people are pleased with the results of their cosmetic surgery,each type of operation carries its own risk. For instance, rhinoplasty, one of the most challenging and difficult surgical tasks, can result in a misshapen or even nonfunctional nose. It can take up to three weeks for the attendantbruising and swelling to subside completely. With rhytidectomy, which produces results that can last for five to ten years, there may be temporary or permanent nerve damage in addition to the puffiness and bruising that can take several weeks to clear up. People who receive abdominoplasty, which removes sagging extra skin from the abdominal area, is performed under general anesthesia, and so carries an extra risk of serious complications. Also, there is often significant scarring in the groin area and recovery may take as long as two or three months. With blepharoplasty, bruising and discoloration around theeyes can take several weeks to fade, and the eyes may feel dry for some time. Less-skilled surgeons have been known to remove too much tissue, resultingin an unnatural, wide-eyed look. Liposuction, while increasingly popular andan effective way to trim stubborn fat deposits permanently, can cause a pocked or uneven appearance in the skin. In addition, some people have reported blood clots, infection, and fluid loss.

The large number of breast implant surgeries have yielded a vast amount of information on the special risks inherent in this type of surgery. Physicians now know, for instance, that there is a danger of rupture (deflation), hematoma, toxic shock syndrome, infection, and systemic problems (including possibleautoimmune disorders) from leaking silicone implants. Many women who have received breast implants (both silicone and saline) have also complained of a marked hardening of the breast tissue around the implant. This is called encapsulation and is the body's normal response to a foreign object. However, sometimes women will experience a painful problem called capsular contracture, inwhich the hardened tissue begins to shrink. Calcium deposits may also form in tissue surrounding the breast, causing pain and further hardening. Leakingsilicone breast implants have been shown to cause noncancerous lumps (granulomas) in the breast and anywhere else the substance migrates, including the armpit, abdomen, chest wall, and arm. Further, some implants shift position over time, creating a lopsided, unnatural look, and they may impede accurate mammography because technicians must take care not to rupture them during the procedure. It is not yet known whether breast implants affect a woman's abilityto nurse or the safety of the milk she produces.

Preparing for and Recovering from Surgery

Preparation for cosmetic surgery includes assessing the risks involved and the physician's close examination of the areas involved in the proposed surgery. Patients should avoid aspirin for one to two weeks prior to surgery, sinceit inhibits the clotting ability of blood and could lead to excessive blood loss. Smoking should also stop for two weeks prior to surgery because it tendsto slow down healing. In addition, sometimes patients will be asked to set aside several units of blood in case they need a transfusion.

After cosmetic surgery--especially that requiring general anesthesia--the patient will spend time in a recovery room, where technicians will monitor his or her vital signs and dispense pain medication as necessary. Smaller-scale cosmetic surgery, such as blepharoplasty, typically require only a night or twoin the hospital, but more extensive operations (i.e., mammoplasty) mandate alonger period of observation--in most cases a week or so. Outpatients usually receive a prescription for antibiotics to prevent infection and can returnhome as soon as their vital signs stabilize.

Ethical Considerations

As cosmetic surgery becomes increasingly popular, safe, and effective, many physicians are beginning to question whether they should participate in it. Some are concerned that they are, unwittingly or not, engaged in changing society's conception of what is normal. Cosmetic surgery has an important psychological dimension because of the tremendous value Western society places on appearance. Because of this preoccupation, many people who do not conform to such strict standards--whether due to congenital or accidental deformations or disfigurement--lead lives of isolation and social rejection. These individualsoften develop psychological problems from being treated badly by others, andcosmetic surgery is sometimes the only way to stop this mistreatment.

In recent decades, however, cosmetic surgery has become a bastion for the vain and those convinced that they must live up to some arbitrary (and ever-changing) standard of beauty. More and more, the people who have cosmetic surgeryare coming from society's upper echelons--those who can afford the high price for the procedures and can take off a month or so from work or other obligations to heal. Some critics believe that this science is making life better for only a privileged few: by making themselves more attractive, they open upeven more opportunities for themselves despite whatever genetic hand nature has dealt them. Thus, as this argument goes, these privileged few are upping the ante, as it were, for the rest of us with crooked noses, small calf muscles, and imperfect breasts.

To feminists, one area of ongoing concern is that women are having cosmetic surgery--and taking on all the risks inherent therein--merely to please men and to get closer to some prepackaged, unrealistic notion of female perfection.Some doctors argue that if a woman is unhappy with her face or her body, itis her right to have them changed to suit her and thus relieve the psychological pain she suffers. However, others remind us that the very reason for thiswoman's unhappiness might be our society itself and the unreasonable, unrelenting demands it places on her.

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