Cosmetic surgery

Cosmetic Surgery (Aesthetic Surgery) is the field of surgery in which operations are aimed to improve appearance rather than to cure disease. "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" (Isenberg JS. The legacy of Narcissus.[comment]. [Comment. Letter] Plastic & Reconstructive Surgery. 110(7):1815; author reply 1815-6, 2002 Dec. UI: 12447085).

Although cosmetic surgery has been a traditional branch of Plastic Surgery, in most countries of the world, any physician licensed to practice any sort of surgery can legally perform cosmetic surgery. Further, some general physicians, including medical doctors who are not trained in surgery, perform at least some of the procedures that are included under the wide umbrella of this field. In some cases, like skin injections of dermal fillers and neurotoxins by dermatologists, who pioneered some of those techniques, this is generally accepted within the medical profession as proper. In other cases, where a physician trained in a unrelated specialty begins practicing such techniques with only very limited qualifications, this is quite controversial.

Plastic Surgery includes much more than Cosmetic Surgery. Although the general public has recently come to regard cosmetic surgery as the calling of plastic surgeons, the great surgeons within the field view cosmetics as a far lesser accomplishment than the other kind of Plastic Surgery; Reconstructive Surgery. When it comes to appearance, cosmetic surgery improves an already acceptable visage, but reconstructive surgery aims to alter an appearance so abnormal that social interaction is inhibited, into one that is at least acceptable enough to allow a normal life. And so, lip augmentation is cosmetic surgery, but the repair of a cleft lip is reconstructive surgery. Although reconstructive surgeons may acheive beauty for their patients, the starting point is never normal. Of course, Reconstructive Surgery also often aims to improve or restore function, and may not focus on appearance at all. In Cosmetic Surgery, appearance is always primary.

Every ethical surgeon follows the ancient admonishment of Hippocrates to "first, do no harm". Following that guideline means using one's best judgement to only expose patients to the risk of surgery if their potential benefit is extremely likely to outweigh the "steep side" of having a given procedure. That means that the full armamentarium of the surgeon, including planning for surgical transformations that involve multiple operations, with a combined total of even days of actual operating time, harvesting bone, muscle and other grafts from all over the body, subjecting the patient to the need for blood transfusions, and employing post-operative life support systems, all might be completely warrented for a patient who has suffered mutilation from cancer surgery, burns, or birth defects, but be inappropriate for the patient who seeks the improvement of an already acceptable appearance.

The best plastic surgeons are able to perform all aspects of plastic surgery, but do not apply the most major and invasive techniques performed in reconstructive surgery to their cosmetic surgery patients.

Benefits and risks of cosmetic surgery

How can surgical intervention be justified when no illness is present? Although cosmetic procedures do not remedy illness, they can improve the quality of life. When 1) patient expectations are reasonable and 2) a satisfactory postoperative result can be obtained, cosmetic surgery is indicated.

An improvement in self-image is a real benefit to the individual having successful cosmetic surgery, but is not likely to be perceived by every individual seeking a cosmetic procedure. A change in appearance alone is never enough to confer a good self-image to a person who lacks one. In general, cosmetic surgery is contraindicated in a person with a deep seated self-loathing who hopes that somehow changing the shape of a part of the body will transform his entire attitude or life. In patients who are bothered by a specific feature, and have a healthy self-image, there is another consideration. Is the desired result one that is obtainable? Depending on skin type, age, and other individual factors, the look that a particular patient is hoping for may not be attainable. In such cases, the patient and surgeon together often agree that it is preferrable not to proceed with a particular cosmetic surgery procedure.

In the case of people whose livilihood depends on personal appearance; such as photogenicity or stage presence, aesthetic surgery can offer the same kind of advantages as exceptional grooming or eye-catching garments. In these circumstances the financial cost of the surgery is often viewed by the patient as a business expense (whether or not it can be deducted as such), - and the time and discomfort involved in undergoing surgery is viewed as a career investment. If, in fact, the desired change in appearance is one that is likely to be technically achieved by procedures that do not confer an undue risk on the patient, then the patient is considered a candidate for cosmetic surgery.

In some situations, aesthetic surgery is performed in order to help increase self-esteem. Such surgery is therapeutic only in selected cases. For example, removal of gang-related tattoos, reduction of scars, straightening of nasal deviations and other physical momentoes from previous assaults can help facilitate rehabilitation. There are certainly individuals who have experienced a tremendous benefit by being freed of these stigmata. In other cases, surgical modification of an unusual feature present since childhood, like a prominant nose or a receding chin, can be a expedient alternative to a continuing struggle to ignore or accept the appearance of these features. However, when low self-esteem is pervasive, then the results of surgical attempts to improve appearance are unlikely to help the individual. Even when results are considered excellent by others, the patient, in that situation, may be unable to acknowledge improvement but instead be excessively bothered by minor scarring or other changes and experience additional loss, rather than gain, of self-esteem.

When congenital anomalies (birth defects) are severe, or when trauma has caused obvious deformity, then surgical improvement of appearance is not called cosmetic surgery, but is classed as a reconstructive procedure. In many countries, reconstructive surgery will be covered by private insurance or government health plans. Cosmetic surgery, on the other hand, is generally considered a luxury that requires payment out of pocket.

The removal of lax skin, resurfacing of sun damaged skin, and tightening of subcutaneous tissues can dramatically remove signs of aging with minimal risk and discomfort. Rejuvenation surgery is often combined with various types of skin resurfacing or dermal fillers. Reversal of a prematurely aged appearance can successfully raise self-esteem in those people bothered by it, and can also be an advantage in maintaining competitiveness in a whole variety of careers in which a more youthful appearance is valued.

On the other hand, real harm can come from cosmetic surgery. Aesthetic procedures do have risks and complications - like all invasive procedures, but outside of these, patients can be especially harmed by submitting to surgical interventions in expectation of an unlikely outcome. Both women and men sometimes seek cosmetic surgery in an attempt to gain affection from disinterested mates, or even at the explicit request of a dissatisfied partner. Other patients falsely assume that disappointment with current life status will be somehow remedied by a surgical change in appearance. These patients can suffer harm from undergoing surgery that is far beyond the discomfort of postoperative healing, with or without surgical complications.

Well-trained ethical aesthetic surgeons are always interested in why their patients desire surgery. Such surgeons, far from "selling" the idea of surgery, will try to dissuade a patient with unreasonable expectations from having surgery, no matter what financial reward is offered. This is not entirely altruistic, it has been said that “a plastic surgeon makes his money from operating and his reputation from refusing to operate.”(reference for quote:Widgerow AD. First signals.[comment]. [Comment. Editorial] Plastic & Reconstructive Surgery. 113(7):2206-10, 2004 Jun. UI: 15253216)

Human beauty : universal attributes

Symmetry

Cultural & ethnic considerations

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 varous fillers injected into the lips, but traditional "cold knife' plastic surgery is used to give more lasting results than the fillers can currently provide. (Mutaf M. V-Y in V-Y procedure: new technique for augmentation and protrusion of the upper lip. [Journal Article] Annals of Plastic Surgery. 56(6):605-8, 2006 Jun. UI: 16721070). All of these procedures are generally safe and effective in expert hands, but, interestingly,there was little demand for lip augmentation a generation ago. That's 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, at the time 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 lips. 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 repetoire 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. Permanent changes in the face and body made to accomodate a preference that is temporary is liable to eventually be regretted by each.

Noses

"Correction" of the ethnic nose

In the 19th and in part of the 20th century, a Northern European Caucasian nose of certain proportions was the one and only aesthetic ideal in the western world. In the earlier portion of that period, outright discussion of the unattractiveness of semetic and negro noses was printed in both lay and professional publications. In the later portion of the 20th Century, wide and hooked noses were no longer so overtly labelled as a detrimental mark of ethnic origin, but still, such features were routinely described as showing "deformities". Patients sought corrections of these attributes that surgeons were willing to provide.

"A 1996 manual describing procedures for altering ethnic noses, for example, indicates that correction of the "Jewish nose" requires "a classic rhinoplasty with lowering of the dorsum, narrowing of the bony pyramid, refinement and elevation of the excessively long hanging tip. Another recent manual, while refraining from explicitly using the Jewish nose as a diagnostic category, notes that 2 patients with noses that "have acute nasolabial angles, plunging tips, or foreshortened nasal tip pyramids" were "of Jewish ancestry" or of "Jewish descent." " (reference for quote:Preminger B. msJAMA: The "Jewish nose" and plastic surgery: origins and implications. [Journal Article] JAMA. 286(17):2161, 2001 Nov 7. UI: 11694162).

The recognition of beauty can change over time, as ethnic characteristics that were once seen as "ugly" because they were a mark of a difference that was held undesireable by the general society become 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 diminuitive button tip.

Weir incisions

Jaw lines

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. "An operation to correct a square angle into a round, smooth angle" is offered by aesthetic and reconstructive surgeons practicing in the East.(reference for quote:Satoh K. Mandibular contouring surgery by angular contouring combined with genioplasty in orientals. [Case Reports. Journal Article] Plastic & Reconstructive Surgery. 113(1):425-30, 2004 Jan. UI: 14707669) Baek, S. M., Kim, S. S., and Bindiger, A. The prominent mandibular angle: Preoperative management, operative technique, and results in 42 patients. Plast. Reconstr. Surg. 83: 272, 1989 Lee DG. Song CW. Kim SG. Lee YC. Cho BO. A simple technique for reduction gonioplasty. [Letter] Plastic & Reconstructive Surgery. 111(2):951-2, 2003 Feb. UI: 12560737

Facial cosmetic surgery

Rejuvenation of the aging 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." (reference for quote:Carruthers JD. Caveat emptor (buyer beware).[comment]. [Comment. Editorial] Archives of Dermatology. 138(9):1243-4, 2002 Sep. UI: 12224991)

Body Recontouring

Bengtson B. Absolutes, beliefs, and preferences. [Editorial] Plastic & Reconstructive Surgery. 118(3):798-9, 2006 Sep. UI: 16932193 (smokers, breast implant-abdominal flap contraindication)

Breast augmentation and "lift"

Hsia HC. Thomson JG. Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation.[see comment]. [Journal Article] Plastic & Reconstructive Surgery. 112(1):312-20; discussion 321-2, 2003 Jul. UI: 12832909 (note:picture with contacture)

"Belly tuck"

Abdominoplasty

These findings indicate significant improvements in body image outcome, including positive changes in patients’ evaluations of their overall appearance, their average body image dissatisfaction, and their experiences of self-consciousness and avoidance of body exposure during sexual activities. As predicted, no changes were seen on any measure of psychological investment in appearance or on patients’ reports of general psychosocial functioning (self-esteem, satisfaction with life, or social anxiety)".(reference: Bolton MA. Pruzinsky T. Cash TF. Persing JA. Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients. [Journal Article. Research Support, Non-U.S. Gov't] Plastic & Reconstructive Surgery. 112(2):619-25; discussion 626-7, 2003 Aug. UI: 12900625)