Cosmetic surgery

Cosmetic Surgery (Aesthetic Surgery) is the field of surgery in which operations serve to improve appearance, rather than to cure disease. As one expert in this field explained: "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. Plastic surgery encompasses both cosmetic and reconstructive surgery.

Patient selection in cosmetic surgery

Surgery has risks of harm, yet there is general agreement (among patients, health care professionals, and society) that surgery is indicated when the benefit of the procedure outweighs that potential harm. Cosmetic surgery presents a special situation. Given that potential harm does exist, how can surgical treatment ever be justified when no illness is present? Although cosmetic procedures do not remedy disease, they can significantly improve the quality of life. When the risks posed by a particular cosmetic procedure is much less than its perceived benefit, then, again, there is general agreement that the surgery is indicated. In cosmetic surgery, however, the ceiling for acceptable risk of harm to the patient is minimal or very low.

High risk procedures to improve appearance are usually undertaken only when a person looks so abnormal that social interaction is impaired, or when deformity is the result of trauma or disease -in all of those cases, corrective surgery is considered reconstructive rather than cosmetic.

One of the most important ways that surgeons ensure that the potential harm of cosmetic surgery does not outweight the potential benefit is by patient selection. That topic is covered in every surgical textbook and every training program, because the ultimate success or failure of cosmetic surgery is as dependant on proper patient selection for a given operation as are the technical considerations of performing the operation. When 1) patient expectations are reasonable and 2) a satisfactory postoperative result can be obtained at little risk; cosmetic surgery is indicated, and a satisfactory outcome can be anticipated. In other circumstances, a patient may not be a candidate for the specific procedure sought, but be well suited for a different procedure, or, in still other circumstances, an individual may not be a candidate for any elective cosmetic surgery at all. When an individual possesses certain attributes that make a good technical result very unlikely to occur, or unlikely to satisfy the patients wants even if it does occur, or that put the patient at unacceptably high risk for severe complications from surgery, then surgery is not indicated.

Benefits of Cosmetic Surgery

An improvement in self-image is a real benefit to the patient having successful cosmetic surgery, however, 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 conviction that there is something terribly wrong with him or her because of the size, shape or appearance of a body part. Generally, there is hope that somehow changing the body will transform or her his entire attitude or life. No matter how the outcome of the surgery may be seen in another observer's eyes, patients who are deeply dissatisfied with themselves are likely to see the results as a failure, and remain dissatisfied with themselves. In such cases, the patient may embark on an endless series of additional operations to seek the elusive improvement, or strike out at the surgeon and health care team held responsible for the surgery.

In the case of people whose livilihood depends on personal appearance, photogenicity or stage presence, aesthetic surgery can offer the same kind of advantages as exceptional grooming or 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 usually considered a good candidate for cosmetic surgery.

In some specific situations, aesthetic surgery is performed in order to help increase self-esteem. 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 accept the presence of these features.

The droop of soft tisues and change in conformation that comes with age can lend fatigue to anyones' appearance, and a sense of rejuvenation can be experienced with successful correction.

Risks of Cosmetic Surgery

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). Additionally, undertaking the surgical transformation of a patient who perceives this change as one of identity, or has demands that cannot be met by surgery because of such underlying disorders as Body Dysmorphism Syndrome, can result in harm to the surgeon. Besides legal suits lodged as a punitive action, there have been cases of assault and even homicide of plastic surgeons by troubled patients after cosmetic surgery. (ref-Morain WD. Up in arms. [Editorial] Annals of Plastic Surgery. 32(4):445-6, 1994 Apr. UI: 8210170)

The ethical surgeon will employ techniques of Shared Decision-making, which includes undertaking a frank discussion of the risks and benefits of cosmetic surgery with the patient, and then helping the patient to make a decision that serves the patient's best interests.

Human beauty : universal attributes

Symmetry

Cultural & ethnic considerations

Whereas certain attributes, like symmetry, seem to be valued by all peoples, there are many preferences that are not uniform - but held by certain people and not by others. The medical literature in cosmetic surgery analyses these preferences, because a good result is dependent upon what the patient, and his peers, see as attractive, and that is not necesarily the same as what the surgeon sees as most attractive.

For example, what does the ideal female eyebrow look like? There were a series of ideal positions and shapes of the female eyebrow in European culture over the first three-quarters of the Twentieth Century. A study by German plastic surgeons in 1976 indicated that the age of the patient was a primary determinant of which eyebrow shape and position was seen as more beautiful, the older patients preferring the high, arched brow, popular in the earlier part of the era, and the younger patients preferring the opposite choice, a lower eyebrow without a definite arch. These surgeons concluded that concerning beautiful eyebrows, at the time of their study "there is not one single choice, but at least three".(Dominik K. Feser, Martin Gründl, Marita Eisenmann-Klein and Lukas Prantl:Attractiveness of Eyebrow Position and Shape in Females Depends on the Age of the Beholder.Aesthetic Plastic Surgery.10.1007/s00266-006-0149-x.)

Facial cosmetic surgery

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 (2006). "V-Y in V-Y procedure: new technique for augmentation and protrusion of the upper lip". Ann Plast Surg 56 (6): 605-8. PMID 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."

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.

Surgical techniques

Rhinoplasty currently strives to enhance the appearance of the nose according to the individual face. Ideal nasal proportions vary according to gender (ref:Rohrich RJ. Janis JE. Kenkel JM. Male rhinoplasty. [Review] [20 refs] [Case Reports. Journal Article. Review] Plastic & Reconstructive Surgery. 112(4):1071-85; quiz 1086, 2003 Sep 15. UI: 12973227), race and facial characteristics. [ [Image:Michael Jackson 1984.jpg|left|50px]]

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.

Rejuvenation of the aging face

The removal of lax skin, resurfacing of sun damaged skin, and tightening of subcutaneous tissues and facial muscles 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 face can successfully raise self-esteem. .

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."

The Neck

Cosmetic operations on the neck are usually focused either on removing a fat pad, or in rejuvenation surgery. (Rohrich RJ. Rios JL. Smith PD. Gutowski KA. Neck rejuvenation revisited. [Review] [30 refs] [Case Reports. Journal Article. Review] Plastic & Reconstructive Surgery. 118(5):1251-63, 2006 Oct. UI: 17016198). The appearance of the aged neck is primarily due to excess skin as well as laxity of the thin sheet of muscle called the platysma. Various surgical methods of removing the excess skin and "tightening" the underlying muscle are employed. (Rohrich RJ. Rios JL. Smith PD. Gutowski KA. Neck rejuvenation revisited. [Review] [30 refs] [Case Reports. Journal Article. Review] Plastic & Reconstructive Surgery. 118(5):1251-63, 2006 Oct. UI: 17016198)

Body Recontouring

Breast augmentation and mammapexy ("lift")

Schwarzman E. Goldan S. Wilflingseder P. The classic reprint. Die Technik der Mammaplastik (the technique of mammaplasty). [Biography. Historical Article. Journal Article] Plastic & Reconstructive Surgery. 59(1):107-12, 1977 Jan. UI: 318746

Breast augmentation techniques and resultant shapes have been revised since the invention of the procedure in the 1960s.

"Belly tuck"

Abdominoplasty

A 2003 study of abdominoplasty patients indicated significant improvements in body image, as measured by several different outcomes. There were no changes reported in self-esteem or other psychological components.

The patient's part in cosmetic surgery

Although cosmetic surgery is traditional branch of Plastic Surgery, in most countries of the world, any physician licensed to practice any sort of surgery can legally perform cosmetic procedures.

Smoking is especially deleterious for plastic surgery patients such as cosmetic surgery recipients, since cigarette smoke components are known to retard wound healing.

Honigman RJ. Phillips KA. Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. [Review] [62 refs] [Journal Article. Review] Plastic & Reconstructive Surgery. 113(4):1229-37, 2004 Apr 1. UI: 15083026

Rohrich RJ. Mirror, mirror on the wall: when the postoperative reflection does not meet patients' expectations. [Journal Article] Plastic & Reconstructive Surgery. 108(2):507-9, 2001 Aug. UI: 11496196