Aesthetic Plastic Surgery

Written by: Niharika Varma from Leicester University,

 

 

'Creating Beauty to Cure the Soul'

 

An Insight into Aesthetic Plastic Surgery [3]

 

This article is for all who are curious and mesmerised by Aesthetic Surgery. It hopes to provide an overview, wet one's appetite and inspire one to find out more.

 

To follow:

  • What is Aesthetic Plastic Surgery?
  • Aesthetic Plastic Surgery Terminology
  • Provision of Aesthetic Plastic Surgery In the UK
  • General Fundamentals
  • Typical Aesthetic Plastic Surgery Procedures
  • Aesthetic Plastic Surgery and Ethnicity
  • Future Developments in Aesthetic Plastic Surgery
  • References

 

What is Aesthetic Plastic Surgery?

 

'...Reconstructive surgery is an attempt to return to normal whereas cosmetic surgery is an attempt to surpass the normal. No man is a plastic surgeon unless he is adept at both.' [4]

Gillies, H. D. and Millard, D. R., Jr. The Principles and Art of Plastic Surgery

 

Personally, the quote from Gillies and Millard's classic textbook captures the essence of Aesthetic Plastic Surgery. There is a general belief that Aesthetic surgery is a whim of technically advanced societies. It is true that aesthetic procedures require the comfort of economic stability but societies, even in crises such as economic downturn, continually engage in body modification.

 

Plastic Surgery consists of two components, Reconstructive Surgery and Aesthetic Surgery. Reconstructive surgery aims to restore form and function whereas Aesthetic surgery aims to alter physical appearance.

 

The term 'cosmetic' is used interchangeably with aesthetic. Aesthetics itself is a branch of philosophy dealing with the nature, creation and appreciation of beauty, art and taste, [6]. Many plastic surgeons prefer the phrase Aesthetic Surgery to Cosmetic Surgery as the later tends to imply connotations of beauty products and makeup.

 

To the aesthetic surgery patient's great delight, 'beauty' and the quest to create it seems to be the obsession of most Aesthetic Plastic Surgeons. They believe NOT that beauty lies in the eyes of the beholder BUT that beauty lies in the hands of the sculptor.

 

Aesthetic Plastic Surgery Terminology

Provision of Aesthetic Plastic Surgeon in the UK

 

The health care system in the UK is subdivided into the National Health Service (NHS) and the Independent Health Care sector.

 

Aesthetic Plastic Surgery and other non-surgical cosmetic treatments are provided in the independent sector rather than the NHS (with a few exceptions). Private sector provision for aesthetic surgery can be found in hospitals, clinics and some beauty salons - the Department of Health recommends [18] patients make an informed decision when it comes to choosing their service provider. Patients should access the private care service through a referral from their General Practitioner, however some chose to go directly to the surgeon.

 

All independent clinics and hospitals providing aesthetic surgery must be licensed with the Care Quality Comission [17] in order to deliver their service. Some procedures must be registered by law to ensure safety and reduction of risk associated with poor practice.

 

General Fundamentals

 

The beauty of aesthetic plastic surgery lies in the result. Aesthetic surgery is an enhancement rather than loss therefore the aim must be perfection. Both careful patient selection and planning are important parameters which help achieve this.

 

Careful patient reduces the chance of patient dissatisfaction and the need for revision surgery. Patients who are vague, indecisive or have minimal deformities should be approached with caution. These patients usually have expectations which may surpass those that are reasonable.

 

As most of the aesthetic procedures are elective in nature, this gives both the patient and surgeon ample time to plan. The patient may choose to focus their time on social implications whereas the surgeon must aim to counsel the patient on results and possible complications, aim to reduce morbidity per and post operatively and aim to be technically prepared for the procedure.

 

Typical Aesthetic Surgery Procedures

 

The British Association of Aesthetic Plastic Surgeons (BAAPS) performs yearly audits and recently released its UK 2010 statistics. Despite the economic climate, there has been a 5% increase since 2009 in surgical procedures carried out by members of BAAPS (36,483 in 2009 and 38,274 in 2010), [21].

 

Impressively the popularity of breast augmentation, increase of 10%, facelifts, increase of 12%, and gynaecomastia procedures, increases of 28%, were recorded last year, [21].

 

For both men and women combined, the top surgical procedures in 2010 were as follows, [21]:

 

  • Breast Augmentation 9,430 - up 10% from last year
  • Blepharoplasty 5,779 - up 6.2.%
  • Breast Reduction 4,959 - up 5.4%
  • Face/Neck Lift 4,756 - up 12%
  • Rhinoplasty 4,207 - up 9.7%
  • Liposuction 3,369 - down 4%
  • Abdominoplasty 3,127 - down 7.5%
  • Browlift 3,127 - down 7.5%
  • Otoplasty 1,114 - down 17%

 

For women (90% of patients), breast augmentaton remains the most popular procedure with otoplasty being the least popular. For men on the other hand, rhinoplasties were the most popular and abdominoplasties the least popular.

 

It is therefore important to have some basic knowledge of common procedures as it is likely that you will meet a cosmetic surgery patient in future practice... Information on Breast Augmentation, Blepharoplasty, Face Lift, Rhinoplasty, Liposuction and Abdominoplasty follows:

 

Breast Augmentation

 

Reasons for the procedure [22, 23]

 

Typical patients include those looking to increase the size and fullness of their breasts. Some women have constitutionally small breasts or have lost breast volume post-partum. Other patients complain of 'droopiness', this can occur as a result of age (age related ptosis) or dramatic weight loss.

 

The procedure

 

This type of surgery is both volume expanding and breast reshaping. Enlargement is achieved through the placement of an implant either under the breast tissue or behind the muscle. Subglandular placement usually gives fuller volume and better uplift, whereas submuscular placement is used for slender patients with little breast tissue. Incisions may be under the breast (inframammary fold) or alternatively around the areola or axilla.

 

The surgeon's skiil will ensure the breasts sit naturally with the build and dimensions of the patient.

 

The implant

 

The implant consists of an outer shell and a filling material - commonly silicone gel or saline. The implant may be a round or tear drop shape (more natural breast). The manufacturers quote a life expectancy of around 10 years, however implants can stay in for much longer without any problems.

 

Silicone safety

 

Silicon forms SiliconE when it is combined with carbon, hydrogen and oxygen. It occurs naturally and is manufactured into may items, e.g. cosmetics, foods, implants etc. Studies conducted show no evidence to suggest silicone breast implants are associated with increased incidences of breast cancer nor are they a cause of autoimmune diseases, as some quote.

 

NHS availability

 

This procedure is not usually offered on the NHS. There are some exceptions to the rule however. Some primary care trusts allow consultations and operations for 'small breasts' in certain circumstances.

 

Complications

 

Surgical complications include:

 

  • Less than 1% risk of bleeding or infection
  • Degree of altered sensation
  • Hardening/Encapsulation around the implant (10% of women in 10yr period will experience this)
  • Breast asymmetry
  • Change in breast shape over time
  • Visible edges of the implants under the skin
  • Gradual failure and leakage of the implant resulting in the need for a further operation

 

Blepharoplasty

 

Reasons for the procedure

 

Unfortunately with age, the skin loses its elasticity and our muscles slacken. The age related changes manifest in the four eyelids (2 upper and 2 lower). When the skin loses elasticity, it accumulates as folds of loose skin in the upper lids and deepening creases in the lower lids. Slackening of muscle beneath the skin allows the cushioning fat to protrude forwards as ‘bagginess’.

 

These problems are worse in the morning as fluid distributions change during the night. The fluid tends to accumulate where the skin is loose such as the eyelids. In some more serious cases, vision can be obstructed. The eyelids droop as a general effect of ageing but also aggravates the accumulation of skin in the upper lids to such an extent that the skin hangs over the lashes obscuring vision.

 

Aim of the procedure

 

By the removal of the surplus/protruding skin, fat or both the patient should have a more alert appearance.

 

 

Brief technical details

 

Procedure time: Dependent on treatment areas, all four eyelids average time is around 4 hours

Anaesthetic: Either local or general anaesthetic

Hospital Stay: Usually a day case with the patient staying for a few hours, however, with large amounts of fat removal, an overnight stay may be required.

 

The procedure involves a series of incisions which follow the natural lines of the eyelids. If only fat is to be removed from the lower eyelids, then an external excision (transconjunctival blepharoplasty) can be avoided and only the inside of the lower eyelid is incised to remove the fat.

Post operative details

 

  • It is important to keep the head elevated to reduce swelling.
  • Cold compresses usually help to reduce inflammation.
  • Suture strips/Steri-strips may be used to support the lower eyelids.
  • Eye closure may be a problem after surgery. The eyes may feel tight due to inflammation as well as the loss of skin - sometimes ointment may be prescribed to help with this.
  • Eyes will feel watery post surgery due to a combination of conjunctival inflammation (chemosis) and swollen tear ducts which do not readily drain.
  • The scars on the upper and lower eyelids will remain pink for a few months but should eventually become invisible.

 

Limitations

 

Unfortunately wrinkles present in the crow’s feet area will remain.

 

Complications

 

Haematoma: A pool of blood may collect under the skin. This may lead to the margin of the lower eyelid being pulled away from the eye. The haematoma should hopefully disperse over 2-3 weeks and may require drainage.

Cysts: Tiny white cysts may appear along the stitch lines but may be pricked with a needle

Blindness: Exceptionally rare complication

 

Facelift

 

Reasons for the procedure [24, 25]

 

The most common reasons include age related changes affecting the lower half of the face. This could be separate from or accompanied by substantial weight loss related changes.

 

What happens with age?

 

  • Skin loses its elasticity
  • Muscles tend to slacken
  • Effects of stress, gravity and sun exposure are visible on the face
  • Smile lines deepen, jaw lines sag, skin on the neck slackens
  • Fine wrinkles develop around the lips

 

Benefits of the procedure

 

The patient should look younger, more vital and cheerful! Facelifts cannot stop the clock BUT they do put the clock back!

 

Before the procedure

 

Advise weight reduction for patients who are overweight as this will affect the outcome. Extra skin may be removed achieving a more pleasing result.

 

The procedure

 

The procedure involves elevating and repositioning of the skin and soft tissue of the face. Incisions are made in front of the ear, extending superiorly and anteriorly along the hairline. The muscles of the lower face and neck (plastysma muscle and its fibrous attachment) are tightened and lifted. Removal of redundant skin, re-draping of the remaining skin followed by redistribution of fat and tissue completes the procedure. Commonly the procedures are performed under general anaesthetic or a combination of local anaesthetic and sedation.

 

Complications

 

Surgical complications include:

 

  • Damage to the facial nerve
  • Discomfort and tightening when opening the mouth
  • Swelling and bruising
  • Feeling low and depressed in the first week
  • Discomfort at night

 

Stitches

 

Stitches may be removed a fortnight post procedure. However the final result of the facelift should not be judged until around six to nine months later.

 

Rhinoplasty

 

The nose is the central feature of the face which contributes to facial balance. Many people wish to alter the shape of their nose in an endeavor to find a more harmonious alignment to their features. The term Rhinoplasty may refer to an augmentation, where the surgery aims to build up the nose, or reduction, where the aim is to reduce the size of the nose.

 

The characteristics of the nose are inherited from the parents and develop during adolescence. Growth continues until 16 years, before which it is unwise to operate. In essence, a rhinoplasty involves reshaping the cartilage framework of the nose in order to change its appearance, (49,50,51).

 

Reasons to have the procedure

 

Common reasons may be subdivided into those which are cosmetic and those which are medical.

 

Cosmetic:

 

  • Alteration of the hump at the nose bridge
  • Reshaping of the nose tip
  • Length and width alteration

 

Medical:

 

  • Reconstruction and repositioning of the nose post injury e.g. a flat nose
  • Opening up of the nasal airways to help breathing

 

Brief technical details

 

Procedure time: 90-180 minutes

Hospital stay: 1-2 nights

 

Nasal reshaping may be approached from two ways depending on the incisions. In a closed rhinoplasty the operation is performed from inside the nostrils, whereas for an open rhinoplasty the operation is performed by making a small cut on the nose and elevating the skin.

 

 

 

Reduction Rhinoplasty

 

The aim here is to reduce the size of the nose by altering the framework. Usually the bridge (dorsum) of the nose needs to be brought closer to the face.

 

The bridge of the nose is comprised of a proximal bony portion and a distal cartilaginous area. This area is approached through incisions made through the nostrils. In order to straighten the bridge and bring it closer to the face - the ridge has to be ‘cut away’ and restored in a new orientation. In order to bring both sides of the nose together, the bony parts connected to the cheek bones are cut. The elasticity of the overlying skin shrinks onto the new frame. What is left is a narrower nose.

 

Augmentation Rhinoplasty

 

Rather than reducing original framework, in order to improve the appearance of a flattened nose, it is necessary to introduce some additional framework. There are various materials which may be used as additional framework - these include:

 

Bone: From the crest of the hip, rib, elbow, outer surface of the skull

Cartilage: Shell of an ear, spare nasal cartilage

 

Sometimes in cases of severe collapse of the nose, skin grafting may be necessary to achieve satisfactory reconstruction.

 

Post operative details

 

  • A firm splint will be used to cover the nose to help settle swelling and bruising of the face especially around the eyes. The splint also protects the new frame by keeping it stable.
  • The nose may feel rather stiff and numb - the numbness should disappear slowly but the stiffness is likely to be permanent.
  • A pad may be placed under the nose (bleeding).
  • Time off work and abstinence from strenuous exercise is also expected.
  • It usually takes up to 1 year for the changes in nose shape to evolve.

 

Complications

 

  • Chest infection post operatively (patient has been under general anaesthetic, check smoking history, make sure the patient is free from a cough, cold or sore throat at the time of the operation).
  • Heavy nose bleeding - which may require treatment in the hospital.
  • Difficulty with nasal breathing.
  • For 10% of patients, the nose does not look right for the patient after all the swelling has settled.

 

Liposuction

 

 

Liposuction aims to contour body shapes by removing unwanted fat deposits. Unsightly distributions of fat are attributed to an inborn tendency to deposit fat in particular areas of the body. Unfortunately these areas are resistant to weight loss by diet and exercise. Liposuction (liposculpture or suction assisted lipectomy) is one of the most popular cosmetic procedures worldwide, (45,46).

 

Areas of the body commonly treated include:

 

  • Neck
  • Upper arms
  • Tummy
  • Hips
  • Buttocks
  • Thighs
  • Knees

 

This procedure works best for patients who are near normal weight and have firm, elastic skin.

Common Liposuction Treatment Areas

Brief technical details

 

Each procedure is tailored to the patient’s needs and physical attributes:

 

  • Procedure time: Dependent on treatment area, on average: 1-3 hours.
  • Anaesthesia: Either local or general anaesthetic dependent of treatment area.
  • Hospital Stay: Usually a day case with the patient staying for a few hours, however, with large amounts of fat removal, an overnight stay may be required.

 

Small incisions in the skin are made near the identified area. A small, narrow, hollow tube (cannula) is inserted through these incisions and is attached to a strong vacuum pump. This pump is then manipulated back and forth within the area of excess fat. This process loosens and removes columns of fat leaving small neurovascular structures intact. The skin then retracts and the incisions are sewn up. Of course there are variants to this technique; suction is usually applied with a powerful vacuum machine, however it is sometimes adequate to use a simple syringe for small areas. Ultrasound assisted lipectomy is also in practice.

 

As fat cells are believed not to regenerate in adult life, removal by liposuction will give a permanent change in contour and is independent from changes in body weight.

 

Post operative instructions

 

At the end of the operation, simple pain killers may be prescribed and sutures may be removed after a week post surgery. Tight bandages or elasticated clothing should be worn to minimise swelling and help the body conform to its new shape - this should be worn for at least three weeks.

Limitations of the procedure

 

  1. This procedure is not a substitute for weight loss.
  2. Dimples and wrinkles of the skin, sometimes referred to as cellulite, is not improved by liposuction.

 

Warn the patient!

 

Some patients have complained of the following post operatively:

 

  1. Stiffness and pain
  2. Swelling
  3. Bruising
  4. Numbness
  5. Unusual sensations
  6. Fine thread veins
  7. Lumpy appearance as fat settles

 

Complications

 

These are usually quite rare, however the following should be taken into account:

 

  1. Infection
  2. Venous Thromboembolic disease
  3. Heavy bruising (in patients on blood thinning medication)
  4. Thrombophlebitis
  5. Irregular contours around treated area
  6. The skin may appear to be tethered

 

Abdominoplasty

 

Reasons for the procedure [26, 27]

 

The aims of abdominoplasty include removal of excess skin and fat, however this procedure can be tailored to suit a patient's wishes and needs.

 

The usual culprit is pregnancy accompanied by weight loss. In some cases tightening of the abdominal muscles is also required, e.g. divarification of recti due to muscle weakening from pregnancy.

 

Standard abdominoplasty

 

Excess skin and fat of the abdominal wall lying between the pubic area and the umbilicus is removed. The umbilicus usually remains in place.

 

The skin at the umbilical level is then brought down and sutured, leaving a long curved scar at the level of the pubic hair.

 

Mini abdominoplasty

 

Surplus skin below the umbilicus is removed leaving a low abdominal scar at the level of the pubic hair. Liposuction may be carried out during the procedure to thin the abdominal wall.

 

Usually, it is the procedure of choice for post ceasarean section patients.

 

Extended abdominoplasty

 

Surplus skin and fat of the loins are also removed so that the scar extends around the flanks.

 

The consequences

 

  • Flat abdomen BUT the waist is not tightened
  • Lower abdominal wall numbness, usually temporary but has potential to become permanent
  • Noticeable scars - standard abdomnoplasty (two scars - transverse scar from one flank to the other and a periumbilical scar)

 

Limitations

 

  • The waist is not tightened - this would form a verticle scar if done
  • A further pregnancy will cause the skin to stretch again - although probably not to the same degree

 

Risks

 

Surgical risks:

 

  • Re-accumulation of fluid after drain removal requiring drainage or aspiration
  • Slow healing - dressings may be needed for weeks (smokers/obese patients)
  • The need for a second procedure (liposuction/scar revision)
  • Venous thromboembolic diseases (Deep Vein Thrombosis/Pulmonary embolism)

 

Special considerations

 

Tell the patient:

 

  • 2-4 day hospital admission
  • Expect to be on a fluid drip post operatively
  • Drainage tubes will be attached to the lower abdomen
  • Expect moderate-sever pain for which oral/intravenous medication may be prescribed
  • Keep the knees and hips bent to relax the abdominal muscles

 

Recuperation information:

 

  • Over activity affects healing time and fluid accumulation
  • No sports for 6 weeks
  • Corsets are useful to reduce swelling and improve comfort in the first 30 days

 

Aesthetic Plastic Surgery and Ethnicity

 

'Ethnicity is a defined social construct based on national origin and phenotypic pigmentatin.' [29]

 

The following diagram is a Global Representation of Indigenous Skin Colour - Luschan's Chromatic Scale, [28]:

 

 

Statistical projections suggest a continued major growth of darker skinned racial populations. The health related impact of different ethnicities is more and more evident. With respect to aesthetic surgery, there are unique physiological and anatomical differences between the skin of different racial groups. The following are features of darker coloured skin which may affect the surgical and cosmetic outcomes, [30]:

 

Skin colour

 

This is one of the defining features of different races. Skin colour is influenced largely by melanin but other components such as haemoglobin and dietary carotenoids also have a role.

 

Melanocytes are dendritic cells which interface with keratinocytes forming an epidermal-malanin unit. The amount of melanin within the keratinocytes determines skin colour. The darker, the greater the content.

 

The melanocytes found in darker skinned races show labile, exaggerated responses to cutaneous injury - a consequence of this sensitivity is a high frequency of dycrasias (melasmas and post inflammatory hyperpigmentation) in darker skinned patients.

 

The assessment and knowledge that colour changes over time are important in aesthetic surgery - especially for predicting outcome. There are different skin classifications, one of which is the Fitzpatrick Classification. This has six categories and darker skins are classified as skin types (IV - brown - rarely burns) and VI (black-never burns).

 

Epidermal structure and function

 

Differences exist between the lighter and darker skinned counterparts. The variations are seen within the stratum corneum, in thickness and water content, in lipid production and in melanin. The barrier integrity and differences in function of the epidermis are important when considering non-surgical procedures.

 

Keloid Scarring

 

Keloid scars have been recognised as abnormal responses to trauma for centuries, [31]. A keloid is an 'abnormal scar that grows beyond the boundaries of the original site of skin injury.' Keloids have the appearance of a raised amorphous growth and are associated with pain and pruritis. Unfortunately, individuals of all ethnic backgrounds can form keloids, however in pigmented ethnic groups, keloid formation is 15 times greater compared to the lighter counterparts. In Hispanic and Black populations, the prevalence may be as high as 16%. When it comes to aesthetic surgery, counselling a darker skinned patient with the risk of keloid scarring is of great importance.

 

Differences in anatomy and physiology of the skin must be taken into consideration when selecting aesthetic surgical procedures for patients of different ethnicities. In 2005, data from the American Society for Aesthetic and Plastic Surgery revealed that darker skinned racial groups accounted for 20% of aesthetic surgery procedures, [30]. Keeping this in mind, surgeons need to recognise the differences and manage appropriately to 'provide optimal patient care, patient satisfaction and an enhanced quality of life', [30].

 

Future Developments In Aesthetic Plastic Surgery

 

Plastic surgery is thriving worldwide; the American Society of Plastic Surgeons predicts [36] that aesthetic surgery procedures may exceed 55 million annually by the year 2015!

 

An article published on the Stem Cell Research and Umbilical Cord Blood Donation website suggests most reconstructive and aesthetic surgery procedures are quite primitive, requiring invasive techniques, long recoveries and complications in essentially healthy individuals, [37].

 

Stem cell technology may be the solution of the future. The stem cell has the ability to divide and under favourable conditions differentiate into many different cells giving rise ultimately to complete organisms. Stem cells are termed pluripotent if derived from the three embryonic germ layers. This term describes their potential to transform into any type of cell.

Aesthetic Surgery and Stem Cells

 

Procedures involving synthetic implants of silicone and saline carry the risk of rupture and leaking - stem cell generated natural tissues should in theory avoid these problems. Jeremy Mao, Univerisity of Illinois, Chicago suggests that 'the stem cell approach might eliminate the need for additional surgery as it may produce a long lasting, shapely and natural implant', [38].

 

In 2005, Mao and his research team extracted mesodermal stem cells taken from the bone marrow of healthy human volunteers and recreated favourable conditions for the cells to grow into fat producing cells. These cells were placed in hydrogel scaffolds; these may be moulded into any shape or size, which were then placed under the skin of mice and left to grow for 4 weeks. After the time, researchers noted that the cells had differentiated and grown into the desired fat producing cells in the shape of the scaffolds, i.e. an implant. The implant also retained both its shape and size when a conventional implant lost its shape within a month.

 

These results were exciting for Mao and his team who reported that '...the present approach represents another step towards an alternative tissue engineering approach for soft tissue augmentation and reconstruction', [38].

 

Since 2005, adipose stem cells from peoples' autologous fat have been used as implants. There have been 'stem cell face lifts' and 'stem cell breast augmentaition' but further research and discussion is still needed. In fact, the 2011 2nd Aesthetic Plastic Surgery and Anti-aging Medicine: The Next Generation symposium to be held in New York will focus on the new developments in the science of stem cells and fat grafting, [39].

 

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