Plastic surgery

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. While famous for aesthetic surgery, plastic surgery also includes a variety of fields such as craniofacial surgery, hand surgery, burn surgery, microsurgery, and reconstructive surgery. The word "plastic" derives from the Greek plastikos meaning to mold or to shape; its use here is not connected with the synthetic polymer material known as plastic.

History
Reconstructive surgery techniques were being carried out in India by 2000 BC. Sushruta (6th century BC) made important contributions to the field of Plastic and Cataract surgery. The medical works of both Sushruta and Charak were translated into Arabic language during the Abbasid Caliphate (750 AD). These Arabic works made their way into Europe via intermediaries. In Italy the Branca family of Sicily and Gaspare Tagliacozzi (Bologna) became familiar with the techniques of Sushruta.

British physicians traveled to India to see Rhinoplasty being performed by native methods. Reports on Indian Rhinoplasty were published in the Gentleman's Magazine by 1794. Joseph Constantine Carpue spent 20 years in India studying local plastic surgery methods. Carpue was able to perform the first major surgery in the Western world by 1815. Instruments described in the Sushruta Samhita were further modified in the Western world.

The Romans were able to perform simple techniques such as repairing damaged ears from around the 1st century BC. Due to religious reasons they didn't approve of the dissection of both human beings and animals, thus their knowledge was based in its entirety on the texts of their Greek predecessors. Notwithstanding this Aulus Cornelius Celsus has left some surprisingly accurate anatomical descriptions, some of which —for instance, his studies on the genitalia and the skeleton— are of special interest to plastic surgery.

The Egyptians were also one of the first people to perform plastic cosmetic surgery.

In 1465, Sabuncuoglu's book, description, and classification of hypospadias was more informative and up to date. Localization of urethral meatus was described in detail. Sabuncuoglu also detailed the description and classification of ambiguous genitalia (Kitabul Cerrahiye-i Ilhaniye -Cerrahname-Tip Tarihi Enstitüsü, Istanbul) In mid-15th century Europe, Heinrich von Pfolspeundt described a process "to make a new nose for one who lacks it entirely, and the dogs have devoured it" by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not until the 19th and 20th centuries that such surgery became commonplace.

Up until the techniques of anesthesia became established, all surgery on healthy tissues involved great pain. Infection from surgery was reduced once sterile technique and disinfectants were introduced. The invention and use of antibiotics beginning with sulfa drugs and penicillin was another step in making elective surgery possible.

In 1792, Chopart performed operative procedure on a lip using a flap from the neck. In 1814, Joseph Carpue successfully performed operative procedure on a British military officer who had lost his nose to the toxic effects of mercury treatments. In 1818, German surgeon Carl Ferdinand von Graefe published his major work entitled Rhinoplastik. Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap. In 1845, Johann Friedrich Dieffenbach wrote a comprehensive text on rhinoplasty, entitled Operative Chirurgie, and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose. In 1891, American otorhinolaryngologist John Roe presented an example of his work, a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses. In 1896, James Israel, a urological surgeon from Germany, and In 1889 George Monks of the United States each described the successful use of heterogeneous free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German orthopaedic-trained surgeon, published his first account of reduction rhinoplasty. In 1928, Jacques Joseph published Nasenplastik und Sonstige Gesichtsplastik.

The first American plastic surgeon was Dr. John Peter Mettauer, who in 1827 performed the first cleft palate operation with instruments that he designed himself.

In World War I a New Zealand otolaryngologist working in London, Sir Harold Gillies, developed many of the techniques of modern plastic surgery in caring for soldiers suffering from disfiguring facial injuries. His work was expanded upon during World War II by one of his former students and cousin, Archibald McIndoe, who pioneered treatments for RAF aircrew suffering from severe burns. McIndoe's radical, experimental treatments, led to the formation of the Guinea Pig Club. In 1951 Gillies carried out the first male-to-female sex change operation.

Plastic surgery as a specialty evolved tremendously during the 20th century in the United States. One of the founders of the specialty, Dr. Vilray Blair, was the first chief of the Division of Plastic and Reconstructive Surgery at Washington University in St. Louis, Missouri. In one of his many areas of clinical expertise, Blair treated World War I soldiers with complex maxillofacial injuries, and his paper on "Reconstructive Surgery of the Face" set the standard for craniofacial reconstruction. He was also one of the first surgeons without a dental background to be elected to the American Association of Oral and Plastic Surgery (later the organizations split to be renamed the American Association of Plastic Surgeons and the American Association of Oral and Maxillofacial Surgeons) and taught many surgeons who became leaders in the field of plastic surgery.

Techniques and procedures
Common techniques used in plastic surgery are:
 * incision
 * excision
 * microsurgery
 * chemosurgery
 * electrosurgery
 * laser surgery
 * dermabrasion
 * liposuction

In plastic surgery the transfer of skin tissue (skin grafting) is one of the most common procedures. (In traditional surgery a “graft” is a piece of living tissue, organ, etc., that is transplanted.
 * Autografts: Skin grafts taken from the recipient. If absent or deficient of natural tissue, alternatives can be:
 * Cultured Sheets of epithelial cells in vitro.
 * Synthetic compounds (e.g., Integra--a 2 layered dermal substitute consisting superficially of silicone and deeply of bovine tendon collagen with glycosaminoglycans).
 * Allografts: Skin grafts taken from a donor of the same species.
 * Xenografts: Skin grafts taken from a donor of a different species.

Usually, good results are expected from plastic surgery that emphasizes:
 * Careful planning of incisions so that they fall in the line of natural skin folds or lines.
 * Appropriate choice of wound closure.
 * Use of best available suture materials.
 * Early removal of exposed sutures so that the wound is held closed by buried sutures.

Reconstructive plastic surgery
Reconstructive Plastic Surgery is performed to correct functional impairments caused by:
 * burns
 * traumatic injuries, such as facial bone fractures
 * congenital abnormalities, such as cleft lip, or cleft palate
 * developmental abnormalities
 * infection or disease
 * removal of cancers or tumours, such as a mastectomy for a breast cancer, a head and neck cancer and an abdominal invasion by a colon cancer

Reconstructive plastic surgery is usually performed to improve function, but it may be done to approximate a normal appearance. It is generally covered by insurance coverage but this may change according to the procedure required.

Common reconstructive surgical procedures are: breast reconstruction for women who have had a mastectomy, cleft lip and palate surgery, contracture surgery for burn survivors, creating a new outer ear when one is congenitally absent, and closing skin and mucosa defects after removal of tumors in the head and neck region.

Plastic surgeons developed the use of microsurgery to transfer tissue for coverage of a defect when no local tissue is available. tissue flaps of skin, muscle, bone, fat or a combination, may be removed from the body, moved to another site on the body and reconnected to a blood supply by suturing arteries and veins as small as 1-2 mm in diameter.

The most common reconstructive procedures are tumor removal, laceration repair, scar repair, hand surgery and breast reduction. According to the American Society of Plastic Surgeons, the number of reconstructive breast reductions for women increased in 2007 by 2 percent from the year before. Breast reduction in men also increased in 2007 by 7 percent.

Cosmetic surgery
Cosmetic Surgery defined as a subspecialty of surgery that uniquely restricts itself to the enhancement of appearance through surgical and medical techniques. It is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal. In 2006, nearly 11 million cosmetic surgeries were performed in the United States alone.

The number of cosmetic surgeries performed in the United States has increased over 50 percent since the start of the century. Nearly 12 million cosmetic surgeries were performed in 2007, with the five most common being breast augmentation, liposuction, nasal surgery, eyelid surgery and abdominoplasty. The increased use of cosmetic surgery crosses racial and ethnic lines in the U.S., with increases seen among African-Americans and Hispanic Americans as well as Caucasian Americans. In Europe, the second largest market for cosmetic procedures, cosmetic surgery is a $2.2 billion business.

The most prevalent aesthetic/cosmetic procedures are listed below. Most of these types of surgery are more commonly known by their "common names." These are also listed when pertinent.
 * Abdominal etching, or Ab etching, is used to contour and shape the abdominal fat pad to provide patients with a flat stomach.
 * Abdominoplasty (or "tummy tuck"): reshaping and firming of the abdomen
 * Blepharoplasty (or "eyelid surgery"): Reshaping of the eyelids or the application of permanent eyeliner, including Asian blepharoplasty
 * Mammoplasty
 * Breast augmentation ("breast enlargement" or "boob job"): Augmentation of the breasts. This can involve either fat grafting, saline or silicone gel prosthetics. Initially performed to women with micromastia
 * Breast reduction: Removal of skin and glandular tissue. Indicated to reduce back and shoulder pain in women with gigantomastia and/or for psychological benefit in women with gigantomastia/macromastia and men with gynecomastia.
 * Breast lift (Mastopexy): Lifting or reshaping of breasts to make them less saggy, often after weight loss (after a pregnancy, for example). It involves removal of breast skin as opposed to glandular tissue.
 * Buttock Augmentation (or "butt augmentation" or "butt implants"): Enhancement of the buttocks. This procedure can be performed by using silicone implants or fat grafting and transfer from other areas of the body.
 * Chemical peel: Minimizing the appearance of acne, pock, and other scars as well as wrinkles (depending on concentration and type of agent used, except for deep furrows), solar lentigines (age spots, freckles), and photodamage in general. Chemical peels commonly involve carbolic acid (Phenol), trichloroacetic acid (TCA), glycolic acid (AHA), or salicylic acid (BHA) as the active agent.
 * Labiaplasty: Surgical reduction and reshaping of the labia
 * Rhinoplasty (or "nose job"): Reshaping of the nose
 * Otoplasty (or ear surgery): Reshaping of the ear
 * Rhytidectomy (or "face lift"): Removal of wrinkles and signs of aging from the face
 * Suction-Assisted Lipectomy (or liposuction): Removal of fat from the body
 * Chin augmentation: Augmentation of the chin with an implant (e.g. silicone) or by sliding genioplasty of the jawbone.
 * Cheek augmentation
 * Collagen, fat, and other tissue filler injections (e.g. hyaluronic acid)
 * Laser skin resurfacing

In recent years, a growing number of patients seeking cosmetic surgery have visited other countries to find doctors with lower costs. These medical tourists seek to get their procedures done for a cost savings in countries including Cuba, Thailand, Argentina, India, and some areas of eastern Europe. The risk of complications and the lack of after surgery support are often overlooked by those simply looking for the cheapest option.

Plastic surgery sub-specialities
Plastic surgery is a broad field, and may be subdivided further. Plastic surgery training and approval by the American Board of Plastic Surgery includes mastery of the following as well:
 * Craniofacial surgery is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, craniosynostosis, and pediatric fractures. Because these children have multiple issues, the best approach to providing care to them is an interdisciplinary approach which also includes otolaryngologists, speech therapists, occupational therapists and geneticists. Adult craniofacial surgery deals mostly with fractures and secondary surgeries (such as orbital reconstruction). Both subspecialities usually require advanced training in craniofacial surgery. The craniofacial surgery field is also practiced by maxillofacial surgeons (see craniofacial surgery).
 * Hand surgery is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. Most Hand surgeons will opt to complete a fellowship in Hand Surgery. The Hand surgery field is also practiced by orthopedic surgeons and general surgeons (see Hand surgeon).
 * Microsurgery is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery.
 * Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed. Reconstructive surgery generally involves plastic surgery.
 * Aesthetic or cosmetic surgery is concerned with the correction of form and aging. Plastic surgeons usually excel in this field because of their thorough knowledge of anatomy and extensive experience with reconstruction and congenital anomalies correction. Popular operations include amongst other breast augmentation, rhinoplasty, face lift, liposuction and mastopexy.
 * Pediatric plastic surgery. Children often face medical issues unique from the experiences of an adult patient. Many birth defects or syndromes present at birth are best treated in childhood, and pediatric plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include craniofacial anomalies, cleft lip and palate and congenital hand deformities.