Plastic surgery has two branches, cosmetic surgery and reconstructive plastic surgery. Cosmetic surgery aims to improve the aesthetic appearance of a person, while plastic surgery may include this, or just the reconstruction (reconstructive surgery). Reconstructive plastic surgery aims to improve function; however, it may also involve trying to approximate normal appearance, but that is not its primary function. Reconstructive plastic surgery is often referred as simply reconstructive surgery.
Some parts of the world completely separate cosmetic surgery and plastic surgery and term cosmetic surgery as elective surgery, non-essential surgery, surgery which the patient chooses to have; while plastic surgery is understood to mean surgery to reconstruct or improve appearance after injury or illness.
This article focuses on cosmetic surgery only.
According to official statistics, approximately 65,000 surgical cosmetic procedures were performed in 2008 in the UK – 50% more than in 2003. Breast enlargement was the most popular procedure, followed by rhinoplasty (nose job, nose reshaping), liposuction, and face-lifts. Cosmetic surgery in the USA is far more popular:
Surgical cosmetic procedures USA, 2007
- Liposuction 456,828
- Breast augmentation 399,440
- Eyelid surgery 240,763
- Abdominoplasty 185,335
- Female breast reduction 153,087
- Total – 1,435,444
(Source: American Society for Aesthetic Plastic Surgery)
Non-surgical cosmetic procedures, USA, 2007
- Botox 2,775,176
- Hyaluronic Acid (Hylaform, Juvederm, Restylane) 1,448,716
- Laser Hair Removal 1,412,657
- Microdermabrasion 829,658
- Laser Skin Resurfacing 647,707
- Total – 7,113,914
(Source: American Society for Aesthetic Plastic Surgery)
Experts say that not everybody is suitable for cosmetic surgery. There may be factors in the patient’s life that may be influencing his/her surgery decisions. In many cases in Europe and North America surgeons may delay the procedure until the patient has received psychological counseling. As most surgical cosmetic surgery procedures have permanent results, it is crucial that the patient is completely sure about wanting to go ahead.
What types of cosmetic surgeries are there?
Below is a list of the most common cosmetic surgeries:
- Tummy tuck (abdominoplasty) – the abdomen is reshaped and firmed. During this surgical procedure excess skin and fact is removed from the middle and lower abdomen, with the aim of tightening the muscle and fascia of the abdominal wall. Tummy tucks are more popular among women after pregnancy and people who have lost a great deal of weight and do not like the sagging that sometimes results from this. Sometimes the sagging skin occurs for genetic reasons (the patient inherited the trait). This procedure may also improve the appearance of stretch marks, especially those located below the navel.It is important that malnutrition is identified among patients who have lost a lot of weight. Identifying malnutrition before surgery in massive weight loss patients seeking body contouring will significantly decrease surgical complications, accelerate wound healing, improve scar quality and boost patient energy levels, a study published in Plastic and Reconstructive Survey reported.
- Eyelid surgery (blepharoplasty) – the eyelids are reshaped, or a permanent eyeliner is applied. This procedure may be either functional or cosmetic, and sometimes both. The aim is to reshape the upper or lower eyelid by removing or repositioning excess tissue. It may also involve reinforcing surrounding muscles and tendons. According to the Mayo Clinic, surgery can improve vision for people with drooping eyelids.
- Mammoplasty, this may include:
- Breast enlargement (breast augmentation; boob job) – the breasts are enlarged. This is one of the most common procedures in cosmetic surgery. This is done either with fat grafting, or with saline or silicone gel prosthetics. Usually carried out because the woman feels her breasts are too small (micromastia), but also if one breast is larger than the other, or if the breasts have changed after pregnancy and/or breastfeeding.Breast implants may also be considered by patients who have had their breast removed (mastectomy), as may be the case with breast cancer. Breast implants come in many sizes, shapes and profiles.Women who undergo breast enlargement often see a sizable boost in self-esteem and positive feelings about their sexuality, a researcher at the University of Florida found.
- Breast reduction – skin and glandular tissue is removed to make the breasts smaller. This procedure may also apply for women who suffer from shoulder or back pain because their breasts are very/too large (gigantomastia).Breast reduction surgery has a much higher percentage of patients who want to relieve a physical discomfort, compared to women who want breast augmentation. Doctors at the Royal Free Hampstead NHS Trust and Royal Free and University College Medical School in London reported in the BMJ (British Medical Journal) that young women undergoing cosmetic breast reduction surgery are being screened for cancer without their informed consent. Breast reduction reduces breast cancer risk among high-risk women, said a study published in the journal Plastic and Reconstructive Surgery.
- Male breast reduction (gynecomastia) – The procedure can also be carried out on men who have abnormally large mammary glands. This condition is much more common than people think – it affects approximately 40% to 60% of the male populations of North American and Western Europe (American Society for Aesthetic Plastic Surgery). A study published in NEJM (New England Journal of Medicine) reported a figure of 40% to 50% of males, at some point in their lives. Some males may have just one affected breast, while others have both.In most cases, experts are not sure why some men have enlarged breasts. We do know that the following factors may have an impact: taking anabolic steroids, medication containing estrogen, alcohol consumption, marijuana consumption, impaired liver function, and some cancers.
- Mastopexy (breast lift) – as the skin loses its elasticity, gravity starts taking its toll, plus other factors such as weight loss, pregnancy and/or breastfeeding alter the shape and firmness of the breasts, some women want a breast lift. The breast lift raises the breasts, giving them a more youthful contour. Sometimes the patient will undergo breast augmentation at the same time.
Researchers at the Memorial Sloan – Kettering Cancer Center New York, found that six major factors that affect how happy a woman feels with the outcome of her breast surgery.
- Lower-body lift – this may include:
- Buttock augmentation – this procedure enhances the appearance of the buttocks by making them larger. The surgeon will either graft fat from another part of the patient’s body, or use a silicone implant.
- Buttock lift – this procedure lifts the buttocks so that they stick out more and have a tighter, more pert appearance. The surgeon does not always need to place implants. A scarless technique can be used for buttock lift.
- May also include procedures to tighten loose, sagging skin in the backs of the thighs, hips, outer thighs, and the front of the thighs. The surgeon will usually utilize incisions which go from the back round the hips to the front of the thighs. The surgeon removes the loose skin as well as some underlying fat tissue so that the remaining skin can stretch and smooth the lower body – especially the thighs and buttocks.
- Chemical peel – popular among people with acne or pock, as well as those with scars and wrinkles. The procedure involves using Phenol (carbolic acid), TCA (trichloroacetic acid), AHA (glycolic acid) or BHA (salicylic acid) as the active ingredient. There are two types of chemical peel:
- Deep (phenol) peel – also known as a deep chemical peel. This is for patients with deep wrinkles, usually from exposure to the sun, as well as the skin that wrinkles around the lips and chin. This treatment reduces the appearance of skin damage and imperfections.
- Light to medium chemical peel – more suitable for patients with finely wrinkled faces, as well as sun-damaged skin, and uneven pigmentation. All chemical peels peel away the top layers of the skin.
Researchers at the Saint Louis University School of Medicine found that chemical peels using either alpha-hydroxy acid or beta-hydroxy acid are both highly effective in treating mild to moderately severe facial acne.
- Labiaplasty – also called labioplasty, labia minor reduction, or labial reduction. This involves surgery of the labia majora or labia minora of the vulva (part of the female genitalia). Labiaplasty reduces elongated labia. This is generally part of a vaginoplasty. However, there exists little clinical or scientific evidence to guide gynecological surgeons as to the safety and effectiveness of different cosmetic vaginal procedures.
- Nose job (rhinoplasty) – the surgeon reshapes the patient’s nose. It is usually done by an otolaryngologist (head and neck surgeon, ear/nose and throat specialist), maxillofacial surgeon or plastic surgeon. The aim is to improve the appearance of the nose, and sometimes its function as well if the patient has breathing problems. Surgeon’s say patients should wait until they are at least 15 years of age (boys perhaps even older). Sometimes rhinoplasty is carried out in conjunction with a facelift. An study published in the Otolaryngology Head and Neck Surgery found that a higher rate of personality disorders among nose job candidates.
- Ear surgery (otoplasty) – generally this involves pining the ear closer to the head. However, surgery may involve reducing the size of very large ears, or reshaping various bends in the cartilage. Most commonly, otoplasty is used for patients with:
- Protruding ears (ears that stick out)
- Large ears
- Ears that have an abnormal shape
Some patients have surgery done on just one ear, while others have both ears done. Ear surgery can be performed on children because the ears reach their near total development when the child is 5 or 6. The American Academy of Cosmetic Surgery reported that cosmetic ear surgery has the youngest age of patients. Cosmetic surgical procedures for children pose ethical dilemmas.
- Facelift (rhytidectomy) – rhytidectomy means to remove wrinkles surgically. The aim is to make the patient’s face look younger. Excess facial skin is removed without tightening underlying tissue – the skin is then redraped on the patient’s face and/or neck. Face lifts may be done in many ways, however, the most popular one is to make an incision in front of the ear which extends into the hairline and also curves around the bottom of the ear and then behind it. The skin is then separated from the deeper tissues with a scalpel or scissors over the cheeks and neck. The deeper tissues are then tightened with sutures (stitches) – sometimes the excess deeper tissues are removed. The skin is then redraped and some excess skin is removed. The incisions are then sutured or stapled. Facelift procedures are continuously evolving.A study published in Archives of Facial Plastic Surgery reported on the surprising high rate of MRSA infections following facelift surgery.
- Liposuction (suction-assisted lipectomy) – also known as fat modeling, liposculpture suction lipectomy, or lipo. Fat is surgically removed from various parts of the body – usually the abdomen, thighs, buttocks, hips, backs of the arms, and neck. Liposuction may also be used for male breast reduction. It is crucial for the patient to be told that liposuction is not a weight loss method.If there is a lot of fat, the surgeon cannot remove it all in one go. How much fat is removed depends on what method is being used, as well as certain aspects relating to the patient – usually the most that can be taken out is about 5 kg (a little over 10 lbs). If too much fat is removed there is a significantly greater risk of complications for the patient.The fat is removed via a cannula (a hollow metal tube) that is passed through the fatty tissue. A pump is attached, generating a vacuum, so that the fat is literally sucked out (suction assisted liposuction). A motor may be attached which makes the cannula vibrate (vacillate back and forth). An ultrasonic generator may also be used – this produces sound waves that break the fat cells which are then removed. Prior to removal the fat cells may also be broken down with laser.Although complications are uncommon, they can occur, including the accumulation of blood under the skin (hematoma), infection, changes in sensation, allergic reactions, damage to underling structures, and unsatisfactory results. It is important that the patient is aware of the risks and has talked about them with a doctor.
Smokers are advised to give up well in advance of the operation and not to resume for at a least a few weeks afterwards. Smoking can significantly undermine recovery.
Liposuction does not reduce the risk of developing diabetes, heart disease or hypertension (high blood pressure), a team at the Washington University School of Medicine in St. Louis found.
- Brow lift – also known as a browplasty or forehead lift. The aim is to raise drooping eyebrows and/or remove forehead wrinkles (worry lines) – conditions associated with aging. It is often performed in conjunction with other cosmetic procedures aimed at achieving a more harmonious facial appearance.
- Chin augmentation – the aim is usually to give the patient a more prominent chin and a better balance of facial features. An implant is usually placed by the surgeon. Often when the patient has a nose job (rhinoplasty) he/she will include chin augmentation surgery in the same session. Sometimes the surgeon is able to manipulate the jaw bone (without using a prosthetic implant). However, chin augmentation with implants is the more popular option for patients with normally functioning teeth and jaw development.
- Cheek augmentation – this surgical procedure is aimed at giving the patient more prominent cheekbones. The surgeon may place an implant at the top of the cheekbones. Many patients say that weak cheeks make their face seem gaunt and aged. As we age our cheeks may lose their fullness.
- Cheek lift – also known as a midface lift. This surgical procedure raises the middle of the face (the cheek) to improve cheek and under-eye fullness and contour.
- Hair transplantation – A large percentage of men, especially Caucasian men, and a smaller percentage of women are affected by hair loss. Most hair loss occurs for genetic reasons. Micro-hair transplantation has replaced larger grafts of hair. Patients may require several sessions to achieve desired results. After six weeks the transplanted hair will fall out and be replaced about three months later when the new hair appears. A dermatologist can help patients suffering from hair loss.
- Collagen injections – collagen is widely used in cosmetic and plastic surgery for burn patients and for the reconstruction of bone. It is also widely used in dentistry, orthopedics and other surgeries. Collagen injections are also used in treating patients with urinary incontinence. One of the drawbacks is that some patients experience prolonged redness. Doctors can carry out a patch test before surgery to find out how susceptible the patient might be. Most collagen comes from young beef cattle – they are free of BSE (bovine spongiform encephalopathy – mad cow disease). Collagen may also be derived from pig tissue.These treatments are dermal fillers used in cosmetic medicine to reduce wrinkles, lines and scars, as well as to augment soft tissue contours. Collagen treatments are not permanent – they are degraded by the body and have to be repeated at later date.
- Fat injections – also called fat grafting, and has broad applications in cosmetic surgery. The patient’s own fat is collected from one part of the body and injected into areas requiring volume-enhancement. The results are generally safe and long lasting. Patients are generally more satisfied with this procedure because often two birds are killed with one stone – fat is removed from a part of the body that needs fat reduction, and then added to another part that requires more volume. When the fat is removed it is washed and purified and then carefully re-injected with specially designed needles. Sometimes the procedure needs to be repeated several times for best results.The hands, face (including lips), and depressions in the skin contour are the most common targets for skin grafting. Rejuvenating newly identified fat compartments in the facial cheeks can help reduce the hollowed look of the face as it ages.A survey suggests that patients may experience higher complication rates with permanent cosmetic fillers than with other types of cosmetic injections.
Stem-cell enriched fat grafts – surgeons at Copenhagen University Hospital in Denmark carried out a randomized human trial using stem-cell enriched fat grafts. They said the procedure is reliable, safe and effective and could become central to plastic and reconstructive surgery.
Choosing a surgeon
UK – it is important that the surgeon is registered in two places:
- The General Medical Council
- The British Association of Aesthetic Plastic Surgeons (BAAPS)
A BAAPS member must have at least 6 years training in plastic and reconstructive surgery, as well as basic surgical training. It is also advisable that a prospective patient seek surgeons who have a specialism or experience in the type of procedure required. Cosmetic surgeons who work in the National Health Service (NHS) also work privately.
Any company in the UK that provides cosmetic surgery must be registered with the Healthcare Commission. Prospective patients should check their inspection reports and double check that their annual registration is up-to-date.
The NHS advises prospective patients to verify what measures the surgeon or company will take to ensure that the surgery progresses as smoothly as possible. The surgeon should explain everything clearly before, during and after surgery. The patient should be told what problems to expect when returning home after surgery or hospital.
USA – Ideally, the surgeon should be a member of the American Society for Aesthetic Plastic Surgery (ASAPS). ASAPS informs that membership is by invitation only and membership is limited to those who are formally trained and experienced plastic surgeons who concentrate their practices in performing cosmetic plastic surgery of the face and body. Membership of ASAPS is an exclusive privilege for surgeons who have the necessary qualifications – only approximately 25% of American Board of Plastic Surgery certified surgeons have been accredited into ASAPS membership. The society does not offer membership to doctors who are trained in specialties other than plastic surgery.
If the surgeon is not an ASAPS member, he/she should at least be certified by the American board of Plastic Surgery.
There are many medi-spas in the USA that offer various services. There is no umbrella organization that sets standards for medi-spas, no recognized definition of what constitutes a medi-spa.
What about cosmetic surgery for people with psychological issues?
A greater proportion of people with psychological issues or who have suffered from domestic violence are more likely to undergo cosmetic surgery. Researchers from the Institute of Educations, UK, believe there is a risk that their psychological conditions could get worse rather than better following cosmetic surgery.
The team examined 192 studies, including 13 systematic reviews and found that people who had undergone cosmetic surgery were much more likely to be in an abusive relationship, or to have some kind of relationship issue. However, they were unable to confirm whether this factor drove them to seek cosmetic surgery.
A much higher percentage of patients who undergo cosmetic surgery have psychological issues, such as depression or BDD (body dysmorphic disorder) compared to the general population.
Lead researcher, Ginny Brunton and team found that cosmetic surgery tended not to improve these conditions. In some cases in fact, they found that people became psychologically worse after their operation.