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Plastic Surgery
Plastic surgery is a medical specialty that fixes the
form and function of some part of the body involving
the skin. Plastic surgery is often performed for
cosmetic/aesthetic reasons only (improving
appearance and/or removing signs of aging), which
is why it is often referred to as cosmetic surgery.
Examples include surgery to reduce nose size purely
for appearances sake (known as a nose job), breast
enhancement, weight loss surgery, scar removal, fat
removal, and scar removal. Over 12 million cosmetic
surgeries are performed per year in the U.S., mostly
on Caucasian people. Cosmetic surgery is also very
common (and increasing) across the world (e.g.,
China and India) and billions of dollars a year is
spent on it.
FEATURED BOOK: Plastic Surgery Secrets Plus
When plastic surgery becomes
extreme: the case of Hang
Mioku before (left) and after
(right). See the end of this entry
for more.
When teenagers undergo plastic surgery for
cosmetic reasons, doctors try to make sure that
they are emotionally mature and stable enough to
proceed with the surgery (e.g., not clinically
Children usually cannot undergo breast enhancement for cosmetic reasons because the salt water
implants are not approved for people under age 18. However, there are exceptions such as when one
breast is significantly larger than the other. In cases where plastic surgery is not considered by the
doctor to be something that should be pursued at the time, the doctor will counsel the patient on
alternative temporary or permanent approaches (e.g., diet instead of surgery, counseling for
depression).
Plastic surgery is sometimes performed for cosmetic reasons and medical reasons (e.g., if a person’s
nose size and structure interfered with breathing; if a scar is so thick that it impedes movement). In
fact, most plastic surgery actually is done for medical reasons (e.g., to improve functioning) and is
reconstructive although reconstructive surgeries can also be cosmetic. Examples include surgery to
repair a part of the body that was significantly damaged (e.g., from burns, lacerations, bone breaks,
animal bites, infections and disease, and cancer/tumors), surgery of the extremities to correct limb
deformities and other birth defects (e.g., constructing an outer ear when one was absent at birth),
surgeries to remove excess tissue (e.g., breast reduction [in women and men] due to excess tissue or
breast cancer), and microsurgery (surgeries that require the use of a microscope).
Burn surgery also takes place in the acute (early) phase after injury prior to the reconstructive surgery
(which takes place after the burns have healed). Burn surgeries generally involve skin grafts, which
are discussed in more detail below. Such surgeries can help replace lost skin and treat tightening of
skin after burns. Microsurgery allows for reconnection of small blood vessels and nerves and allows
transfer of tissue from one part of the body to another when no local tissue is available. It is used in
reconstructive surgery of the neck, head, breast, hand, and brachial plexus (a major nerve in the spine
that goes to the arms). Skin, bone, fat, and/or muscle can be moved from one part of the body to
another by reconnecting them after suturing arteries and veins together to establish a blood supply.
With microsurgery, even arteries and veins with very small diameters can be sutured together.
Another form of plastic surgery is craniofacial surgery (surgery of the skull and face), which is done
with children and adults. In children, craniofacial surgery is often performed to repair birth defects such
as skull fractures, cleft lip/palate, and craniosynostosis. In cleft lip, the upper lip has not formed properly
and there are one or more openings in it. In cleft palate, there is an incomplete formation of the roof of
the mouth. In craniosynostosis, one or more of the skull sutures (joints) on a baby’s head closes earlier
than normal.
Adult craniofacial surgery also is done to treat skull fractures, reconstruction of the mouth (such as
after an injury) and surgery of the jaw. Hand surgery is another form of plastic surgery for treating acute
and chronic (e.g., from birth defects) diseases of the hand and wrist, some of which involve nerves of
the hand. Plastic surgery is sometimes used when re-attaching an amputated hand. Hand surgery is
performed by plastic surgeons, general surgeons, and orthopedic (bone) surgeons. Of note, some
surgeons specialize in treating children and are known as pediatric plastic surgeons. They generally
treat cleft lip/palate and birth defects of the hand.
WHAT ARE SOME COMMON PLASTIC SURGERY TECHNIQUES?
As noted earlier, plastic surgery often involves skin grafts. This can involve transferring skin tissue from
one part of the body to another part (known as an autograft) in the same person. It can involve
transferring skin from one person (known as a donor) to another person (known as the recipient), which
is known as an allograft. It can also involve transferring skin from one species to another species,
which is known as a xenograft. Sometimes, skin products can be grown in the laboratory or
synthetically produced. The latter is referred to as artificial skin. In 1981, a product known as Integra
was developed that causes a new skin layer to grow. It is made of silicone (a rubber-like compound),
pig tendon connective tissue, silicone, and glycosaminoglycans (substances that help with wound
repair and cell growth). Some plastic surgery does not involve incisions. Examples include using lasers
(e.g. removing unwanted hair, tattoos, or birthmarks) or sanding skin to improve severe scarring.
Other common plastic surgery techniques are:
Abdominoplasty: Surgical reshaping and tightening of the abdomen. Abdominoplasty is also known as
a tummy tuck.
Blepharoplasty: Surgical reshaping of the eyelids or application of permanent eyeliner. In an Asian
blepharoplasty (also known as double eyelid surgery), a crease is surgically created for an eyelid
without a crease. A blepharoplasty is also known as eyelid surgery.
Brachioplasty: Removal of excess skin (e.g., loose skin) and fat from beneath the underarm and
elbow. It is also known as an arm lift.
Buttock augmentation: This procedure reshapes the buttocks by grafting silicone implants or fat from
other areas of the body (known as a Brazilian butt lift).
Cheek augmentation: Implants in the cheek area. Cheek augmentation is also known as a cheek
implant.
Chemical peel: This procedure applies strong chemicals (usually carbolic acid, trichloroacetic acid,
glycolic acid, or salicylic acid) to the face to cause the skin to peel off. In doing so, the procedure
treats acne, certain scars, shallow wrinkles, skin blemishes, and skin damage from the sun.
Chin augmentation: Altering chin size with an implant (usually silicone) and/or manipulating the jaw
bone. Chin augmentation is also known as a chin implant.
Dermabrasion: Wearing away of the top and middle layers of the skin with strong abrasive materials
to decrease scarring and skin imperfections.
Face lift: The removal of wrinkles and other signs of aging from the face. It often involves tightening of
the cheeks (known as a cheek lift or midface lift) and a browplasty (making the eyebrows higher and
making the forehead skin smoother). A browplasty is also known as a brow lift or forehead lift. A facelift
is also known as a rhytidectomy.
Filler injections: Injection of filler material into tissues to enhance the appearance of a body part.
Substances injected can include fat, collagen (a protein found in the skin), and hyaluronic acid (type of
substance distributed widely throughout the body tissues).
Labiaplasty: Surgically reshaping and reducing the size of the labia (part of the female genitalia).
Laser Skin Rejuvenation/Resurfacing: Decreases the depth of skin pores in the face.
Lip Enhancement: Surgically enlarging the fullness of the lips.
Liposuction: Removal of fat deposits through suction or by applying ultrasonic energy. Liposuction is
also known as suction lipectomy , lipo, lipoplasty, and liposculpture suction lipectomy.
Mammoplasty: Surgical alteration of the breast(s). This can take the form of increasing breast size
(e.g., for women with small breasts), which is known as breast augmentation/implantation. It typically
involves filling the breast area with fat, salt water, or silicone gel products. Breast tissue reduction
surgery (also known as reduction mammoplasty) is performed for women with abnormally large breasts
(often to relieve back and shoulder pain) and for men with enlarged breast tissue (known as
gynecomastia). Another surgery is known as a mastoplexy (breast lift) which is performed on saggy
breasts to reshape them and make them less saggy. Unlike breast reduction surgery, this procedure
involves removal of breast skin as opposed to breast tissue. The procedure is often performed after
weight loss (e.g., after pregnancy).
Orthognathic surgery: Purposely fracturing the facial bones in a controlled manner to restructure
them.
Otoplasty: Reshaping the ear. This is usually done by pinning the protruding part of the ear closer to
the head. Otoplasty is also known as ear pinning or ear surgery.
Rhinoplasty: Reshaping the nose. Rhinoplasty is also known as a nose job.
WHAT IS THE USUAL OUTCOME FOR THOSE UNDERGOING PLASTIC SURGERY?
The answer to this question depends on the severity and type and condition. While not all patients are
satisfied with the results and some procedures are botched, most people undergoing plastic surgery
have a good outcome and have increased self-esteem due to aesthetic enhancements. A good
outcome is enhanced by choosing a reputable surgeon (see below), careful planning of incisions so
that they overlay natural skin lines and skin folds, choosing appropriate wound closure methods and
suture materials, and removing exposed sutures early so that the wound is kept closed by buried
sutures.
HOW CAN I FIND A PLASTIC SURGEON?
Many people find a plastic surgeon by word of mouth (e.g., from friends and family), the phone book,
internet searches, and/or a referral by a health care provider. However, it is always a good idea to
check if the plastic surgeon is board certified and if he/she has particular expertise performing the
procedure of interest. Board certification means that the surgeon has been deemed competent by
his/her peers to provide specialized services to the public based on a series of examinations and a
review of credentials (e.g., training and education). The only certifying organization for plastic surgery
that is part of the American Board of Medical Specialties (ABMS) is the American Board of Plastic
Surgery. ABMS is the main medical organization in charge of 24 approved certifying boards in various
specialties.
There is another certifying board known as the American Osteopathic Board of Surgery, which
certifies doctors of osteopathy who perform plastic surgery. A Doctor of Osteopathy (often
abbreviated D.O.) is a health professional that has earned a Doctor of Osteopathy degree after
studying and graduating from a course of study at an approved medical school. Osteopathy is an
approach to medicine that uses common medical procedures, but it places a greater emphasis on
understanding the relationship between the organs, muscles, nerves, tissues, bones (such as those
that surround the spine), and tendons, than traditional medical training does.
WHAT IS THE MODERN HISTORY OF PLASTIC SURGERY?
Wars have a way of creating avenues of opportunities in non-military professions and this is the case
for plastic surgery. Specifically, due to facial disfigurements in soldiers caused by injuries in World
War I (1914 to 1918), Dr. Harold Gilles (ear, nose, and throat doctor) developed many of the
techniques of modern facial surgery. He is thus widely considered the father of plastic surgery. The
most famous surgery he performed was on Walter Yeo, a sailor injured in battle, who received a skin
flap placed across his eyes and upper face to cover up the loss of his upper and lower eyelids. Yeo is
widely considered to be the first person to benefit from advanced plastic surgery in 1917. Overall,
Gilles and his colleagues performed more than 11,000 surgeries on over 5,000 men His colleague and
cousin, Dr. Archibald McIndoe, expanded the techniques of Gilles during World War II, particularly for
aircrew who suffered severe burn injuries.
WHAT IS THE OLDER HISTORY OF PLASTIC SURGERY?
Plastic surgery owes much of its history to India. Reconstructive surgical techniques date as far back
to 800 B.C. in India when skin grafts were used. The Indian physician, Sushruta, who is considered
the father of surgery, also made important contributions to plastic surgery around this time by
performing surgical reconstructions of the nose. He described his work in a book known as Sushruta
samhita. His use of skin from the forehead to replace missing nasal tissue remains in use today. He
and his students also described plastic surgery techniques to reconstruct body parts that were
amputated from punishments.
India was not the only country where early plastic surgery techniques were performed. For example,
the ancient Egyptians used plastic surgery techniques to preserve the dead to make mummies appear
like they did when they were alive. An example would be the insertion of a small bone and seeds into
the nose to make it appear as it did during life. In the 1st century B.C., the Romans performed simple
plastic surgery techniques such as repairing damaged ears and other body parts, often in wounded
soldiers. They also removed branding scars for freed slaves, reshaped the ears of women whose
earlobes were stretched by wearing heavy earrings, and performed cosmetic plastic surgical
techniques for rich upper classmen. A Roman encyclopedia writer known as Aulus Cornelius Celsus
described plastic surgery of the face by using skin grafts from other body parts. This was described in
his book, De Medicina, along with other plastic surgical techniques. Celsus does not appear to have
been a physician but to have made his writings based on observation, research, and study.
The writings of Sushruta were translated into Arabic in 750 A.D. and eventually made its way to
Europe. For example, the Italian physician, Gasparo Tagliacozzi, described nasal reconstruction
surgeries that were being performed by the Branca and Vianeo families of Sicily since the 15th
century. British physicians also travelled to India to learn how to perform nose jobs.
In 1460, the surgeon, Heinrich von Pfolspeundt, published a book on bandaging and surgery. In it, he
described surgical reconstruction of the nose by using skin from the back of the arm, repair of cleft-lip,
and how to place stitches so they result in as little deformity as possible. In 1792, the French
surgeon, Francois Chopart, performed plastic surgery of the neck by using a flap from the neck.
Nose job surgery details were also published in the English publication, The Gentleman’s Magazine, by
1794. The English surgeon, Joseph Constantine Carpue, spent 20 years in India studying plastic
surgery methods. He performed the first modern plastic surgery in the Western world in 1815 with a
nose job based on techniques from India, by using a flap of skin taken from the forehead. He is known
for performing this surgery with a soldier who lost his nose to the toxic effects of mercury treatments.
Indian plastic surgery techniques continued to be modified in the West. Plastic surgery of the nose did
not become more common until the 19th and 20th centuries, when surgeries in general were less
dangerous and painful due to advances in science (e.g., development of new antibiotics such as
penicillin which reduced infection rates) and anesthesia (reducing pain). In 1818, the German
surgeon, Ferdinand von Graefe wrote his book, Rhinoplastik, describing plastic surgery of the nose.
He founded nose surgery in Germany and described a way to perform this surgery using a skin graft
from the arm. He also pioneered eyelid surgery and performed one of the first surgeries for cleft
palate.
The first plastic surgeon in the United States was John Peter Mattauer, who performed the first plastic
surgery for cleft palate with instruments he designed himself. In 1845, the German surgeon, Johann
Friedrich Dieffenbach, published a book on nose surgery called Operative Chirurgie in which he
introduced the concept of operating on the nose a second time to improve the cosmetic appearance
of an already reconstructed nose. In 1891, the American physician, John Roe, performed surgery on
a young woman to reduce a hump on her nose. In 1892, physician Robert Weir unsuccessfully tried to
transfer tissue from a duck’s chest to reconstruct sunken noses. The use of a bone grafting
technique to treat saddle nose was described in 1891 by an American physician (George Monks) and
in 1896 by a German urologist (James Israel). Saddle nose is a condition in which the bridge of the
nose collapses, resulting in decrease nose height. The German surgeon, Jacques Joseph, published
a book on nose jobs in 1898. In 1896, he published a book called Rhinoplasty and Facial Plastic
Surgery that popularized nose jobs for cosmetic reasons and described many modern techniques.
WILL INSURANCE COMPANIES PAY FOR PLASTIC SURGERY?
Insurance companies will usually pay for part of plastic surgery that is performed for reconstructive
reasons but will cover it for any amount when performed only for cosmetic reasons. Thus, plastic
surgery for cosmetic reasons is generally paid for out of pocket.
WHY ARE SOME PEOPLE OBSESSED WITH PLASTIC SURGERY?
Some people are literally obsessed with plastic surgery, having so much surgical work done on
themselves that they wind up looking dramatically worse compared to when the surgical work began.
This is of course, the opposite of what plastic surgery is intended for. The dramatic abnormal
evolution of Michael Jackson’s face is often cited as an example of plastic surgery obsession.
However, more dramatic cases than this exist such as the case of Hang Mioku (see picture above), a
former model who was so obsessed with having softer skin that she ultimately wound up severely
disfiguring herself (especially her face) through multiple plastic surgeries and self-injections (with
silicone, cooking oil, and other foreign substances) when physicians refused to perform additional
surgeries on her. The dramatic transformation is shown to the right. Even her own parents could not
recognize her. Ten attempts to surgically correct her severe swelling and scarring have been
unsuccessful. She has gone on record saying she wishes she could have her old face back.
The main reason why people become obsessed with plastic surgery and undergo extensive plastic
surgeries is due to body dysmorphic disorder (BDD). BDD is a psychological disorder in which a
person becomes preoccupied with an imagined defect in appearance or has a markedly excessive
concern if a slight physical anomaly is present. The development of BDD can be influenced by images
of beauty perpetuated by the media, entertainment industry, and advertising industry. It is estimated
that 2% of people in the U.S. have BDD but that 15% of people seeing dermatologists (skin doctors)
and cosmetic surgeons have the disorder. About 50% of patients with BDD are not satisfied with the
results of plastic surgery. Some patients with BDD become so depressed that they commit suicide.
WHY IS IT CALLED PLASTIC SURGERY?
The reason why this form of surgery is referred to as “plastic” is because the word plastic comes from
the Greek word “plastikos” which means “able to me molded.” This makes sense because plastic
surgery involves molding the body into a different form even though this does not usually involve the
use of actual plastic.
Although most people who undergo plastic surgery are adults, over 300,000 children a
year undergo plastic surgery. The most common plastic surgeries teenagers undergo
are nose reshaping, ear surgery, scar and acne removal, and breast size reduction.
depressed or presenting with another mental health disorder), that
the reason for the surgery makes sense (e.g., doing it for yourself;
that the perceived problems cannot be corrected without surgery),
that they understand the risks (e.g., not liking the result, pain
during the healing process, temporary swelling and bruising, length
of post-surgical healing, infections), and that they are old enough
to have the procedure in order to wait for certain bones to stop
growing naturally (e.g., mid to late teens for nose jobs).