Plastic surgery

Plastic surgery is defined as a surgical specialty dedicated to reconstruction of facial and body defects due to birth disorders, trauma, burns, and disease. Plastic surgery is intended to correct dysfunctional areas of the body and is reconstructive in nature. Though cosmetic or aesthetic surgery is the most well known kind of plastic surgery, plastic surgery itself is not necessarily considered cosmetic and includes many types of reconstructive surgery, craniofacial surgery, hand surgery, microsurgery, and the treatment of burns.

Etymology

In the term plastic surgery, the adjective plastic implies sculpting or reshaping, which is derived from the Greek πλαστική (τέχνη), plastikē (tekhnē), “the art of modelling” of malleable flesh.[1] This meaning in English is attested as early as 1598.[2] The surgical definition of "plastic" first appeared in 1839, preceding the modern "engineering material made from petroleum" sense of plastic (coined by Leo Baekeland in 1909) by seventy years.[3]

History

Plates vi & vii of the Edwin Smith Papyrus at the Rare Book Room, New York Academy of Medicine[4]

Treatments for the plastic repair of a broken nose are first mentioned in the Edwin Smith Papyrus,[5] a transcription of an Ancient Egyptian medical text, some of the oldest known surgical treatise, dated to the Old Kingdom from 3000 to 2500 BC.[6] Reconstructive surgery techniques were being carried out in India by 800 BC.[7][8] Sushruta was a physician that made important contributions to the field of plastic and cataract surgery in 6th century BC.[9] The medical works of both Sushruta and Charak originally in Sanskrit were translated into the Arabic language during the Abbasid Caliphate in 750 AD.[10] The Arabic translations made their way into Europe via intermediaries.[10] In Italy the Branca family[11] of Sicily and Gaspare Tagliacozzi (Bologna) became familiar with the techniques of Sushruta.[10]

Statue of Sushrut, the Father of Plastic Surgery, at Haridwar

British physicians traveled to India to see rhinoplasties being performed by native methods.[12] Reports on Indian rhinoplasty performed by a Kumhar vaidya were published in the Gentleman's Magazine by 1794.[12] Joseph Constantine Carpue spent 20 years in India studying local plastic surgery methods.[12] Carpue was able to perform the first major surgery in the Western world by 1815.[13] Instruments described in the Sushruta Samhita were further modified in the Western world.[13]

The Roman scholar Aulus Cornelius Celsus recorded surgical techniques, including plastic surgery, in the first century AD.

The Romans also performed plastic cosmetic surgery. The Romans were able to perform simple techniques, such as repairing damaged ears, from around the 1st century BC. For religious reasons, they did not dissect either human beings or animals, thus their knowledge was based in its entirety on the texts of their Greek predecessors. Notwithstanding, Aulus Cornelius Celsus left some surprisingly accurate anatomical descriptions,[14] some of which — for instance, his studies on the genitalia and the skeleton — are of special interest to plastic surgery.[15]

In 1465, Sabuncu'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. 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 common.

Up until the techniques of anesthesia became established, surgeries involving healthy tissues involved great pain. Infection from surgery was reduced by the introduction of sterile techniques and disinfectants. The invention and use of antibiotics, beginning with sulfonamide and penicillin, was another step in making elective surgery possible.

In 1793, François 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.

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

Development of modern techniques

Walter Yeo, a sailor injured at the Battle of Jutland, is assumed to have received plastic surgery in 1917. The photograph shows him before (left) and after (right) receiving a flap surgery performed by Gillies

The father of modern plastic surgery is generally considered to have been Sir Harold Gillies. A New Zealand otolaryngologist working in London, he developed many of the techniques of modern facial surgery in caring for soldiers suffering from disfiguring facial injuries during the First World War.[16]

During World War I he worked as a medical minder with the Royal Army Medical Corps. After working with the renowned French oral and maxillofacial surgeon Hippolyte Morestin on skin graft, he persuaded the army's chief surgeon, Arbuthnot-Lane, to establish a facial injury ward at the Cambridge Military Hospital, Aldershot, later upgraded to a new hospital for facial repairs at Sidcup in 1917. There Gillies and his colleagues developed many techniques of plastic surgery; more than 11,000 operations were performed on over 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds). After the war, Gillies developed a private practice with Rainsford Mowlem, including many famous patients, and travelled extensively to promote his advanced techniques worldwide.

Jimmy Edwards, comedy actor who underwent plastic surgery on his face at the hands of McIndoe — he disguised the traces of surgery with a huge handlebar moustache. He was a member of the Guinea Pig Club.

In 1930, Gillies' cousin, Archibald McIndoe, joined the practice and became committed to plastic surgery. When World War II broke out, plastic surgery provision was largely divided between the different services of the armed forces and Gillies and his team was split up. Gillies himself, was sent to Rooksdown House near Basingstoke, which became the principal army plastic surgery unit; Tommy Kilner (who had worked with Gillies during the First World War, and who now has a surgical instrument named after him, the kilner cheek retractor), went to Queen Mary's Hospital, Roehampton, and Mowlem to St Albans. McIndoe, consultant to the RAF, moved to the recently rebuilt Queen Victoria Hospital in East Grinstead, Sussex, and founded a Centre for Plastic and Jaw Surgery. There, he treated very deep burns, and serious facial disfigurement like loss of eyelids, typical of those caused to aircrew by burning fuel.

McIndoe is often recognized for not only developing new techniques for treating badly burned faces and hands but also for recognising the importance of the rehabilitation of the casualties and particularly of social reintegration back into normal life. He disposed of the "convalescent uniforms" and let the patients use their service uniforms instead. With the help of two friends, Neville and Elaine Blond, he also convinced the locals to support the patients and invite them to their homes. McIndoe kept referring to them as "his boys" and the staff called him "The Boss" or "The Maestro".

His other important work included development of the walking-stalk skin graft, and the discovery that immersion in saline promoted healing as well as improving survival rates for victims with extensive burns - this was a serendipitous discovery drawn from observation of differential healing rates in pilots who had come down on land and in the sea. His radical, experimental treatments led to the formation of the Guinea Pig Club at Queen Victoria Hospital, Sussex. Among the better known members of his "club" were Richard Hillary, Bill Foxley and Jimmy Edwards.


Sub-specialties

Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by American Board of Plastic Surgery.[17] Subdisciplines of plastic surgery may include:

Aesthetic surgery

Aesthetic surgery is an essential component of plastic surgery and includes facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance.[18]

Burn 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.

Craniofacial surgery

Main article: Craniofacial surgery

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. Adult craniofacial surgery deals mostly with fractures and secondary surgeries (such as orbital reconstruction) along with orthognathic surgery. Craniofacial surgery is an important part of all plastic surgery training programs, further training and subspecialisation is obtained via a craniofacial fellowship.

Hand surgery

Main article: Hand 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. The Hand surgery field is also practiced by orthopedic surgeons and general surgeons. Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough. There have been cases of surgery to women's hands in order to correct perceived flaws to create the perfect engagement ring photo.[19]

Microsurgery

Main article: Microsurgery

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.

Pediatric plastic surgery

Children often face medical issues very different 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.

Techniques and procedures

In plastic surgery, the transfer of skin tissue (skin grafting) is a very common procedure. Skin grafts can be derived from the recipient or donors:

Usually, good results would be expected from plastic surgery that emphasize careful planning of incisions so that they fall within the line of natural skin folds or lines, appropriate choice of wound closure, use of best available suture materials, and early removal of exposed sutures so that the wound is held closed by buried sutures.

Reconstructive surgery

Navy doctors perform reconstructive surgery on a 21-year-old patient

Reconstructive plastic surgery is performed to correct functional impairments caused by burns; traumatic injuries, such as facial bone fractures and breaks; congenital abnormalities, such as cleft palates or cleft lips; developmental abnormalities; infection and disease; and cancer or tumors. Reconstructive plastic surgery is usually performed to improve function, but it may be done to approximate a normal appearance.

The most common reconstructive procedures are tumor removal, laceration repair, scar repair, hand surgery, and breast reduction plasty. 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. In 2012, there were 68,416 performed.

Some other common reconstructive surgical procedures include breast reconstruction after a mastectomy for the treatment of cancer, cleft lip and palate surgery, contracture surgery for burn survivors, and creating a new outer ear when one is congenitally absent.

Plastic surgeons use microsurgery to transfer tissue for coverage of a defect when no local tissue is available. Free 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 to 2 millimeters in diameter.

Cosmetic surgery

Cosmetic surgery is an optional procedure that is performed on normal parts of the body with the only purpose of improving a person’s appearance and/or removing signs of aging. In 2014, nearly 16 million cosmetic procedures were performed in the United States alone.[20] The number of cosmetic procedures performed in the United States has almost doubled since the start of the century. 92% of cosmetic procedures were performed on women in 2014 up from 88% in 2001.[21] Nearly 12 million cosmetic procedures were performed in 2007, with the five most common surgeries being breast augmentation, liposuction, breast reduction, eyelid surgery and abdominoplasty. The American Society for Aesthetic Plastic Surgery looks at the statistics for thirty-four different cosmetic procedures. Nineteen of the procedures are surgical, such as rhinoplasty or facelift. The nonsurgical procedures include Botox and laser hair removal. In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p. 5). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p. 12).[22] The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans, Asian 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.[23] In Asia, cosmetic surgery has become more popular, and countries such as China and India have become Asia's biggest cosmetic surgery markets.[24]

The most prevalent aesthetic/cosmetic procedures include:

The most popular surgeries are Botox, liposuction, eyelid surgery, breast implants, nose jobs, and facelifts.[26]

Evolutionary psychology and female cosmetic surgery

Plastic surgery procedures are more common among women than men (see above for statistics). The reason for this discrepancy may be explained by current evolutionary theoretical and empirical findings which suggest that differences in male mate preference play a role in motivating females to make alterations to their perceived attractiveness.[27]

There is an underlying assumption in current evolutionary theory that humans, regardless of social or geographic position, find a definable set of traits attractive in possible reproductive mates.[28] The theory follows that humans have evolved to become interested in these traits which provide reliable clues about an individual’s potential reproductive viability.[27]

It is thought that heterosexual males value female beauty and physical attractiveness [29] because certain "attractive" attributes are associated with fertility and reproductive value.[29] Most human females hit their fertile peak between the ages of 23 and 31. Around age 31, fertility starts to decline by about 3% per year.[30] Evolutionary psychologists propose that men possess perceptual mechanisms which have evolved to detect these traits as a means of determining whether or not a woman is a desirable potential mate.[27]

A heterosexual female desiring to promote her reproductive value can manipulate a male’s evaluation of her by enhancing her anatomical features [35]. By undergoing plastic and cosmetic surgery, these desired and admired features of human female beauty can be acquired in a permanent state by women who do not naturally possess these signals.

Cosmetic surgery is a relatively new concept and it is not yet fully understood what psychological mechanisms underlie these procedures. Recent evolutionary theory suggests that cosmetic surgery may act as a form of intra-sexual competition, whereby women compete with each other to have assets which are considered to be the most desirable by the opposite sex.[31] The fact that cosmetic surgery is much more common in women than in men could reflect women's awareness of the importance of physical attractiveness to potential mates.[32]

Waist-to-hip ratio

Evolutionary theory proposes that a low waist-to-hip ratio in women is a powerful signal of age and therefore also of fertility to potential male mates.[33] Before puberty, males and females have fat deposits in similar places but puberty triggers hormones in females which inhibit fat stores on the abdominal region and stimulates deposits in the hip and buttock region, therefore changing a woman’s waist-to-hip ratio.[33] Menopause also changes a woman’s waist-to-hip ratio, with more fat being stored in the mid-region of the body.[33] Waist-to-hip ratio is therefore proposed as a reliable signal of age and consequently reproductive status.[33] Furthermore, waist-to-hip ratio has been found to be a reliable indicator of fertility - for example, one study found that women with a high waist-to-hip ratio had more problems conceiving children than those with lower ratios.[34]

Liposuction is a very common procedure[35] which can be used to help women achieve a waist-to-hip ratio that is desirable to mates according to evolutionary theory.[36] In addition, micro-fat grafting surgery is a procedure in which fat tissue is take from the waist region and implanted on the buttocks resulting in a lower waist-to-hip ratio. One study demonstrates the effect that this surgery can have on male opinion. Photographs of women who had just undergone micro-fat grafting surgery were rated by men as being more attractive than the same women’s pre-operative photograph.[37]

Other examples

Breast Augmentations, which can alter the size and shape of breasts, were the most common cosmetic procedure in 2014 in the USA.[38] Surgery enables women to achieve 'large, shapely, symmetrical breasts'.[39] This is thought to be attractive to men, according to evolutionary theory because breast shape and size is an indicator of fertility and youth.[39] As a woman ages, her breasts may change shape and begin to droop,[39] which could send signals to potential mates that she is no longer in her most fertile stage in her lifespan.

Surgery that target signs of aging of the face, makes up a large proportion of cosmetic procedures carried out each year.[40] The Times of India lists '17 Cosmetic Procedures to Look Younger'[41] which includes many treatments targeting the face. This focus on looking youthful could reflect the importance that evolutionary theory stresses on a woman's age, in terms of mate value. Studies have found that cross-culturally, men prefer women who are younger than them and it is calculated by Buss (1989) that men prefer to marry women who are 24.83 years old.[29] This age roughly corresponds to the age when women are at their most fertile during their lifespan.[29] Signs of youthfulness shown in the face include fuller lips, little or no wrinkles and smooth skin and it is proposed that men may have evolved to find these features attractive.[32] Cosmetic surgery enables older women to achieve these aforementioned characteristics of youthfulness.[39]

Dishonest signalling

Honest signals (for example, waist-to-hip ratio, breast size or wrinkles) work on the basis that they honestly communicate information about that person's reproductive value to a potential mate.[39] But cosmetic surgery alters a person's attractiveness, without improving their true reproductive value. Therefore, cosmetic surgery can be considered to be a dishonest signal.[39] Dishonest signals are thought to arise from the conflicting intentions of men and women in their mating strategies.[27] Both males and females commonly use deception in order to attract a mate, with women placing focus on enhancing their physical appearance, among other things.[27]

Male cosmetic surgery

Whilst women make up the majority of cosmetic surgery clients, approximately one in ten procedures are accounted for by men.[42] The total number of cosmetic surgery operations for men in the UK alone have risen from 2,440 in 2005 to almost double 4,614 in 2015.[43] Popular cosmetic surgery procedures for men include rhinoplasty, liposuction and breast reduction.[44] There are various factors that affect the likelihood of completing cosmetic surgery operations for both men and women; these may include the personal experience of cosmetic surgery previously and the exposure to television media.[45] Some theorists explain that this change is due to a changing view of the male body as something that can be improved and beautified.[46] This change may be driven and encouraged through a changing image of male bodies in popular media; a recent online survey revealed that when visitors to a cosmetic surgery Q&A were asked ''“Has social media influenced you to consider or choose to have a cosmetic procedure?”, 15.37% said yes.[47]

Bilateral symmetry

Rhinoplasty or nose surgery, is one of the most commonly requested cometic surgery procedures for men with 32,641 procedures taking place within the US in 2014 alone.[48] This procedure is used to create a more proportionate and symmetrical appearance of the face.

Some theorists suggest that the reasons for male cosmetic may be similar to reasons behind female cosmetic surgery, as attractiveness is also a key factor in female mate choice as evolutionary history, women are seen as being highly selective in choosing mates for reproduction.[49] A symmetrical face shows developmental competence as it indicates resistance to disease, harmful mutations or injuries, all of which are factors associated more with fluctuating asymmetry.[50][51][52]

Facial attractiveness has more reproductive advantages than survival advantages.[53] It can connote a persons physical health and fitness and may guide mate preference for a fertile mate with high genetic quality.[54][55] Symmetry may also correlate with men's sexual success.[56] One study has linked sexual activity with facial symmetry in men, finding that men with symmetrical faces may have earlier and more sexual experiences than men with asymmetrical faces.[57]

A significant body of research finds that facial attractiveness in men can signal to different qualities, such as socio-economic success;[58] for example, it has been found that more attractive males are more likely to be hired for jobs.[59] Other research has linked pleasing physical appearance with better promotions and a higher salary, all of which are qualities seen as desirable and positively in a partner.[60][61][62] Male cosmetic surgery which enhances and improves symmetry, a cue associated with modern concepts of male sexual attraction such as financial success; this may explain its popularity and provide males who undergo surgery with a competitive advantage over others in attracting women.[63][64][65]

Increasing masculinity

Some male cosmetic surgery procedures are aimed at creating a more stereotypically masculine look. For example, male breast reduction to treat gynecomastia has risen by 117% since 1997; the rise has been 7.1% since 2013.[48] This procedure, in addition to other such as insertion of male pectoral implants and chin augmentation aim to de-feminize the body; for example, 'a weaker jaw' is seen to create 'a less of a masculine appearance', which indicates that increasing masculinity and getting rid of telltale signs of femininity is a strong motivator for these procedures.[46][66]

A more masculine face can also be perceived as being more dominant.[67] Psychological research has found that masculine faces can also act as honest signals for phenotypic quality and genetic quality of a male.[68] Males with testosterone enlarged features such as strong jaws, high cheekbones and muscular builds are credited as being more attractive[51] and may also be related to mating success.[69][70] From an evolutionary perspective, there is research to suggest that such 'masculine' features have undergone sexual selection and also function as signals of quality and condition.[71] This may explain the popularity of procedures in cosmetic surgery that enhance masculine features for males who do not naturally possess them.

Male genital modification

A specific form of male surgery is male genital modification. Procedures include penile lengthening, insertion of penis inserts and penile girth enhancement. Motivation for this form of surgery may stem from evolutionary concepts, as body ornamentation and bodily enhancements have been seen as an evolved consequence of sexual selection,[72] in a bid to compete for female mates. The appearance of male genitalia has also been linked with self-esteem generally, and especially with sexual identity.[73]

Such forms of genital enhancement may have implications for female mate choice, who consider the male genital appearance to be an honest signal of their status, dominance and virility. A male that undergoes genital modification has to face high risks and costs of having the procedure, including pain and risk of the surgery going wrong. This form of risk taking may be seen as a honest signal by some women, who may recognise the costs the man has taken and may therefore feel they are worthy of long-term investment in the form of a relationship.[74]

Complications and risks

All surgery has risks. Common complications of cosmetic surgery includes hematoma, nerve damage, infection, scarring, implant failure and organ damage.[75][76][77] Breast implants can have many complications, including rupture. In 2011 FDA stated that 1 in 5 patients who received implants for breast augmentation will need them removed within 10 years of implantation.[78]

Psychological disorders

Though media and advertising do play a large role in influencing many people's lives, researchers believe that plastic surgery obsession is linked to psychological disorders.[79] Body dysmorphic disorder (BDD) is seen as playing a large role in the lives of those who are obsessed with plastic surgery in order to correct a perceived defect in their appearance.

BDD is a disorder resulting in the sufferer becoming “preoccupied with what they regard as defects in their bodies or faces.” Alternatively, where there is a slight physical anomaly, then the person’s concern is markedly excessive.[80] While 2% of people suffer from body dysmorphic disorder in the United States, 15% of patients seeing a dermatologist and cosmetic surgeons have the disorder. Half of the patients with the disorder who have cosmetic surgery performed are not pleased with the aesthetic outcome. BDD can lead to suicide in some of its sufferers. While many with BDD seek cosmetic surgery, the procedures do not treat BDD, and can ultimately worsen the problem. The psychological root of the problem is usually unidentified; therefore causing the treatment to be even more difficult. Some say that the fixation or obsession with correction of the area could be a sub-disorder such as anorexia or muscle dysmorphia.[81]

In some cases, people whose physicians refuse to perform any further surgeries, have turned to "do it yourself" plastic surgery, injecting themselves and running extreme safety risks.[82]

See also

References

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