Patients & Families

Plastic surgery is a specialty of medicine that seeks to heal and restore patients with injury, disfigurement, or scarring resulting from accidents, disease, or birth defects. It includes aesthetic or cosmetic surgery to correct or recontour facial and bodily features not pleasing to the patient. The word plastic, from the Greek, means molding, or giving form and does not refer to the synthetic plastic materials which are sometimes used.

Plastic surgery is not limited to skin grafting, although plastic surgeons may use skin grafts in some cases.

In order to become board certified by the American Board of Plastic Surgery, a physician must pursue a course of postgraduate training of five to seven years including a thorough grounding in general surgery and a minimum of two to three years in an approved plastic surgery training center.

In addition, he/she must also pass a rigorous examination before he/she is officially certified by the American Board of Plastic Surgery or its Canadian equivalents, the Royal College of Physicians and Surgeons of Canada or the Corporation Professionelle du Medicins de Quebec.

The American Board of Plastic Surgery is the only board approved by the American Board of Medical Specialties for passing upon the qualifications of applicants for certification in the exclusive practice of plastic surgery.

• Consult your family physician or internist.
• Call your local county medical society.
• Ask your local teaching or first class community hospital.
• Write to the Executive Office of the American Society of Plastic Surgeons, Inc., at 233 North Michigan Avenue, Suite 1900, Chicago, IL, 60601 or phone 1-800-514-5058, the 24-hour patient referral service.

Caution

Be wary of anyone who makes exaggerated and sensational claims in the news media about plastic surgery.

Healing of tissue is affected by several factors, some of which are beyond control of the surgeon. No guarantees of a perfect or even a good result can be given in any branch of medicine. Since medicine is an inexact science, results are sometimes unpredictable. The more thorough the surgeons' training, skill, and experience, the greater the chances for a satisfactory result. Certification means that the particular surgeon has fulfilled at least minimum requirements for full-time practice as a specialist in the field.

• Aesthetic, sometimes called cosmetic, problems of the face, neck, and trunk, including the nose, eyes, ears, chin, neck, breasts, abdomen, arms, and thighs
• Birth deformities of the hands and of the face, clefts of the lip and palate
• Birth defects of the genitalia (often treated with with urologists and gynecologists)
• Benign and malignant tumors of the head and neck, skin, and soft tissues
• Injuries of the face and facial skeleton, of the hand, soft tissue injuries of any part of the body
• Surgery of the hand
• Surgery of the jaws and facial skeleton
• Burns, including chemical, electrical, and radiation (X-ray) and the correction of resulting scars and deformities
• Skin cover and replacement problems (unstable scars and chronic ulcers)
• Reconstruction following disfiguring or deforming cancer surgery of the face, jaws, breasts, or other areas.

Although the primary interest of the skin specialist, called a dermatologist, is in the diagnosis and treatment of diseases of the skin, the plastic surgeon has an equally important role in the treatment of benign and malignant tumors of the skin. His/her skills are especially needed where large areas of skin must be removed and replaced, and where disfigurement may result from treatment of a tumor. Injuries to the skin, whether thermal (burns), or from radiation, or mechanical trauma, are usually managed by the plastic surgeon.

A plastic surgeon does not treat active cases of acne but may use scraping, planing, sandpapering, or chemical peeling to minimize the pits and scarring in the late phases of acne. There are limits to the improvement that can be expected.

Scarring is nature's way of healing and uniting wounds. Fortunately not all scars are prominent or unsightly. Some turn out to be only a fine line that is scarcely noticeable although the same operation that produces a fine scar in one patient may result in a raised, depressed or widened scar in another. Also, certain areas of the body, such as the back, chest and outside of the upper arm often produce a wide scar, no matter how carefully the wound is closed.

In many cases, the plastic surgeon can use special techniques (the so-called Z or W-plasty) to resuture or rearrange disfiguring scars to make them less prominent. Prospective patients should not expect scars to be "erased" or "removed completely." Depending on the direction of the scar, patient's age, skin type and color, and individual healing factors, the plastic surgeon may advise the patient that excellent, moderate or no improvement can be expected from plastic surgery.

Sometimes nature grows too much scar tissue and produces a raised welt-like overgrowth called a keloid. They are usually wider, firmer, thicker, and redder than normal scars and may remain raised and red during the patient's lifetime or even grow larger over a period of years. Not all heavy scars are keloid, though they are frequently diagnosed as such. The so-called hypertrophic scar enlarges during the first few months after injury or surgery, but unlike the keloid, slowly softens over the following months. Treatment of the true keloid is difficult and unpredictable. X-ray and injections of cortisone drugs have been used in some cases, but more recently, the beneficial effects of prolonged pressure with specially designed garments and devices have been recognized. Sometimes a combination of surgery, cortisone drugs, and pressure may prove effective. X-ray is rarely used today.

To improve contours when there is not enough of the patient's own tissue available. Plastic-like materials are used increasingly for a variety of purposes, such as augmentation (enlarging) the breast, or reconstructing breasts that have been removed surgically for malignant or benign disease, improving the contour of the chin, as a framework in certain types of ear reconstruction, and in some instances replacing finger joints. Plastic-like materials are also used, when necessary, to improve contours in reconstructive surgery. Synthetic implants that create very little local reaction are being improved constantly. However, the plastic surgeon uses the patient's own tissue whenever possible.

No. Skin grafting is used when there is no other satisfactory way of closing a large wound or defect. Skin grafts also are used to release a tight scar. A qualified plastic surgeon relies on his/her judgment and experience to decide when a graft is necessary, what type to use, where on the patient's body to take it from, and to predict how it may look. A skin graft seldom matches the color and texture of the normal surrounding skin, although many blend well, especially on the face. Some scarring will occur where the graft joins the adjacent skin. There also may be scarring at the site from which the graft is taken, as well as changes in color and texture. For this reason, grafts are usually taken from areas covered by clothing, if possible.

A pedicle graft, sometimes called a flap, consists of a segment of skin and underlying fatty (subcutaneous) tissue, which is shifted from one area to close another requiring a soft, thicker covering. Unlike the free graft which is thin and completely detached, the pedicle graft or flap remains attached at one end to its donor area, from which it continues to receive its blood supply until it completely unites to the new location. A flap may cover a local adjacent area, or reach the recipient site from a distance, such as from one calf to the opposite leg. This will, of course, necessitate a second operation to release it from the donor area after it has acquired a blood supply from its new location.

In recent years, the development of myocutaneous (skin and muscle) flaps has made many of the traditional skin flaps obsolete, especially those that require multiple operations to move large amounts of skin to a distant part of the body. In the case of myocutaneous flaps, the skin receives its blood supply from one or more relatively large vessels in the muscle. Patterned pieces of skin can now often be moved to their final destination in a single operation. Perhaps the most common example of such flaps is the latissimus dorsi flap used in breast reconstruction following mastectomy. The large back muscle with an attached piece of skin is swung from the back to the chest to replace necessary skin and muscle in one operation. Usually an implant can be placed under the transplanted muscle at the same time. Most patients find the resulting back scar (which can often be covered by a brassiere) a good trade for amelioration of the deformity and scarring of the mastectomy.

In some specialized centers, free flaps can be done. These are sometimes the best solution to complex reconstructive problems. These flaps are removed completely from the body with the tiny blood vessels that supply them still attached. These vessels are then sutured by microsurgery techniques to vessels in the area to which the flap is to be transplanted. Great technical skill and constant practice is needed to perform these operations safely. The sutures used to form the blood vessels, which are often less than 1 mm in diameter, will penetrate a human hair.

Aesthetic surgery, popularly known as cosmetic surgery, seeks to improve an individual's appearance. While the operations may not be necessary for physical health or safety, they may benefit the patient emotionally and psychologically, as well as aesthetically. The operations usually involve the nose, ears, face, eyelids, breasts, abdomen, and loose skin folds of the thighs.

Rhinoplasty reshapes the nose, usually to improve appearance, but sometimes to correct deformities from injury or to relieve nasal obstruction and sinus congestion. The result is usually not predictable because of variations in healing. This is especially true when the skin is thickened, coarse, and oily. After the surgery there will be swelling both on the outside and the inside of the nose. Patience is required while normal healing takes place.

Most patients are surprised to find that there is little more than mild discomfort. A splint or bandage is worn for several days. The eyes usually blacken because of normal bruising of loose tissues around the eyelids. Whites of the eyes may turn red but this clears up in a few weeks.

Unlike the unreal world of movies and television when the bandage comes off to reveal immediate beauty, the final appearance of the nose is not apparent for 6 to 12 months because normal healing takes place gradually. Scarring takes place inside the nose and is not visible. In operations to narrow wide nostrils, it is necessary to leave tiny external scars, quite inconspicuous, at the base of the nostrils.

Minor adjustments, called revisions, are occasionally necessary. It should be emphasized that improvement rather than perfection is what should be expected from a rhinoplasty. The patient should discuss the result with the operating surgeon to determine whether further improvement can be expected. Sometimes relatively small changes in a previously operated nose require more extensive operations, including cartilage grafting, than patients might think.

Mentoplasty is aesthetic surgery to reshape the chin (usually to enlarge a receding chin). This can be done using bone or plastic material, or a cartilage graft, introduced either through the mouth or via a small incision beneath the chin.

Otoplasty is an operation for changing the position of correcting protrusion of the ears and is usually performed through an incision behind the ear. The cartilages are reshaped until a normal contour is approached. Both ears are usually operated in a single operation. The scars are usually behind the ears and are only visible when the ear is pulled forward. After surgery, the ears may not match each other exactly. Normally, the ears of any individual are rarely alike. Although ears reshaped by surgery should have a good contour and be closer to the head, they may not be identical. Both ears are seldom seen at the same time, so that exact symmetry is not necessary for a good result.

The face-lift tightens and lifts the redundant skin of the face and neck. Baggy and wrinkled eyelids are treated by blepharoplasty; and superficial wrinkles, especially those about the mouth, may be decreased or made less conspicuous by a chemical peel or dermabrasion.

Incisions are made in the hairline at the temples and extend down in front of the ear, around the lobe and up behind the ear, ending in the hair at the back of the head. The type of incision varies according to the surgeon's preference and with the problem presented by the individual case. Then the skin of the face and neck is undercut, forward into the cheeks, downward and backward into the neck, thereby freeing it so it can be drawn up, tightened and smoothed. The excess is cut away. The skin edges are carefully tailored to fit smoothly into the scalp and around the ear. Some surgeons now tighten the facial tissues in two layers, first elevating and tightening the platysma muscles and a layer of tissue called the SMAS, then tighten the skin separately. Others remove the fat from beneath the jaw and in the neck to improve their contours.

Does a face-lift leave scars?

Yes, but they are so placed as not to be readily visible. The surgeon may show the patient where the scars will be.

Can anyone have a face-lift?

No. Only those for whom the surgeon feels a significant improvement will result for a reasonable length of time. This is fairly extensive surgery and should be undertaken only by those who have demonstrated ability and have had specific training and experience in the procedure. It should be done in hospitals or clinics or offices well equipped with operating facilities.

Aesthetic surgery, including face lifting, is an important part of the plastic surgeon's practice. Face lifting involves a major dissection of the skin and should only by undertaken by plastic surgeons, or other individuals who have had specific training and experience in this procedure and have demonstrated their ability to perform with skill and safety.

The operation known as blepharoplasty is used to correct these conditions. The tendency to wrinkling, particularly to have visible fullness or bags, may be inherited and may appear quite early. The excess skin is removed and the resulting incisions are so placed as to be quite inconspicuous. Ordinarily, the scars of a blepharoplasty are quite fine and near the hairline. As always, there are variations from individual to individual. The bags represent fat from the orbit bulging forward into the lids. These are corrected at the same time the skin is tightened. As in all aesthetic procedures in the facial area, there is a degree of swelling and ecchymosis (bruising, or black and blue), which persists for a varying length of time after surgery. Heavy lines or wrinkles under the eyes will usually be improved by a blepharoplasty, but wrinkles cannot be erased.

Wrinkling and bagginess may be corrected independently of a face-lift or at the same time.

Small hair-bearing segments of the scalp can be transferred as free grafts to other areas of the scalp where they will usually continue to grow hair similar to the hair in the area from which they are taken. In baldness, hair-bearing skin from the back and sides of the scalp is used to reestablish a hairline at the forehead. There must of course be enough hair to cover the area where hair is needed.

In some cases, hair bearing scalp can be transferred to bald areas by means of scalp flaps. The pros and cons of scalp flaps and hair transplants should be discussed with your surgeon. Sometimes the procedures can be combined.

Strips of hair-bearing skin are occasionally used to reconstruct an absent eyebrow. In extensive loss or destruction of a portion of the scalp, part of the remaining scalp can be used to reconstruct the defect. Hair implants, synthetic fibers placed or injected directly into the scalp, have caused major problems, including serious infection, and are not recommended.

The two common procedures are called reduction mammaplasty and augmentation mammaplasty, respectively.

Reduction mammaplasty, as its name implies, is designed to make the overly large breast smaller. Patients seeking this type of surgery are often interested in relief of painful dragging sensations and backache due to the weight and bulk of greatly enlarged breasts. Embarrassment and the inability to wear swim suits and sports clothes, especially in the case of young women, are additional reasons for undergoing a reduction mammaplasty.

It is impossible to move the nipple to a higher location and to remove the excess skin and breast tissue without scars. These fade to an acceptable degree in most cases and are placed around the nipple and below so that even a half-cup brassiere conceals them. Nonetheless, they are heavier than the usual scars people associate with plastic surgery.

Unusually small breasts can be safely enlarged by augmentation mammaplasty in which a silicone envelope filled with either silicone gel or saline solution or a combination of the two is placed in a pocket, surgically created behind the breast and in front of the underlying pectoral muscle. Silicone implants are not to be confused with liquid silicone injections. Injection of liquid silicone directly into the breast is unapproved as a surgical technique and is considered dangerous.

The silicone envelope or prosthesis is introduced through a small incision either in the fold beneath the breast, at the edge of the nipples, or in the armpit. The improvement in physical appearance often induces a sense of well-being and confidence in the under-endowed women.

Tattoos are very difficult to remove, but there are several available techniques. Although post operatively the tattoo is no longer seen, it is impossible to accomplish removal without some degree of residual scarring.

The patient's psyche is an important factor in all surgery. The nature of aesthetic surgery is such that the patient's psychological problems are apt to be magnified to some degree. Patients may look to surgery to solve their social, sexual and business difficulties and are quite disappointed to find their problems still exist.

Other patients with psychological problems will tend to be hypercritical and will worry over what they consider to be defects following surgery, not visible to anyone else.

Others will consult the plastic surgeon and will request surgery that is completely unrealistic, in view of the tissues and features at hand. They are often angry and upset when the surgeon refuses to operate. Psychiatric help or consultation is frequently advisable, but these patients are often unwilling to seek such advice.

A stable emotional base should exist before one undergoes aesthetic surgery.

Yes. A very high degree of special knowledge and skill is necessary to form a well-based opinion on whether or not a plastic operation is possible or is indicated. Many patients seem to feel that because they are not physically ill, they are shopping for a commodity, rather than consulting a highly trained specialist. The patient has to realize that though he/she may receive a negative reply to the request for services, it requires time, skill, and judgment on the part of the consulting physician to make this decision.

It is customary for these fees to be paid prior to surgery. The patient and the doctor may, however, make other mutually agreeable arrangements in consideration of a given case. The patient is seeking an aesthetic operation leading to improvement in appearance. This does not constitute an emergency and the patient will have sufficient time to arrange his/her finances.

Payment in advance assures the surgeon that the patient is not undertaking elective surgery which he/she is unable to afford. The patient is also assured that his/her fee is paid in full and that there will be no unexpected charges by the surgeon.

DO

• Be sure that your plastic surgeon is fully qualified (certified by the American Board of Plastic Surgery) and a recognized, full-time expert in his/her specialty. Be wary of such statements as "board certified cosmetic surgeons" or "cosmetic surgeons certified in their specialties"--these may be doctors certified in a specialty unrelated to plastic surgery or by "Boards" set up by individuals and not recognized by the American Board of Medical Specialties (ABMS).
• Feel free to ask your specialist to give you adequate evidence of his/her background and training, if you are in doubt. Don't feel shy in asking. Qualified plastic surgeons are proud of their accomplishments.
• Discuss your problem freely with your surgeon.
• Be sure you understand the risks as well as the benefits to be anticipated.
• Know that your plastic surgeon will exercise his/her greatest care and skill for your benefit.
• Call your doctor if you suspect any minor complication after surgery. A simple telephone call will usually save you many hours of unnecessary worry.
• Cooperate fully with your surgeon and carefully follow all instructions after surgery.

DON'T

• Fall for glib, deceptive, or false publicity about plastic surgery.
• Hesitate to check on your plastic surgeon's standing through your own doctor, your hospital or your county medical association, the directory of medical specialists, etc.
• Expect to be able to select the style or shape of a feature you desire. It simply cannot be done.
• Worry excessively about risks or complications, because they are rare.
• Expect a guarantee or warranty of a good result, nor warranty against an untoward result.
• Hesitate to ask your surgeon complete details about fees involved for the procedures that are being projected for you. This can and is done in most instances, with the exception of emergencies, at which time there is no time for discussion about finances and you can expect your doctor to do his/her very best for you.
• Hesitate to ask your doctor for a consultation with another plastic surgeon if you feel that your treatment is not going well.

For every plastic surgery procedure, patients must undergo thorough preoperative consultation with a plastic surgeon. During this session, the doctor determines whether or not an operation is feasible or advised, and discusses realistic expectation of surgery results.

Healing of tissue is affected by several factors, some of which are beyond the control of the physician. For this reason, no medical guarantees of perfect results are possible. The more thorough a surgeon's training, skill and experience, the better the chances for a satisfactory plastic surgery result. Board certification means that a particular surgeon has fulfilled at least minimum requirements for full-time practice as a specialist in the field. You should ask to see proof that your plastic surgeon is certified by the American Board of Plastic Surgery.

Unless specifically arranged with the doctor, all aesthetic surgery fees are paid in advance.

Some patients may be unable to pay a full or even greatly reduced fee. Surgery at reduced rates is available at universities and teaching hospitals, children's hospitals, burn or cleft palate centers, and government-run hospitals. Most large hospitals with plastic surgery training programs, and your state's equivalent of vocational rehabilitation or crippled children's services, can help patients find such reduced rates. If you need further help, write to the ASPRS at the address listed below.

Tel-Med, a telephone library of tape recorded medical messages, has more than ten tapes on plastic surgery. You can call the number listed in the white pages for additional information on remaining healthy, recognizing signs of illness, coping with serious illness, and more. Just tell the operator who answers at Tel-Med the type of information you are seeking. Tel-Med is sponsored by local hospitals and medical societies throughout the country.