Plastic Surgery

Plastic surgery is denoted as the process of reconstructing or repairing parts of the body. It is principally concerned with the revamp, renovation and improvement of lost, injured, or body parts deemed imperfect. The usage of the word plastic is considered synonymous with surface as it implies a graft or implantation of certain parts into or onto humans. As it stands, there are currently two specific types of plastic surgery: cosmetic plastic surgery and reconstructive surgery. There are pros and cons to each. Cosmetic surgery deals with improving an individual's features on a merely visual level, while reconstructive surgery is performed to correct a physical feature or some aberration. There are many types of plastic surgeries that can be performed. Three distinctive types are: blepharoplasty, rhinoplasty and abdominoplasty.

Blepharoplasty

Blepharoplasty or the surgical procedures on the eyelids is aimed at correcting aspects that have been deemed inadequate due to heredity or age. This procedure can be performed on the upper or lower eyelids alone or operated on at the same time. The technique is carried out alone or in association with other cosmetic facial surgery. The purpose of blepharoplasty is to "correct signs of aging and remove the tired look due to the heavy eyelids by a more rested, relaxed appearance. The unsightly aspects most commonly found are the following: drooping heavy upper eyelids, with a more or less marked skin-fold; lower eyelids which have drooped and shrunk, leading to horizontal wrinkles due to distended skin or bulging fat, responsible for bags under the eyes at the lower eyelid or upper eyelid sagging" (Cohen, 1994). Before operation begins, a methodical inspection of the eyes and eyelids are performed to in effect distinguish any anomalies which could confuse the procedure or indeed shown that the process is not recommended. A specific operation known as an ophthalmologic assessment is performed as well as a preoperative checkup. With blepharoplasty, there are three distinct possibilities obtainable regarding the type of anesthesia: local anesthesia, "where the eyelids are numbed by an injection given locally; standard anesthesia, where the individual sleeps throughout the procedure and local anesthesia with sedation given by intravenous drip, also known as twilight anesthesia" ("Cosmetic Surgery of the Eyelids or Cosmetic Blepharoplasty," 2008). This particular type of surgery can be carried out through an outpatient basis or with a brief hospital stay.

Every surgeon has opted for his/her own detailed procedure which he/she adapts in order to reach the best results in each case. There are some all-purpose points associated with the procedure, however. Incisions are made on the upper and lower eyelids. On the upper eyelids, they are "concealed in the fold situated at the mid-point of the eyelid, between the mobile and fixed parts. On the lower eyelids, they are 1 to 2 mm below the eyelashes, and can go slightly beyond them. The line of these incisions corresponds of course to the position of the scars, which will therefore be hidden in the folds of skin. Once the incision is made, unsightly excess fat is removed, as are redundant muscle and sagging skin. At this stage, numerous appropriate adjustments can be made in order to tailor the procedure to the specific needs of the individual" ("Cosmetic Surgery of the Eyelids or Cosmetic Blepharoplasty," 2008). When an “upper lid blepharoplasty is wanted, the location of the lacrimal glands and the degree of lateral hooding and medial bulging are central. In lower lid blepharoplasty, imperative features to note are the existence of fine rhytids, also known as wrinkles, lid laxity and scleral show and pigmentation characteristics. Most, if not all surgeons use old photographs to determine the patient's youthful upper eyelid fold configuration. The old photographs act as a guidepost. Eyelid skin tends to mend better than most skin on the body, however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. In Asian and Black patients, a CO2 laser can be safely used inside the skin for fat removal, but laser skin incisions are to be avoided in these patients due to scar hypertrophy and dyspigmentation" (Oestreicher and Mehta, 2012) Following the resectioning of the skin, stitches are made.

Stitches are characteristically created from thread and are removed a few days after the procedure. The procedure itself can take between 30 minutes to 2 hours depending upon the intricacies linked with the individual. There are some risks associated with this type of plastic surgery such as injury to the vision, obscurity closing the eyes while sleeping and double vision. While these risks are minimal, they are still risks, nevertheless. Typically, individuals can go home the day of the surgery, unless the surgeon suggests that the patient stay for the night or for a brief period of time in the hospital. The eyes are enclosed with salve and a dressing and the eyelids tend to feel sore as the anesthesia wears off. The uneasiness is on average alleviated through pain medication. Some doctors may prescribe eye drops to reduce any burning or itching sensations that may result after the surgery. If any complications such as this arise, it will be seen within a minimum of 2 to 3 days. Usually, the stitches that were placed in the operating area are removed 2 to 7 days after the surgery is completed (Cohen, 1994; "Eyelid lift," 2013). The surgery has been noted to be popular as the skin around the eyelids tends to begin sagging as a result of the aging process.

Rhinoplasty

Rhinoplasty perhaps is considered to be one of the more multifarious plastic surgery procedures. There are various dependent anatomic components connected and that must be managed during the surgery. Producing positive results in a Rhinoplasty procedure have proved to be tricky to say the least. Patient satisfaction is a multidimensional concept because of the way the surgery is done. As with other forms of plastic surgery, a formulation of a procedure plan has to be performed. A discussion usually takes place between the patient and the surgeon. The patient commonly knows what they want done to their nose and thus, they want the surgeon to perform what they see fit. Rhinoplasty is similar to chess in that it requires considerable thought before any kind of process can be undertaken. Surgeons will scrutinize the radix and dorsum, the tip, and base of the nose. The radix is analyzed on a lateral view and a decision has to be made in order to retain, enhance, or condense it. When surgeons evaluate the tip of the nose, they perform a basic view and then a multipart one to ascertain the assorted sutures and modification grafts that may have to be done as a result of it being operated on. The base of the nose consists of the alar bases, nostrils and columella. Factors must be assessed including the caudal septum, anterior nasal spine and maxilla. The most general choice with the base of the nose is whether to reduce the nostril dimension along with the width of the alar base (Cohen, 1994; Daniel, 2010). Surgeons note that inconsequential modifications made at the time of surgery can result in vivid changes years later. Once the consultation has been done between the surgeon and the patient, markings are made on the person’s face as to which areas of the nose are to be operated on.

When individuals are being prepped for a Rhinoplasty, they are commonly placed under general anesthesia’s because this what most patients prefer. In fact, surgeons recommend this. Certain precautions have indeed improved the protection of general anesthesia. The procedure of general anesthesia in a Rhinoplasty consists of two components: "a picture frame block to reduce the regional blood supply and then specific areas of surgery (1) tip and columella, (2) lateral wall, (3) dorsum/extramucosal tunnels, (4) incision lines, and (5) septum, if appropriate. The needle is inserted from the vestibule toward the infraorbital foramen, lateral nasofacial groove and alar base. The columella base is injected extended outward below the nostril sills. The septum is blocked from posterior to anterior and the access incisions are injected with local anesthesia" (Daniel, 2010). Aging patients frequently have diverse motivations for opting for this form of plastic surgery and it is important that surgeons frankly discuss the pivotal aspects of this form of surgery and address the realistic goals of the patient they will be operating on. The skin changes as we age, and it is important that individuals seeking out this procedure understand this from the onset. Rohrich et. al (2003) note that “the changes in the skin can sometimes cause several different developments during the surgical procedure. As a result of the decreased skin elasticity and generalized skin redundancy mandate, the aesthetic aspects of the nose will have to be determined as this will be noticeable. During the procedure, the nasal tip perhaps undergoes the most significant changes in the aging patient, which in turns affects the features of the nose. This issue affects both women and men, with an influx of men opting for these procedures. There are several different aspects that may result as a result of the complexity surrounding the nasal tip restructuring such as fragmentation and potential ossification of the attachments between the upper and lower lateral cartilages with resultant downward migration of the lateral crura; weaking or loss of suspensory ligament support with loss of medial crural support and/or potential thickening of the cartilage leading to significant prominence” (Rohrich et. al, 2003). Although each and every operation is diametrically different, there are certain goals that each patient and surgeon should be working towards. 

In the Rhinoplasty procedure, an osteotomy is usually performed where a bone is cut to curtail, elongate or alter its configuration. Usually, lateral osteotomies are done to narrow the bony width of the nose. Two common osteotomy methods are low to high and low to low. The low to high osteotomy starts "at the pyriform aperture on the nasal process of maxilla and passes tangentially across it to the nasal bone suture line at the level of the medial canthus. In contrast, the low-to-low osteotomy is done in two steps. First, a transverse osteotomy is done with a 2 mm osteotome placed through a small vertical stab incision just above the medial canthus. The osteotome is gently tapped to insure a complete vertical osteotomy in the lateral nasal wall. Second, a low-to-low lateral osteotomy is done using a straight osteotomy. It begins at the pyriform aperture on the nasal process of the maxilla and passes straight up the lateral wall to end at the level of the medial canthus" (Daniel, 2010). Following the osteotomy, graft preparation begins.

As the focus of Rhinoplasty is to accomplish equilibrium and synchronization with the face, preserving it as best as possible will achieve the most favorable outcome. The ultimate objective of the Rhinoplasty surgeon is to use a graft or implant without major complications that will accomplish patient contentment. There are three broad categories for grafts: autografts, which are derivatives of the patient's own tissues; homografts, which are obtained from a different donor and alloplasts, which are synthetic grafts. Autograft materials normally come from cartilage, bone, skin and fascia. Cartilage possesses superb suppleness, resistance and as a result of this, is the ideal material that Rhinoplasty surgeons opt to use. Rhinoplasty surgeons often state that homograft materials are not idyllic to use because of the long-standing volatility that can cause infection. Homograft materials are not used in most surgeries unless the patient specifically elects that. With the improvements made in biomaterial science and technology, the usage of implants in facial operation has become much more prominent. Alloplast materials are porous in nature for the most part, although there are solid materials used sometimes. If a solid material is used it is usually silicone or porous polyethylene. The majority of alloplasts do not allow for injectable substances (Lin et.al, 2007; Cohen, 1994). After grafting, the surgeon will begin suturing.

There are many choices that a surgeon can use regarding suturing as each nose is inimitable. The surgeon should understand the propensity of options and choose the most dependable among the techniques as not to distort or disrupt the surgery. Grafting tends to carry with it the potential for discernible irregularities, disarticulation and malpositioning. For these reasons, suturing has been adopted as the primary methodology for recountouring. Several surgeons such as Joseph (1931) used what is now known as the columella-septal suture to secure the tip cartilages to the caudal septum. Dome-type sutures were first popularized in 1926 by Sebileau and Dufourmentel. These are occasionally used in Rhinoplasty operations. Another popularized suture technique was introduced by McCollough and English (1985) and is known as single bidomal spanning where the suture is passed through both the intermediate and lateral crura using an endonasal approach (Akkuzu, 2011). The challenge with suturing, is understanding which type to use given that each and every nose is different and distinctive to the individual patient.  

Each incision that is made by the surgeon is sutured. Following the suturing process, the surgeon will utter an operative account that is replete with diagrams associated with what was done. The "smoothness of the postoperative course is directly proportional to the amount of time spent at the preoperative visit explaining to the patient what to expect. Post-op medications are then confirmed, and the patient is reminded to clean all suture lines, usually on a two to three times a day timescale. At 6 days, dressings are removed in the following sequence (1) the external cast, (2) steri-strips, (3) internal splits after cutting the suture on the left side and (4) columellar and alar sutures" (Daniel, 2010). Usually the patient does not have to remain in the hospital following the procedure as technology has gotten a lot better as time as passed. The margin of error is infrequent, although it does occur and when this happens; a patient may opt for a secondary Rhinoplasty which in turn will extend their stay in the hospital.

Abdominoplasty

Abdominal contouring began in 1899 with Kelly performing a procedure by eliminating a hefty segment of the abdomen. The procedure itself did not become trendy until the introduction of liposuction in the late 1970s. People were forgoing diets in favor of surgeryMatarasso (1980) made a momentous role in the type of procedure by introducing liposuction in conjunction with tailored abdominoplasty procedures. Patients who are seeking out this type of procedure are doing so as a result of excess skin and subcutaneous tissue in the abdomen. A traditional abdominoplasty is indicated when deformities entail both the supra and infraumbilical regions where a mini-abdominoplasty is designated when the issues lie solely in the infraumbilical area. The superlative contender for such a process is a nonsmoking, within the standard weight young woman. Surgeons advocate that overweight individuals are not ideal candidates for abdominoplasties because of the surplus primitive fat that they have over their abdomen. The "intra-abdominal cavity can be thought of as a balloon that fits inside a second external skin balloon. If the internal balloon is overly inflated by visceral fat, it cannot be effectively flattened by musculoaponeurotic plication. Thus, it will maintain a convex profile, which is translated to the external balloon and will lead to a convex appearance for the entire abdomen. This defeats the major reason why most patients seek abdominoplasty surgery" (Aly et.al, 2009).  

When an abdominoplasty is performed, the plastic surgeon will remove the excess abdominal skin and adipose tissue "usually from just above of the umbilicus to 2 cm above the pubis symphysis; repair of diastasis recti, and creation of a neoumbilicus. The patient must be placed in the reflexed position to close the skin. A mini-abdominoplasty is surgical removal of limited excess abdominal skin and adipose tissue, confined centrally and below the umbilicus, and plication of rectus abdominis fascia. The umbilicus is floated (i.e. is not detached from its surrounding abdominal skin). The patient may be placed in limited reflexed position for skin closure. During an abdominoplasty, the surgeon does not create a new umbilicus area, but the present belly button is brought up through a newly created hole in the skin (Logan, 2008). Patients have to be proper candidates for this type of procedure, as aforementioned to ensure that procedure is indeed a success. Patients should consult with their physicians on the realistic outcomes associated with this type of plastic surgery because of the significant cosmetic aspects of it. 

The abdominoplasty process is a step by step one. Prior to the patient arriving in the operating room for the procedure, the circulating nurses will turn the bed 180 degrees and make sure that the bed can curve into a lounge chair location. The circulating nurse coordinates the recommended anesthesia’s ahead of the patient is brought into the operating room. Once the individual arrives to the OR, the patient then moves to the bed in the supine placement. Prior to anesthesia being ordered, the circulating nurse places sequential density devices onto the patient's subordinate legs and turns on a machine to avert deep vein thrombosis from happening. The nurse is sometimes recommended to place a pillow under the knees in order to thwart any kind of lower back damage. Once anesthesia is given to the patient, the nurses then makes certain that all pressure points are well padded. Every surgeon performs the abdominoplasty in a dissimilar way. First, a methodical excision is made around the umbilicus and then a lower abdominal incision down to the fascia is made. The surgeon then repairs the diastasis recti by plicating the abdominal aponeurosis in the midline using a permanent suture. The patient is then placed in a reflexed location and any surplus skin is trimmed watchfully by the surgeon. During this stage of the procedure, two flat silicone drains are positioned in the hair-bearing region of the mons to exhaust any postoperative coagulum. Depending upon the patient's cadaver, the surgeon may perform liposuction on the abdominal flap and other areas near the stomach (Goldman, 2007; Logan, 2008). After the operation, the patient is informed by the surgeon not to stand up straight or lie flat. If this order is not followed, the patient can suffer much. Some patients may have to stay in the hospital following this type of procedure. Some surgeons require that patients remain in a 23-hour stay when they speak with the potential contender for this form of surgery.

There are other types of abdominoplasty procedures such as the mini-abdominoplasty, the panniculectomy, circumferential abdominoplasty and extended panniculectomy. A mini-abdominoplasty is the optimal procedure for men and women to improve their appearance but are not necessarily severe enough per a consultation to warrant a full abdominoplasty. This procedure lasts about 1 to 2 hours and the side effects are temporary swelling, numbness and discomfort. The circulating nurse performs similar operations in the operating room preparation, but they are not extensive as with a full abdominoplasty. There are three distinctive types of anesthesia that can be administered with this procedure: local, local with sedation and general. When a mini-abdominoplasty is performed, the surgeon makes a minimal incision directly above the pubic region, thereby cutting away loose skin and in turn a liposuction is done in conjunction with fat removal. The belly button is not repositioned with this procedure. Bandages are applied and secured following the closing of the incisions with small sutures (Logan, 2008). Surgeons typically note that patients do not have to remain in an overnight stay with mini-abdominoplasties. 

A panniculectomy is the "surgical removal of excess abdominal skin and adipose tissue (ie, pannus) only. The patient is not placed in the reflexed position for skin closure. Men and women can expect to see moderate to massive weight loss after this procedure. A circumferential abdominoplasty is the surgical removal of the pannus and excess back skin and adipose tissue—a single continuous incision is made circumferentially around the patient. A neoumbilicus is created, and plication of the rectus fascia may or may not be performed. The patient's back is done first with the patient in the prone position after which the patient is turned supine for removal of the pannus. The patient is placed in limited reflexed position to minimize strain on the back-wound closure. Usually, individuals are told that they can expect massive weight loss following this procedure. An extended panniculectomy is the removal of pannus, usually from just above the umbilicus to 2 cm above the pubis symphysis, and the creation of a neoumbilicus. There is no plication of rectus fascia and the patient is placed in the reflexed position for skin closure" (Logan, 2008). When patients meet with their doctor during a consultation, the recommended procedure is agreed upon accordingly. Liposuction has been on the rise in conjunction with the abdominoplasty because of its effectiveness.

In 1921, Dujarrier noted in a report the very first use of a cannula to eliminate excess fat for aesthetic purposes. Adipose tissue was removed from the knees of a ballerina. Interest in liposuction in conjunction with the abdominoplasty did not arise significantly until Matarasso's introduction of it in the 1980s. Liposuction is considered by patients to be a surgical course of action for body augmentation rather than a modality for those seeking weight loss, which is what happens when a patient only opts for an abdominoplasty. Patients who have experienced substantial weight loss may decide to undergo liposuction of their arms and legs in addition to the stomach so the changes can be felt throughout the body. Liposuction by and large requires patients to make considerable lifestyle changes such as eating an appropriate diet and exercising frequently to achieve long-lasting results. Currently, there are two types of liposuction procedures, the SAL and ultrasound-assisted liposuction. These procedures are still being performed with cannulas that are connected to machines that are suction based. The surgeon moves the cannula in a repetitive movement along the axial plane analogous to the skin surface to aspirate the fat cells. A circulating nurse may assist the surgeon in this process by getting the equipment ready. The surgeon must follow strictly guidelines during these types of procedures because of the volume of wetting solution that is to be used. If guidelines are not followed accordingly, there can be considerable complications that may result (Logan, 2008). With liposuction only, patients do not have to stay in the hospital, but are rendered on an outpatient basis. They are also encouraged to stay away from unhealthy foods and behaviors. 

Conclusion

Plastic surgery is an extensive aspect of the medical field spanning multiple areas of the body. With an ever-changing society and technology as a whole, plastic surgery aids individuals in feeling better about themselves, as long as they have a consultation with their medical physician who will educate them on the positives and negatives associated with it. Patients need to be aware of the risks associated with plastic surgery as well as the pleasing results that can come from it. Perhaps the most complex of the three aforementioned surgeries is the Rhinoplasty because of the distinctive appearance of one's nose. That is not to say that the other two are not just as noteworthy and considerable in altering one's appearance of their self-image. Plastic surgery is a wide-ranging, all-encompassing field that continues to expand on a daily basis.

References

Akkuzu, G. (2011, April 2). Primary Tip Rhinoplasty and Suture Techniques. Retrieved March 10, 2013, from Rhinoplasty Archive website: http://www.rhinoplastyarchive.com/articles/primary-tip-rhinoplasty-and-suture-techniques

Aly, A., Rotemberg, S. C., & Cram, A. (2009). Abdominoplasty. In B. Guyuron, E. Eriksson, J. A. Persing, K. C. Chung, J. Disa, & A. Gosain, (Eds.), Plastic Surgery: Indications and Practice. Elsevier Health.

Cohen, M. (1994). Mastery of Plastic and Reconstructive Surgery Volume 3 (1st ed.). Lippincott Williams & Wilkins.

Cosmetic Surgery of the Eyelids or Cosmetic Blepharoplasty. (2008, November).Société Française de Chirurgie Plastique Reconstructrice et Esthétique, Retrieved from http://www.chirurgie-esthetique-nice.fr/pdf/english/A3.Cosmetic.blepharoplasty.pdf

Daniel, R. K. (2010). Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques with Integrated Video Clips (2nd ed.). Springer.

Goldman, M. A. (2007). Pocket Guide to the Operating Room (3rd ed.). F. A. Davis Company.

Eyelid lift. (2013). Retrieved March 9, 2013, from Medline Plus website: http://www.nlm.nih.gov/medlineplus/ency/article/002977.htm

Lin, G., & Lawson, W. (2007). Complications using grafts and implants in rhinoplasty. Operative Techniques in Otolaryngology, 18, 315-323.

Logan, J. M. (2008, October). Plastic Surgery: Understanding Abdominoplasty and Liposuction. AORN Journal, 88(4), 587-604.

Oestreicher, J., & Mehta, S. (2012). Complications of Blepharoplasty: Prevention and Management. Plastic Surgery International, 10.

Rohrich, R. J., Hollier, L. H., Janis, J. E., & Kim, J. (2003, September 4). Rhinoplasty with Advancing Age. Techniques in Cosmetic Surgery, doi:10.1097/01.PRS.0000143308.48146.0A