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1. History Of Cosmetic Surgery
The earliest traces of Plastic Surgery date back almost 4000 years ago in ancient Egypt with evidence of skin grafts being used for the treatment on the face to repair fractures and facial injury. But the earliest written record was by Hindu surgeon, Shushruta in 600BC on procedures done on the nose, now known as Rhinoplasty. There were also traces in ancient Rome of breast reductions done on obese men and reconstructing ears and noses sliced off in gladiator fights(Lanham, 2009). Given that the procedure was done before polymer plastics was found, it is interesting to note that the term “Plastic” is derived from the Greek word plastikos, which means to mold or shape. During the Middle Ages in Europe, Plastic Surgery became less popular due to a number of factors. First, it was deemed sinful by the Church as it is believed that the body was a work of God and should not be mended.
Second, the procedures were known to be very painful, as anesthetics were not developed until the 19th century. It was only after local anesthetics became available that people were more receptive of the idea of Plastic surgery. Thirdly, the risk of infection was high as antibiotics were not available, the techniques and equipment were primitive and hygiene safety standards only started to improve during the Renaissance area. Apart from the invention of anti-infection drugs and anesthetics, other non-medical events also changed people’s attitudes towards plastic surgery. The two World Wars changed attitudes towards reconstructive surgery as it was used to mend disfigurements such as shattered jaws and open skull wounds(Lanham, 2009). The original intention of Plastic Surgery was mainly reconstructive, that is to correct aesthetic or functional problems. The first Plastic Surgeon in the United States, Dr. John P. Mettauer work on Cleft Palate patients in 1827(Schnur & Pamela, 2010).
However today, plastic surgery has branched into two main fields: Cosmetic Surgery and Reconstructive Surgery. The techniques may be similar, but the intentions and results are different with the former being about enhancing physical appearance and the latter closer to the original intention, though the line between the two can sometimes be blurred. Today, Plastic surgery has become much more accessible, with costs and risk going down and a wide variety of procedures available, from the invasive to the non-invasive. Apart from this, with increased prominence and exposure through the mainstream media, more people are considering Cosmetic Surgery as a commonplace procedure.
2. Reconstructive Surgery
Reconstructive surgery can be defined as a procedure that restores the function and appearance of a specific part of the body (Mosby, 2009). In 2009, it was performed 3.5 times more than cosmetic procedures (ASPS, 2010). It is appropriate under 3 conditions: 1) medical purposes, 2) birth defects and developmental abnormalities, and 3) traumatic injuries (Erhardt, 2010).
2.1 Medical Purposes
Reconstructive surgery is often performed to treat or prevent medical conditions. Among the procedures, the treatment of tumors and skin cancer constitutes the largest proportion, accounting for more than 75% of procedures performed in the US in 2009 (American Society of Plastic Surgeons, 2010) The removal of skin cancer or tumors by surgical biopsy often requires reconstruction of the affected area that may involve skin flap or grafting procedures. The aim of these procedures is on the treatment of an undesirable appearance or on curbing an internal spread of the disease. With the tremendous advancement of medical equipment, surgical tools and techniques, tumor and skin cancer patients are now able to receive treatments that are effective in both the removal of diseases and preservation/restoration of normal physical appearances (Erhardt, 2010).
2.2 Birth Defects
Reconstructive surgery has helped solve birth defects and developmental abnormalities that inhibit daily activities that may also result in social and self-esteem issues (Operation Smile, 2010). Among the most common are cleft lips and cleft palates of which there is one per 500-700 births (World Health Organization, 2001) – accounting for more than 60% of all birth defect reconstruction procedures carried out by ASPS member surgeons (American Society of Plastic Surgeons, 2010). An opening in the upper lip between a newborn’s mouth and nose marks a cleft lip while a cleft palate occurs when the roof of the mouth has an opening in it, affecting children’s ability to eat, speak, hear, breathe and socialize.
With the help of anesthetics, the surgery takes about 45 minutes to perform and involves repositioning of tissue and muscles to close the cleft and rebuild the roof of the mouth (The Smile Train, 2010). The full treatment involves prosthetics, anesthetics and expertise from a host of healthcare specialists. These are necessary measures that ensure the most effective diagnosis, treatment, recovery and hence life quality that a child can have. However, this would not have been possible without the technical and technological sophistication that is characteristic of modern day healthcare and medicine.
2.3 Traumatic Injury
Plastic surgery has been used to treat traumatic injuries such as those caused by burns, animal bites and car accidents. One of the most cutting-edge procedures in this area is face transplant surgery, described as the single most important area of reconstructive research (Mason, 2005). The procedure involves surgically transferring healthy tissue from a brain-dead donor to a recipient. During the actual procedure, healthy tissue is harvested from the donor while non-viable injured tissue is removed from the recipient. Surgeons then restore blood flow, reattach nerves, muscles and bony structures, and reconnect each layer of the transplanted face to that of the recipient.
More often than not, patients require other follow-up surgeries and require lifelong use of immunosuppressant drugs, which may increase the long-term risk of cancer, infection and kidney failure. Other potential complications that may arise include rejection of the new face and reduced sensation or movement of the transplant. The first full face transplant was performed on a Spanish farmer on 20 March 2010 by a team of 30 Spanish doctors (Consumer Guide to Plastic Surgery, 2010).
3. Cosmetic Surgery
Cosmetic surgery has been on the increasing trend since technology vastly improved efficiency and success rates while surgical procedures in the field have been made more commercially available in recent years. In 2007, there were approximately 11.7 million procedures undertaken in the US, an increase of 557% from 2.1 million in 1997. (Cosmetic Surgery Statistics, 2008). Multiple reasons have propelled cosmetic surgery to its current status of ubiquity. These include increased commercialization, improved technology, media influence and societal pressures. Due to limitations in this report, we will focus on the most popular including, breast augmentation, liposuction, and sexual rejuvenation such as penile enlargement (phalloplasty) and vaginal rejuvenation.
3.1 Breast Augmentation
Breast augmentation is designed to increase bust size by implanting silicone gel implants into a pocket either directly behind the breast tissue or underneath the pectoral muscles. The implant will be inserted by making a small incision under the breast, below the areola, or within the armpit. One innovation is an instrument called the Keller Funnel, which is a cone-shaped, nylon-based device used to propel instead of pushing the implant into place via the normal procedure. It drastically decreases the risk of bacterial infection and capsular contracture, an immune reaction by the muscles (Keller, 2009). Tests have showed a direct increase in self-esteem in correlation to the surgical procedure, an approximate 17% increase on the Rosenberg scale (Figueroa-Haas, 2007).
Liposuction was first done by inserting a cannula under the skin and forcefully moving it back and forth to dislodge fat, which was then sucked out. Today, there are many new techniques and procedures. Lipo-Vibe utilizes air pressure to generate 3D acoustic energy one-dimensional vibration of ultrasound to dislodge fat that is then removed by a cannula. The pattern of movement enables the Lipo-Vibe to operate at infrasonic frequencies, which are much safer than the high-frequency energy generated by ultrasound. Another technique is Waterjet-Assisted Liposuction, which uses water containing anesthetic fluids to reduce pain and burising to flush out targeted fat without injuring surrounding tissues. Laser liposuction uses ultrasonic energy applied through the cannula or from outside the body, through the skin to burst the walls of the fat cells fiber optic laser technology to melt fat and tighten skin. It is extremely precise, requiring only local anesthesia.
3.3 Sexual Rejuvenation
For the women, laser vaginal rejuvenation uses laser technology to help tighten the vagina, which increases frictional forces and sensitivity during sexual intercourse. Another popular procedure is laser labiaplasty that reduces the vaginal area by sculpting the labia minora and surrounding areas, creating a cleaner and more youthful appearance. For the men, there is girth expansion that involves the use of liposuctioned fats, which uses of fat extracted from local fat stores such as the abdomen or buttocks and directly injected into the penis. In dermal graft transfer, two fatty strips, about an inch wide and a quarter of an inch thick from the gluteal fold are removed and a small incision is made at the fatty strips are placed under the skin at the head. Length Elongation involves severing the suspensory ligament that joins the penis to the pubic bone. Additional penile length that is suspended within the body will then be free to extend further, resulting in increased length.
4. Drivers & Implications
The plastic surgery industry is rapidly growing. In 2009, about 12.5 million cosmetic surgical procedures were performed in the US, a 69% increase since 2000 (ASPS, 2010). These procedures generated more than US$ 10 billion of consumer expenditure, more than the nominal GDP of around 60 countries (International Monetary Fund, 2010). Beyond the USA, the global market for cosmetic surgery products and services stood at US$36.1 billion in 2008, and is expected to reach $47.1 billion in 2013, with a compound annual growth rate (CAGR) of 5.2% for the service sector and 9.5% for the product sector (BCC Research, 2009).
One main driver is the development of Minimally Invasive Procedures, which is described under Section 4.2. It has also been cited that the rise in demand for cosmetic surgery is due to the baby boomer generation coming of age and their desire to preserve youth and health (American Academy of Cosmetic Surgery, 2010). The recent prevalence of financing companies providing loans for individuals who wish to go for elective cosmetic surgery has also become another driver for growth (MedChoice Financial, 2010)
The main driver for demand of cosmetic surgery is the media, which has perpetuated and bombarded society with an idea of physical beauty. From the physical scrutiny put on celebrities to reality TV shows such as “Extreme Makeover” and the “The Swan”. These shows portray drastic changes that exaggerate the likelihood of positive results. Condensing the procedures into short television programs makes the procedures and recovery seem shorter than the actually are. Complications, infections, failures and side effects are hardly mentioned, creating the illusion that the procedures are low-risk. In this sense, the media has greatly influenced society on what a being good looking and normal is without caution to viewers that it might not be real. Hence many viewers try to meet this standard by going under the knife.
With the increased accessibility of plastic surgery, this poses a threat to the security of the country and community. Terrorist suspects or criminals at large can simply alter their appearances to avoid being identified and captured. With the combination of fake identities, doctors will not be able to identify them, making them even more elusive.
An estimated 30 percent of Korean women aged 20 to 50, or some 2.4 million women, had surgical or nonsurgical cosmetic procedures in 2008 with many having more than one procedure (Fackler, 2009). Children from as young as 14 have undergone eye surgery and parents have begun to bestow these procedures as popular graduation gifts to their children. This emphasis on looks should not be coupled with the quiet acceptance that one’s looks are inadequate. There is a fear that one will fall behind his or her peers if they have not been remade and this plagues the entire younger generation of Koreans.
It is reported that about 7 to 15 percent of people requesting plastic surgery suffer from body dysmorphic disorder – an obsession with a small or imaginary flaw in ones appearance. These patients attempt to correct themselves but feel the same, if not worse, after surgery. About 15 to 20 percent of candidates are depressed because of their appearance and have substance abuse issues (Hyland, 2008).
5. Future and Emerging Trends and Technologies
Among the numerous new technologies emerging, a few have stood out to be at the forefront of medical innovation that have transcended into or have the potential to contribute to the development of Plastic Surgery. We will explore three in this report including the use of Stem Cells, development of minimally invasive procedures as well as Robotic Surgery.
5.1 Stem Cell Treatment
At the forefront of new trends is the use of Stem Cells in Plastic Surgery. They have the power to heal damaged tissues, restore beauty and have been proven to have the potential to treat and even cure previously incurable disease(National Institutes of Health, 2009). There are stem cells derived from embryos or adult stem cells, the former of which is at the centre of many ethical controversies. As such, the latter, derived from fat and are able to become different tissues including fat, bone and nerves, taking the form of surrounding cells as they grow(National Institutes of Health, 2009). Today, these cells can be harvested from one part of the body and injected into another to repair, rejuvenate and regenerate the desired area. In Cosmetic Surgery, they are used to enhance and treat the wrinkles, eyes, temple, chin, scars, and dimples among many others.
In term of reconstruction, these stem cells have been used to repair heart tissues after heart attacks, knee joints and cartilage, nerves, bones and even organs such as the pancreas in diabetics. Among the new procedures is Organic Breast Augmentation whereby a woman’s own fat is used instead of silicon or saline implants(Templeton, 2009). It has been touted as being safer, more realistic and the fact that it involves liposuction has increased its appeal as it has a two-in-one benefit.
This is not only a cosmetic surgery but can also be used to reconstruct deformities of breast cancer patients resulting removal of cancerous lumps. Plastic Surgeons have been using stem cells for over a decade and it has proven to have not only long lasting results but also therapeutic results in injured tissues. Also, because stem cells are found in a patient’s own body, there is a low probability of rejection and easily accessible with ample supply in most individuals – making it safer and more affordable.
5.2 Minimally Invasive Procedures
Pain, risk and the thought of going under the knife have long been deterrents to people considering plastic surgery, be it for reconstructive or cosmetic means. This has fueled the development of minimally and even non-invasive procedures. Among the most popular procedures are Botox, known medically as Botulinum Toxin Type A, which is a chemically injected to inhibit the release of acetylcholine, which produces wrinkles (Miller, 2010). Other popular procedures include non-surgical Rhinoplasty. Though it cannot be used to reduce nose size, it can be used to enhance the appearance and symmetry injecting dermal fillers instead of a full operation. By making procedures less invasive, lowering the time required for healing and using new technology such as Lasik for the correction of eye problems, it has increased the overall appeal of Cosmetic Surgery. There is also the potential of treating people with minor deformities and disabilities such as poor eyesight and scars. The appeal and potential both socially and economically is making this one of the main directions Plastic Surgeons are taking to.
5.3 Robotic Surgery
Robotic surgery is at the cutting edge of new medical technology. Since the PUMA 560 was used in 1985 for a neurological biopsy(Desai, Meyers, Lanfranco, & Castellanos, 2003), robots have been used to perform many major operations including cases of cancer and heart problems. By using robots, endoscopic technology, pinhole and 3D cameras, robotic surgery has allowed for surgery to be more accurate as the surgeon is now able to see better, and the cuts the surgeon has to make can also be smaller – resulting in a lower risk of infection(Cowles, 2009). Currently, most robotic surgeries are done within the same or adjacent rooms, but with greater Internet connectivity, tests are being done for renowned surgeons to conduct operations miles away from where they actually are.
This opens opportunities for top surgeons to conduct operations in many places, sharing the knowledge and skills with local doctors present in the operating theatre with the patients. Given the high costs of implementation and operation, it might not be feasible for common cosmetic surgery, but if it can be used for major operations, it could be applied to reconstructive surgery patients such as those requiring major skin grafts or deformities resulting from an accident. It speeds up the response time and doctors with unique skills can conduct their surgeries in the Emergency Room almost anywhere. Being a new development, much more testing still needs to be done, but this could potentially be a tool for ‘Celebrity Surgeons’ to market themselves to high paying customers in other countries as well.
Plastic surgery has a wide range of benefits for society. But with the increase accessibility and appeal of cosmetic procedures, the issues have overshadowed the possibilities. It must be emphasized that plastic surgery is not a cure-all for any self-esteem and sexuality issues. Surgeons also play in an important but conflicting role, balancing both business and medical interests. Where it will take us in the future is still uncertain, but we are definitely going to see more of it.
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