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Cosmetic vs. Reconstructive Surgery
Although the outward effects may be similar or even identical, the terms cosmetic and reconstructive surgery are not interchangeable. The plastic surgeon performs cosmetic surgery to reshape normal structures of the face or body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed to correct abnormalities of facial or body structures caused by congenital defects, developmental abnormalities, injuries, previous or concurrent surgeries, infection, tumors or other disease. The purpose of reconstructive surgery is generally to improve function, but it may also be used to restore a normal appearance.
These distinctions have implications for insurance coverage. Nearly all insurance carriers cover reconstructive procedures for functional restoration, but not those performed purely for cosmetic reasons. In general, the classification as cosmetic or reconstructive depends upon the reason that the surgery is performed. For example, rhinoplasty to change the shape of the nose is considered cosmetic. However, rhinoplasty to change the shape of the nose following traumatic deformity is reconstructive.
Corrective surgery to remove or minimize the effects of scarring usually provides cosmetic improvement. Insurance carriers, however, may recognize these procedures as reconstructive in nature because scars are abnormal formations that develop on the body as a result of injury or illness.
Origins of Cosmetic Surgery
Cosmetic surgical techniques originally evolved from reconstructive procedures, and some techniques are the same, whether they are used for cosmetic or reconstructive purposes.
Suction-assisted lipectomy, commonly known as liposuction, is a procedure used to remove lipomas (fatty tumors), defat flaps and remove fatty deposits in various reconstructive procedures, but it has a much wider application as a cosmetic technique to streamline the body by suctioning away localized deposits of unwanted fat.
Many other procedures that today are more widely used to enhance appearance began as solutions to reconstructive problems. The relationship between the two types of procedures is so close that surgeons well-versed in reconstructive procedures are most likely to also have the background and training required for cosmetic surgery.
Background on Common Procedures
The following descriptions provide basic information on the most common reconstructive and aesthetic surgical procedures.
A tummy-tuck is a major surgical procedure to flatten the abdomen by removing excess skin and fat from the lower abdominal region and tightening the muscles of the abdominal wall. The best candidates for tummy-tucks or abdominoplasty, are men or women who are in relatively good shape but who are bothered by large fat deposits or loose abdominal skin that won’t respond to diet or exercise. The surgery is particularly helpful to women who, through multiple pregnancies, have stretched their abdominal muscles and skin beyond the point where they can return to normal. Loss of skin elasticity in older patients, which frequently occurs with slight obesity, can also be improved.
Complete abdominoplasty usually takes two to three hours, depending on the extent of work required. Partial abdominoplasty may take an hour or two. Most commonly, the surgeon will make a long incision from hipbone to hipbone, just above the pelvic area. A second incision is made to free the navel from surrounding tissue. With partial abdominoplasty, the incision is much shorter and the navel may not be moved, although it may be pulled into an unnatural shape as the skin is tightened and stitched.
Next, the surgeon separates the skin from the abdominal wall all the way up to the ribs and lifts a large skin flap to reveal the vertical muscles in your abdomen. These muscles are tightened by pulling them close together and stitching them into their new position. This provides a firmer abdominal wall and narrows the waistline.
The skin flap is then stretched down and the extra skin is removed. A new hole is cut for the navel, which is then stitched in place. Finally, the incisions will be stitched, dressings will be applied, and a temporary tube may be inserted to drain excess fluid from the surgical site.
For the first few days after surgery, the abdomen will probably be swollen and some pain and discomfort may occur which can be controlled by medication. Depending on the extent of the surgery, the patient may be released within a few hours or remain hospitalized for two to three days.
The doctor will give instructions for showering and changing. And though it may be difficult to stand at first, walking as soon as possible is suggested.
Surface stitches will be removed in five to seven days, and deeper sutures will come out in two to three weeks. The dressing on the incision may be replaced by a support garment.
Breast augmentation is performed to balance a difference in breast size, improve body contour or as a post-surgery reconstructive technique. Silicone shells filled with saline solution are implanted either directly under the breast tissue or beneath the chest wall muscle, giving breasts a fuller and more natural contour.
While a relatively straight surgical procedure, there can be discomfort associated with breast augmentation, such as scar tissue around the implant tightening over time. This tightening, known as capsular contracture, sometimes can be remedied by removing or scoring the scar tissue.
The methods for inserting and positioning implants depend on the patient’s anatomy and doctor recommendations. Incisions are made in an inconspicuous an area as possible – usually the armpit, around the areola (nipple area), or under the breast itself – to minimize visible scarring. Working through these incisions, the doctor lifts the breast tissue and inserts the implant. It is then centered beneath the nipple, either under or above the pectoral muscle. Possible risks include bleeding, infection, wound disruption, scarring, capsular contracture, sensory change or loss and implant rupture or failure.
After a post-surgical recovery period of 24 to 48 hours and an additional reduced-activity period of a few days, patients will likely experience soreness and swelling for a few weeks. Exercise and normal activity can resume at the direction of the surgeon.
Breast reconstruction is performed on mastectomy patients, allowing women who have lost breasts to cancer to preserve their natural profile and aid in their psychological healing. Breast reconstruction surgery is an effective way to rebuild the breast.
After the doctor assesses a patient’s situation, he or she explains surgical options appropriate for the patient’s age, health, and goals for appearance. Most cases of reconstruction will require more than one operation, but the process can begin right after the mastectomy has been performed. This can spare the patient some trauma associated with loss of the breast.
Depending on the surgeon’s evaluation of the many factors affecting a patient’s case, he or she can use a variety of techniques to reconstruct the breast. The most common technique combines gradual expansion of chest tissue (commonly called the tissue expansion technique) with the use of breast implants. With skin expansion, a balloon expander is inserted beneath the skin and is inflated with injections of salt-water solution over a period of weeks. After the breast area is sufficiently stretched, the expander is removed and replaced with a permanent implant. The nipple is then reconstructed in a subsequent procedure.
An alternative to skin expansion is the flap reconstruction technique. This involves creation of a skin flap using tissue taken from another part of the body such as the abdomen or back. The flap is attached to the chest area to create a pocket for an implant or used to build up an actual breast mound.
Flap surgery allows for single-stage breast reconstruction, which may allow some women to wake from their mastectomy surgeries with a fully reconstructed breast, rather than having to undergo several stages of reconstructive surgery.
After completion of the reconstruction process, doctors may recommend further operations on the healthy breast to match it to the re-built one. The ultimate result helps restore the patient’s physical appearance and improve her self-confidence.
Techniques for breast reduction vary, but the most common procedure involves an anchor-shaped incision that circles the areola, extends downward, and follows the natural curve of the crease beneath the breasts. The surgeon removes excess glandular tissue, fat, and skin, and moves the nipple and areola into their new position. He or she then brings the skin from both sides of the breast down and around the areola, shaping the new contour of the breast. Liposuction may be used to remove excess fat from the armpit area. In most cases, the nipples remain attached to their blood vessels and nerves. However, if the breasts are very large or pendulous, the nipples and areolas may have to be completely removed and grafted into a higher position. (This will result in a loss of sensation in the nipple and areolar tissue.)
Stitches are usually located around the areola, in a vertical line extending downward, and along the lower crease of the breast. In some cases, techniques can be used that eliminate the vertical part of the scar. And occasionally, when only fat needs to be removed, liposuction alone can be used to reduce breast size, leaving minimal scars.
After surgery, the patient will be wrapped in an elastic bandage or a surgical bra over gauze dressings. A small tube may be placed in each breast to drain off blood and fluids for the first day or two. Some pain might occur for the first couple of days--especially when moving around or coughing-- and some discomfort for a week or more. The surgeon will prescribe medication to lessen the pain.
The bandages will be removed a day or two after surgery, though the patient will continue wearing the surgical bra around the clock for several weeks, until the swelling and bruising subside. The stitches will be removed in one to three weeks.