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									 The Ethics of
Plastic Surgery

Jason, Tim, Jina, Cassandra,
     Khanh and Gloria
                             Plastic Surgery
  A specialty that uses surgical techniques to improve the appearance and function
                                   of patients' bodies

             Cosmetic                               Reconstructive
-Changes features the patient finds         -Corrects or masks birth defects and the
unflattering                                destructive effects of trauma, surgery or
-Aims to make the patient looks more
youthful                                    -Gives the patient a more normal

                                                              Cleft lip
              Joan Rivers
A Brief History of
 Plastic Surgery
                      4th Century
 Byzantine physician Oribasius
  wrote Synagogue Medicae, a
  encyclopedia of techniques and
  procedures in reconstructive surgery
 Discussed using flaps, a mass of
  tissue that remains partially attached
  & retains its blood flow, to avoid
  facial distortions
18th Century – Resurgence
 Gained popularity in Europe, particularly
 Introduction of anesthesia, allowing the
  surgery to be less risky
 1891
    Dr. John Roe was the 1st person to introduce
     the aesthetic advantages of rhinoplasty
    Started the beginning of cosmetic surgery
 World War I
   Doctors were called upon to treat a large number of
    individuals who had experienced severe head injuries
    and as a result were often missing noses, ears, lips and
    other body parts.
 World War II
   the popularity of plastic surgery continued to grow
    and become more advanced. During this time
    surgeons learned to perform the procedures with
    speed, precision and accuracy and this allowed more
    people than ever before to benefit from the surgery.
 American Society of Plastic and
  Reconstructive Surgery (ASPS)
 Established by two European
  surgeons named Jacques Maliniac
  and Gustave Aufricht
 Gave plastic surgery recognition
  and popularity
   A Few Types of
Laceration Repair
Scar Revision
Animal Bite
Burn Surgery
           Laceration Repair
       -A wound caused by sharp
object producing edges that jagged,
dirty, or bleeding.
       -Affect the skin, subcutaneous
fat, nerve, tendon, muscle or bone.
Purpose of Laceration Repairs
   Laceration repair aims to do four things:

      1.   Stop bleeding
      2.   Prevent infection
      3.   Preserve function
      4.   Restore appearance

   The goal is to promote healing, minimize risk of
       infection, minimize premature splitting of
       sutures, and avoid poor cosmetic result.
     A Laceration Should Be
            Repaired If It…
 Continues to bleed after application of pressure
  for 10-15 minutes.
 Is more than one-eighth to one-fourth inch deep.
 Exposes fat, muscle, tendon, or bone.
 Causes a change in function surrounding the
  area of the laceration.
 Is dirty or has visible debris in it.
 Is located in an area where an unsightly scar is
Four Ways To Repair a

 Direct Closure
 Skin Graft
 Tissue Expansion
 Flap Surgery
      Direct Closure

 Performed on wounds that
  are not too deep and have
  straight edges of skin.
 Permanently closes wound
  and minimizes scarring by
     Skin Grafts

 Used for wounds that
  are wide and difficult
  or impossible to close.
 The technique is to
  remove healthy skin
  from another area to
  cover the open
  wound with.
Tissue Expansion
Growing extra new tissue to the
  site that will require the skin.

     Skin grown in this way remains
      connected to its original blood
      supply, so the risk of loss of
      sensation in the area of the
      wound is greatly diminished.
     The scars that result are less
      noticeable than those from skin
      grafts or skin flaps.
     Near perfect color match
      provided by the newly grown
                     Flap Surgery
Removal of living tissue and
  transplanting it to the area that needs it.
Microsurgery is needed to remove the
  flap and transplant it to another part of
  the body.
    Able to restore both form and
     function to area of the body that
     have lost skin, fat, muscle, and/ or
     skeletal support
                      Scar Revision
What is Scar Revision?
   Surgical scar revision is an option for those
    who faced with scars originating from injury
    or through surgery.
   Depending severity of scars, revision of
    scarred tissue may restore both form and
    function (size and depth of wound, blood
    supply to the area, thickness and color of
    skin, and the direction of the scar).
   Considered as a cosmetic surgery by most
    insurance companies.
   To be a reconstructive procedure, candidate
    must have loss of mobility of muscles or
    joints caused by the scar.
Different types of scars

 Hypertrophic scars
 Facial scars
 Thick, puckered, reddish scar
  resulting from excessive growth
  of fibrous tissue outside the
  boundaries of the original
 Can be treated by injecting a
  steroid medication directly to
  scar tissue
 Scar can be reduced or redness
  of scar may diminish however
  keloids have tendency to recur
 Can be found on the earlobe,
  shoulder and over the breast.
  Hypertrophic Scar
 Do not grow out of the
  boundaries of the scar
 Thick and raised texture.
 May restrict the natural
  movement of muscles and
 Can be treated with
  steroid injection.
Scars that result from skin edges
   pulling together as the skin is
   healing over a large area.
 Can affect nearby muscles and
 Restrict normal movement.
 Can be found on patient who
   experienced burn injuries.

Techniques to correct contracture:
      Skin grafts
      Flap surgery
      Z-plasty
      Tissue expansion
                       Facial Scars
 Cosmetic problem
 Hypertrophic
 Procedure:
    Steroid Applications and Injections
        Flatten and reduce the redness of hypertrophy
         and keloids
        Break down the skin’s collagen
        Reduce itching and/or pain associate with these
 Tiny stitches-thinner, less noticeable scar
 Z-plasty- Method to move a scar from one
  area to another, usually into a natural fold
  or crease in the skin to minimize its
 Dermabrasion- Method to remove or to
  smooth out the topmost layer of the skin
         Animal Bite Repair

 Facial reconstruction after dog bite.
          Forehead laceration from
                           dog bite

Before:         After:
                    Burn Surgery
 Death rates dropped with many burn
 Survivors are often left with:
   Functional impairments
   Distortion of appearance (head and neck)
   Change in color and texture of burned
 Reconstructive burn procedure
   Skin grafting and flap reconstruction
Before and After
Surgery for Children
  Cleft Lip and Palate
  Downs Syndrome
  Conjoined Twins
         Cleft Lip and Palate
 One of the most common major birth
 Birth defect in which the tissues of the
  mouth or lip fail to form properly during
  fetal development.
 In the US, clefts occur in 1 in 600 to 800
 These may impact an individual’s self-
  esteem, social skills, and behavior.
        What is Oral Clefting?

 this occurs when the tissues of the lip or palate
  of a fetus don’t grow together early in pregnancy.
 children with clefts often don’t have enough
  tissue in their mouths and the tissue they do
  have isn’t fused together properly to form the
  roof of their mouths.
                                 Cleft Palate

 Occurs when the roof of the mouth
  doesn’t completely close, leaving an
  opening that can extend into the nasal
 This can extend from the front of the
  mouth to the back of the throat.
 This is not as noticeable as the cleft lip
  because it’s inside the mouth.
 This may be the only abnormality in the
  child, or it may be associated with cleft
  lip or other syndromes.
                    Cleft Lip
 The lip doesn’t completely form
  during the prenatal fetal

       3 different kinds:

     1) unilateral incomplete: a
        cleft on one side of the lip
        that doesn’t extend into the
                                     Cleft Lip
                       2) unilateral complete: a cleft
                          on one side of the lip that
                          extends into the nose

3) bilateral complete: a
   cleft that involves both
   sides of the lip and
   extends into the nose
        Complications related to
                  Oral Clefting
 A child with a cleft
  lip or palate are more
  likely to get colds,
  hearing loss, and
  speech defects
 Dental problems:
  missing, extra,
  malformed, or
  displaced teeth, and
                    Treating Cleft:
            Reconstructive Surgery

Cleft lip
 often requires only one reconstructive surgery especially if
  the cleft is unilateral
 The surgeon will make an incision on each side of the cleft
  from the lip to the nostril
 Then the two sides of the lip are drawn together and stitched
  back together
 Bilateral cleft lips may be repaired in 2 surgeries about a
  month apart
                 Treating Cleft:
         Reconstructive Surgery

Cleft Palate
 To repair it, the surgeon will make an incision
  along both sides of the cleft
 Tissue is drawn together from both sides of
  the cleft to rebuild the roof of the mouth
 This requires 2 or 3 nights in the hospital:
          Down Syndrome
What is Down Syndrome?
 Caused by an extra copy of chromosome
  21 inside each of the body’s cells –
  chromosomal accident.
 It affects 1 in every 800 babies born.
 The common physical features:
    Extra skin at the inner corners of the
    Flattened nasal bridge.
    Flattened mid-face region.
    Shorter limbs.
    Speech impairment.
Plastic Surgery in Children
      with Down Syndrome

    The surgery can be divided
      into two groups:
      1. Face reconstruction
      2. Tongue reduction
 Facial Reconstruction
 Purposes:
    To improve the appearance of the
    To improve social acceptance.
 Surgical procedures:
    Resection of the tongue.
    Correction of the down-turned lip.
    Lifting of the nasal bridge.
    Removal of fat from the neck.
    Placing implants in the cheeks.
       Tongue Reduction
  Children with down syndrome often
   have an open mouth and a protruding
 Tongue reduction consists of
   removing a wedge of tongue to make
   it smaller and shorter.
 Purposes:
  1. It helps the children to keep his or
       her mouth closed while eating or
       breathing ->mouth-breathing can
       be harmful.
  2. It can improve the speech
              Conjoined Twins
 What is a conjoined twin?
   Twins whose bodies are joined together at
   They occur once in every 200,000 live births.
   The overall survival rate: 5-25%.
   They are more likely to be females.
   Forms when a single fertilized egg fails to
    divide completely to create two distinctive
   They are fused in the skull, thorax, head,
    chest, or back and so on…
   Reconstructive Surgery
 Life without the surgery.
    Because they are joined together, they don’t have
     the ability to move independently.
    Potential pulmonary problems such as the risk of
     blood clots, shared illnesses that reduce their life
 Surgery:
    Lasts from 24-48 hrs or even longer.
    Risks:
       Excessive intracranial bleeding.
       Formation of blood clots in the blood vessels.
       Brain swelling.
       Heart complications and infection.
       Death of one of the twins.
Tumor Removal and
Breast Reconstruction
           What is a tumor?

A tumor is a swelling of a part of
 the body, generally without
 inflammation, caused by an
 abnormal growth of tissue.
A tumor can either be:
   Malignant or
   Benign
               Benign Tumors

 Benign tumors are non cancerous.
 They are usually localized to one
  area of the body.
 Most commonly found on the skin.
 Usually they are easy to remove
  with surgery.
            Malignant Tumors
 Malignant Tumors are the cancerous
 They metastasize to other parts of the
 They can be invasive which makes them
  difficult to remove all of the tumor.
 Radiation or Chemotherapy is a common
  method of treatment in conjunction with
      Removal Procedures

 The procedure for tumor removal
  largely depends on the following
  three criteria:
   Type of tumor.
   Stage of tumor.
   Location of tumor.
Skin Cancers and Growths

 Skin cancers and growths can be
  removed by excision.
   A scalpel is used to cut off the tumor
    growth and the resulting wound is
    sutured closed.
   The patient is left with a thin scar that
    will fade over time.
Skin Cancers and Growths

 Mole removal
 176 pound tumor removed from
  woman in Romania.

                                                  QuickTime™ and a
           QuickTime™ an d a
  TIFF (Uncompressed) decompressor      TIFF (Uncompressed) decompress or
     are need ed to see this picture.      are needed to see this picture.
          Invasive Cancerous
 Major surgery is usually needed to remove a
  tumor of this kind.
 Grafts and skin flaps from other parts of the
  body are usually used when the tumor is
 Once the tumor has started to spread to other
  tissues it becomes difficult to remove all of it
  and in many cases additional surgeries are
 The reconstruction process can take a few
  surgeries as well depending on the damaged
  caused by the tumor.
      Breast Reconstruction

 When a woman is diagnosed with
  breast cancer there are usually 2
  options of treatment:
   Lumpectomy - the removal of the
    lump and radiation therapy.
   Mastectomy - the removal of the entire
     Breast Reconstruction
In 2005 there were about 58,000 breast
   reconstruction surgeries performed by
   three different procedures.
The popular of the procedures is the
   tissue expansion surgery which made
   up 60% of breast reconstruction
The other two procedures are flap
   reconstruction and just implants,
   making up 20% each.
                                                        Breast Reconstruction:
                                                               Skin Expansion
                                                                           1.   A tissue expander is inserted under
                                                                                the skin following mastectomy.
                                            Qui ckTi me™ and a
                                   TIFF (Uncompresse d) d eco mpressor
                                     are ne ede d to see thi s pi cture.   2.   Through a valve buried in the skin
                                                                                salt water will be injected
                                                                                periodically over a few weeks or
                                                                           3.   Once the desired size is achieved a
                                                                                second surgery is done to replace the
                                                                                expander with a more permanent
         Qui ckTi me™ and a
                                                                                implant. In some cases the expanders
                                                                                are designed to serve as the implant.
TIFF (Uncompresse d) d eco mpressor
  are ne ede d to see thi s pi cture.
     Breast Reconstruction:
 In some cases a tissue expander
  may not be necessary.
 In the case of a lumpectomy there
  may be enough tissue remaining
  that an implant can be inserted
  without having to expand the tissue.
 Cuts down on the number of
  procedures and also on cost.
                                                       Breast Reconstruction:
                                                         Flap Reconstruction
         Qui ckTi me™ and a
TIFF (Uncompresse d) d eco mpressor
  are ne ede d to see thi s pi cture.
                                                       This method of reconstruction
                                                       involves the transplantation of skin,
                                                       fat, muscle, and its blood supply to
                                                       create a new breast.

                                                       The tissue usually comes from the
                        Qui ckTi me™ and a
               TIFF (Uncompresse d) d eco mpressor
                 are ne ede d to see thi s pi cture.
                                                       abdomen, back, or thigh and requires
                                                       a skilled microvascular surgeon to
                                                       reconnect the blood vessels to new
                                                       ones at the site of transplantation.
                                                                           Breast Reconstruction:
         Qui ckTi me™ and a
TIFF (Uncompresse d) d eco mpressor
  are ne ede d to see thi s pi cture.
                                                                             Flap Reconstruction
                                                                           •Another method of flap reconstruction
                                                                           involves moving a section of skin
                                                                           muscle and fat from the abdomen
                                            Qui ckTi me™ and a
                                   TIFF (Uncompresse d) d eco mpressor
                                     are ne ede d to see thi s pi cture.
                                                                           through a tunnel created under the skin
                                                                           to its new site.
                                                                           •Here the transplanted tissue remains
                                                                           connected at its original source which
                                                                           means it will have a solid blood supply.
                                                                           •The patient will have scarring on the
         Qui ckTi me™ and a
TIFF (Uncompresse d) d eco mpressor
  are ne ede d to see thi s pi cture.

                                                                           abdomen and the newly formed breast.
                                                                           •Additional surgeries may be required.
     Breast Reconstruction:
       Additional Surgeries
 In many cases a second or third
  surgery may be needed.
 Reasons:
   Reshape breast, adjust size
   Swap for a more permanent
   Nipple reconstruction.
      In some cases they are just tattoos.
Breast Reconstruction:
      Before and After
            Breast Augmentation
 Official named Mammoplasty
 A procedure to enhance the size and shape of a woman’s
 3rd most popular surgical procedure in 2005
 Why people do it?
     To enhance the body contour when a woman feels her
      breast are too small
     Correct a reduction in breast volume due to pregnancy
     To balance a difference in breast size
     Reconstruction of breast from previous breast surgeries
               Breast Augmentation (cont.)
 The Implant
   It is a silicone shell filled with either silicone gel or saline (salt water

   Gel-filled breast implants
       Insufficient information on the safety of silicone implant, only available
        to woman participating in approved studies

   Saline-filled breast implants
       It is unrestricted and available to all surgical patients
       Pending review of FDA
  Breast Augmentation (cont.)
 The Surgery
    2-hour procedure

     Surgeon lifts the breast tissue and skin to create a pocket
      either behind or in font of the breast tissue

     Incisions:
         Crease under breast
         Around areola
         Armpit
         Bellybutton
  Breast Augmentation (cont.)
 Risks
    Most common problem: Capsular Contracture:
        When the scar or capsule around the implant tightens,
         squeezing the soft implant causing the breast to feel
        Treatment: replacement or removal of implant
    Excessive bleeding leading to swelling and pain
    May develop and infection around an implant
    Loss of sensitivity in the breast or nipple, at points of
    Implants can break, leak, or rupture
                               Nose Surgery
 Official name Rhinoplasty
 Surgery to reshape the nose
 2nd most popular surgery in 2005

 Why people do it?
     Can reduce or increase the size of your nose, change the
      shape of the tip or the bridge, marrow the span of the
      nostrils, or change the angle between your nose and upper
     Can correct a birth defect or injury
     Relieve breathing problems
                   Nose Surgery (cont.)
 The Surgery
    1 to 2 hour procedure
    The skin of the nose is separated from its supporting
     framework of bone and cartilage, which is then sculpted to
     desired shape and incision is made inside the nostrils

 Risks
    Infections, nosebleeds, a reaction to anesthesia
    Small burst blood vessels may appear as tiny red spots on
     the skin’s surface
    Overall minimal risks with a qualified surgeon
 Comes from Botulin Toxin
    This is a neurotoxic protein produced by Clostridium
    It is the single most poisonous naturally occurring substance
     in the world. (100 grams could kill every human on earth!)
    It was also used in chemical warfare.
        It was injected into Fidel Castros cigars as an attempted
         assassination attempt, but the cigars were never planted.
                    Botox continued..
 So why is such a dangerous substance used in Cosmetic

     It is proven that in low doses, Botox can relax muscle
      tissue and reduce wrinkles.
     This procedure can be performed in office and takes
      only a few minutes.
     It costs about $200-$400 dollars per area that is
     This procedure is the most performed, having been
      done 3,839,387 in the year 2005 alone. We will bring
      this up again later.
                Botox continued

 Side effects involved with botox.
   Drooping of the eyelids
   Uneven smile
   Inability to close eyes.
   This can be caused by the botox
    leaking out of the muscle and into
    other parts of the face that were not
 Otherwise known as a Facelift.
 This surgery is used to rid the face of wrinkles and
 It costs from $7000-$9000.
 Most of the people that undergo this surgery are in there
  early forties.
 The best candidates for this procedure are people with
  some elasticity in their skin, this helps in the procedure.
 The surgery takes a few hours to complete and may be
  split into two separate sessions depending on the extent of
  the procedure.
      Rhytidectomy continued
 The procedure-
    Incisions are first made above the hairline at the
    This incision is then followed around the contour of
     the hairline until it passes the top part of the ear.
    Any excess fat is then removed and the skin is pulled
     up to tighten against the contour of the face.
    The skin that is left over after being stretched is
     removed and the skin is reattached by stitches.
    In addition to having a few bruises, a tube may be
     inserted behind your ear to collect any blood that may
Rhytidectomy continued

 Before and After
      Rhytidectomy continued
 The numbers
    108,955 facelifts were performed in the year 2005.
    The number has actually decreased by 19% since the
     year 2000.
    Does this mean that cosmetic surgery has gone down
     in popularity?
    Consider this
         The number of botox injections in 2005 was
         This is a 388% increase since 2000!
         So cosmetic surgery is not losing popularity, its
          just finding better ways to change us.

 Removes fat from
  many different sites
  on the human body
 Most sought after
  cosmetic surgery
 Removes 10 pounds
  of fat
                 Mechanisms for
 Suction-assisted       Power-assisted
                          liposuction (PAL)
  liposuction (SAL)
                         External ultrasound-
 Ultrasound-assisted
                          assisted liposuction
  liposuction (UAL)
 Liposuction will not boost
 Body fat is linked to many diseases
 Removal of body fat will not
  decrease body chemistry
 Only removes the outer layer of fat
 Fat cells need to shrink in size not
 No type of liposuction is a
  substitute for dieting and exercise
Liposuction In Men
              Celebrity Influence
 Today more than ever stars are receiving plastic
 From liposuction to Botox, plastic surgery is the
  newest thing in Hollywood, just a simple trip to
  the doc’s between your trip to the spa and lunch
  at the most exclusive restaurants
 Now a days magazines like OK!,
  InTouch,People, etc. follow celebs around and
  give the latest gossip on the plastic surgery of
  the stars
Celebrity Before & After

 Ashlee Simpson’s Nose Job
Celebrity Before & After
   Cher – Forever Young
Celebrity Before & After
     Tara Reid
     Reality shows and cosmetic

 The Swan (Fox), I Want a Famous
  Face (MTV) and Extreme
  Makeover (ABC), Dr. 90210 (E!)
 Promote unrealistic expectations
 Different from real life
 Plastic Surgery Reality Shows
                             More Men Having Cosmetic
                                                   Increased 200% to 700%
                                                    in many procedure
1200                                               Most popular are
1000                               Buttock Lift     liposuction, nose
                                                    reshaping, and eyelid
 800                               Lip              surgery
 600                               on              Most involve the face
                                   Lower Body
 400                               Lift            Due to the competitive
       2005   2004   2003   2002
Body Dysmorphic
 Is a preoccupation with an imagined
  physical defect in appearance or a
  exaggerated concern about a minimal
 Individual’s obsessive concern most often
  is concerned with facial features, hair or
  odor .
 It begins in adolescence, becomes chronic
  and leads to a great deal of internal
                  Body Dysmorphic
 Afflicted individuals may begin to consult many
  dermatologists or plastic surgeons and undergo painful or
  risky procedures to try to change the perceived defect

 Despite these medical procedures it does not relieve the
  individuals negative perception of themselves

 BDD tends to be chronic and can lead to social isolation,
   school dropout major depression, unnecessary surgery
   and even suicide
Plastic Surgery Obsession
 The Cat Woman Before & After
Plastic Surgery Obsession
         Michael Jackson
Insurance Companies
  Insurance Companies
Do insurance companies cover plastic
surgical procedures?
       Probably not.

Insurance companies and plastic surgery
have a lot of overlapping grey areas which
if you are not familiar with could cost you
a lot of money.
   Insurance Companies
How do Insurance companies define plastic
         They break it down into two groups…

Reconstructive - procedures performed on
abnormal structures of the body caused by
congenital defect to approximate normal
appearance. This means that in order for them to
cover the surgery there needs to be a loss of

Cosmetic - are those procedures that reshape
normal structures to increase self esteem.
Anything not out of necessity.
                  What is covered?
Here are some procedures that may be covered:

PERFORMED TO:alleviate health problems such as back
pain, sores, hernia, rashes, restore the ability to walk

TO:correct congenital asymmetry;reduce overly large
breasts that are causing health problems (shoulder
grooving, neck and back pain etc.);reconstruct a breast lost
to disease;correct congenital absence of breast;reduce over-
developed male breasts - gynecomastia.
congenitally deformed ears;reconstruct ears that are deformed by
disease or injury.
drooping of upper eyelids that are obscuring vision;correct out-turned
or in-turned lower eyelids.
asymmetrical appearance caused by facial paralysis;treat conditions
affecting the facial muscles lips and cheekstreat traumatic
deformities;correct head and neck deformities.
tunnel syndrome;correct Dupuytren's contracture, treat tendon & nerve
injuriescorrect syndactyly (fused fingers) and other congenital
deformities .
deformities resuming from birth defects or disease;treat injuries or
nasal deformities that may affect breathing

Breast Augmentation - $5,000 - $8,000
Collagen Injection - $500 - $1,500
Eyelid tuck - $4,000 - $5,500
Face Lift - $7,000 - $9,000
Hair removal $300 - $500
Liposuction - $2500 - $10,000
Nose - $5,000 - $6,000
Peck Implants - $6,000 - $7,000
Tummy Tuck - $6,000 - $8,000
           Partial Coverage

•Some insurance companies may only cover
part of the cost of the reconstructive surgery
leaving the rest on the patent to pay or the
doctor to take a discount on.
•This is why most plastic surgeons do not
participate with insurance companies.
•Some doctors may take on pro bono cases
like the woman with the 176 pound tumor.
•Also there are companies like operation
               Operation Smile

 A private non-profit organization.
   They provide reconstructive surgery to
    indigent children in 30 countries all
    over the world.
   These patients suffer from cleft lip or
    cleft palate.
   They have 25 mission sites in 24
    countries every year.
                Operation Smile

 2005
   Worldwide they raised
    enough money for
    8,359 surgeries.
Images of the perfect body

 The media and pop culture force many people to
  believe that there is something wrong with them.
 We are bombarded with images of perfectly chiseled
 Many shows and music artists also show us that we
  need to look like them.
 This leads to many people feeling that plastic surgery
  can fix what pop culture thinks is wrong with them.
 Images of the
“perfect body”

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