Cosmetic Surgery Review

Cosmetic surgery is a rapidly growing medical specialty both in the numbers of patients treated and in the techniques and approaches available. This review consolidates the information available on cosmetic surgery from popular literature, the media, and advisory services. Doctors differ in their attitude to surgery for cosmetic reasons only. Patients requesting such surgery are usually normal individuals, but with a heightened consciousness about their looks. A proportion of them may seek advice on what, to them, seems an unsatisfactory appearance. They deserve the same professional approach and empathy as patients seeking help for clinical disorders. I would like to encourage the non-specialist to approach cosmetic surgery objectively. By understanding what may be achieved cosmetically, patients can receive invaluable advice, and appropriate referrals can be organised.

Summary points:

• Cosmetic surgery remains highly dependent on the skill of the operator, and technological advance should be viewed with this in mind.
• Large volume infiltration can reduce the cost to benefit ratio for selected indications.
• Lasers have a relatively limited niche in medical aesthetics.
• No single method of breast augmentation has all advantages.
• Three surgical procedures can correct facial ageing: resurfacing, subdermal augmentation, and face lift surgery.
• Multidisciplinary team work is a practical way to provide a comprehensive service for the patient requiring cosmetic surgery.

Requests for cosmetic surgery can be divided into three categories: correction of abnormal features (eg prominent ears, a large nose, gigantomastia, breast hypoplasia, hirsutism); reversal of the signs of ageing (eg facial wrinkles and creases, thinning hair and baldness, irreversible skin stretching, drooping of prominent tissue such as breasts and buttocks); and treatment of health related problems (eg obesity, tooth decay, abdominal bloating, cellulite, facial fluid retention, chronic skin problems, brittle hair and nails). None of these conditions can be classified as overt clinical disease. Nevertheless, their correction or treatment can significantly enhance patients’ self perception and reduce self consciousness.

Patients requesting cosmetic surgery are generally well, so surgical risks should be minimal.

Recent advances in anaesthetic techniques have reduced the need for general anaesthesia for certain cosmetic procedures, adding to the popularity of cosmetic surgery.1 Large volumes of dilute local anaesthetic and adrenaline are now used for subcutaneous infiltration, enabling up to 10% of the body surface to be anaesthetised locally and perioperative bleeding to be significantly reduced. Therefore haemodynamic stability can be maintained without intravenous fluid replacement or blood transfusion.2,3

Infiltration with a large volume of local anaesthetic furthermore reduces the need for general analgesics. Hypnotics can also be avoided in favour of intravenous sedation for simple procedures, so patients can keep control of their airway and vital functions. Such patients can even be upright during the procedure, and the surgeon can observe the effects of gravity and voluntary muscle activity during surgery.

Minor cosmetic procedures can take place safely under intravenous sedation in the doctor’s surgery.4 For more extensive surgery requiring general anaesthetic or intravenous sedation, hospital remains the best choice.