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Plastic surgery versus aesthetic surgery over the course of time

What comes to mind when you hear the term “plastic and esthetic surgery”? If you think that plastic surgery is just for models and millionaires, you are wrong. If you are not only thinking of esthetic surgery, but also a reconstructive, burn and hand surgery, then you have a good knowledge of the matter.

The assertion that “the genius of creation is unsurpassable” is undisputedly correct, and yet it has been 530 years since any correction of the God-given exterior was considered blasphemy and iniquity. Times have changed, modern plastic surgery can look back on a proud age of over 530 years.

Its actual history is quite exciting and begins more than 2800 years ago,  800BC, in ancient Indian medicine, when the very first form-reproducing interventions were carried out. It was not until much later that such procedures were named surgery of congenital and acquired defects of form and function. The term “plastic” means “shaping” and was first used in that context in the “Handbook of Plastic Surgery” by Eduard Zeiss from 1838.

The World Health Organization (WHO) defines health as a complete physical, mental and social well-being.

The liberation of medicine from philosophy and the orientation towards research as well as the general structure of knowledge made it clearer that general health and well-being also include an intact external appearance. This insight led to the development of plastic surgery. In the centuries in which it has been practiced, it has developed not only as a methodologically-oriented discipline, but also as a domain that has always to some extent mirrored the state of society.

Esthetic surgery is a part of plastic surgery that exclusively deals with the external appearance. Esthetic surgery interventions are determined exclusively by the patient’s wishes. When translating the term “esthetics”, one tends to associate it with something like “beautification”, and before you now it, everyone is talking about “cosmetic” or “beauty surgery”, which does not exist as such. This designation does not sufficiently express what is meant.

Terms like “physical integrity”, “beauty” and “youth” became decisive for the efficiency of a modern, fast-moving person. The fairy tale question “Mirror, mirror on the wall, who is the fairest of them all” became louder and louder. Thus an “Eldorado” was created, and the unmedical business of so-called “cosmetic surgery” thrived. There was a danger of the actual plastic surgery being degraded to a “beauty treatment with a scalpel”. In 1968, a union of plastic surgeons (formerly VDPC, now DGPRÄC) was founded as a countermeasure in order to protect patients from the botch-up and mere cosmetic services by educating them and to maintain the high standards of plastic and esthetic surgery.

Every year, over 3 million people around the world resort to plastic surgery to improve their appearance and to correct either congenital or acquired esthetically displeasing defects. In Germany, the estimated number of esthetic surgeries among women is well over 100,000 per year. For men, the number is 20,000 per year. The trend is rising.

The ideals of beauty have changed considerably over time. The maxim, “de gustibus non disputandum est” is truer than ever and goes back a long way. Greek culture discovered the shapeliness of the body and created its own ideal of beauty. This is how the ancient “laws of proportion” came into being, later giving rise to the “laws of beauty”, which define the demand for harmony and esthetics as follows: “Perfect beauty is based on perfect health and on the perfect cultivation of all the assets which nature has bestowed on the human organism”.

The concepts of physical integrity, beauty and youth essentially shape the subjective feeling of each individual person who expects help paired with success from the plastic surgeon. Therefore, the essential medical task of a plastic surgeon performing esthetic surgery is to educate the patient. This includes risk assessments, complications and performance expectations, which are to be discussed well in advance of the planned surgery. The subjective decision to be operated on must be understood free of social, economic and psychological constraints and lies with the patient. The strict standards of the indication must be adhered to.

Despite the high momentum of esthetic surgery, it has effectively remained a pillar of plastic surgery, requiring special, meticulous knowledge, skill and experience. As a physician, the plastic and esthetic surgeon should remain autonomous, be aware of their responsibility towards nature and society, and stand against pseudomedical advertisements and the flood of misinformation with both their personality and their expertise in order to protect their patients from any harm.

Do you know the difference between a general surgery patient and a plastic surgery patient?

A general surgery patient comes to the surgeon in the hope of being told that no surgery is necessary, whereas a plastic surgery patient hopes that they will be operated on.

And now the question arises what modern esthetic surgery can do.

The most popular procedures on the head are correction of the lobes, facelift, nose correction, hair transplantation, ear correction, BTX therapy, wrinkle treatment, and laser therapy.

The most frequent operations on the torso are breast augmentation, breast reduction and breast lifting, abdominal lifting, abdominal liposuction, buttock enlargement and lifting, and body lifting.

The most frequent operations on the extremities are liposuction, inner thigh lifting, calf augmentation, and upper arm lifting.

Thus, the maxim, “beauty must be promoted, for few have it, and many need it”, still rings true.

On October 14, 1958, Pope Pius XII declared, “If we consider physical beauty in its Christian light, and if we respect the ethical conditions, then esthetic surgery, by restoring the perfection of the great work of creation, of man, is not in contradiction with the will of God”.

Plato’s beauty, which he considered second to health but more important than happiness, is badly defined. What is beauty? What do the books say? Encyclopedias? Philosophers? Our experts from the “Pearl of Esthetic”, a private clinic for esthetic and plastic surgery at the Breidenbacher Hof in Duesseldorf, will inform you about this in our next issue.

Dr. med. Branislav Matejic
Specialist for Plastic and Esthetic Surgery
Specialist for Surgery / Hand Surgery
Email: dr.matejic@online.de
Mobile: +49172 243 44 88

ESTHETIC AND RECONSTRUCTIVE BREAST SURGERY

The anatomy of the female breast is an extremely complex system of a mammary gland with external secretion, which is largely made up of fat and glandular cells and pervaded by innumerable milk ducts. Its shape and size depends on many factors, e.g. menstrual cycle, pregnancy, age, connective tissue structure, body fat, obesity, lifestyle, genetic factors, nicotine abuse, illnesses or hormonal status of a woman.

The milk ducts flow into the nipple, which has a normal size of approx. 0.5-1.2 cm. Variations in nipple form such as inverted nipples are not uncommon. The areola is equipped with so-called “Morgagni nodes”, has a standard size of approx. 4.2-5.0 cm in diameter, has a central position on the breast, rounds off the shape of the nipple and has no noticeable function other than guiding the infant to the food source. The breast is connected to the skin with so-called Cooper’s ligaments and rests on the large pectoral muscle. The European standard size of the female breast is cup size B-C.

The female breast is also a sexual organ attracting a man’s attention and sexual interest and causing his arousal, thus stimulating copulation. According to statistics, there are many reasons why men prefer women with large breasts, but the most important one seems to be sexuality. Modern times demand a performance-oriented woman, and the premise that beauty comes from within is forgotten. Society is still considered a male-dominated domain, driven by media reports that dictate the taste for beauty, and this taste undoubtedly tends towards large breasts.

In order to avoid a loss of self-confidence, to prevent feelings of inferiority, not to be laughed at, humiliated or embarrassed, the modern woman does not only submit to these requirements through anti-aging applications, oxidative anti-stress therapies, fitness, extra care, cosmetic treatments, hormonal skin therapies, diets, vitamins, minerals, trace-element ingestion, beauty treatments, etc.; she even goes one step further and considers healing with a scalpel.

Fortunately, modern plastic and esthetic surgery provide treatments and methods that are very effective at improving the attributes of the breast (e.g. firmness, size and volume).

WHAT IS EXPECTED OF A “BEAUTIFUL” BREAST?

Normally, a perfect breast is considered to be firm, round and full, of medium to slightly larger circumference, in the lateral view rising from the top to the middle of the breast and from there in the opposite direction, with a central mammilla that does not exceed a standard size of up to 1.2 cm, and surrounded by an areola of no more than 5 cm in diameter. It is to be covered by soft, smooth skin with no tendency to sag and without any asymmetries.

Baumgarten defined esthetics as “the doctrine of the laws of good taste, art and beauty” as early as 1773. Every year, many millions of people around the world undergo plastic surgery to improve their appearance and correct esthetically displeasing imperfections.

According to statistics published by the German Society of Plastic, Reconstructive and Esthetic Surgeons (DGPRÄC) and the Association of German Esthetic Plastic Surgeons (VDÄPC), 660,000 treatments were carried out in Germany in 2005, and more than 870,000 treatments in 2008 (rising tendency).

Breast surgery is not an exclusively esthetic issue, but also poses a reconstructive challenge, especially in case of breast tumors, which are medically indicated, and often demands a profound knowledge of microsurgery due to the fact that free tissue transfer is necessary to build up the lost breast tissue. 160,000 breast operations were performed by trained specialists for plastic and esthetic surgery in the abovementioned year. Breast surgery performed by other specialists is not included in this statistic.

Esthetic breast surgery includes breast augmentation, breast reduction and breast lift.

BREAST ENLARGEMENT (AUGMENTATION)

Breast augmentation is one of the most common esthetic procedures on the female body after liposuction. A full breast is the epitome of femininity. The aim of the operation is to form a breast that synchronizes in shape and size with the anatomy of the body. In principle, breast augmentation is very often esthetically indicated and thus not covered by health insurance. A medical indication (covered by insurance) may present itself in the event of pathological changes in the mammary gland (such as asymmetries) or complete absence of the breast (aplasia) or loss or partial loss of the breast due to a disease (such as tumors).

All the patient’s questions will be answered in a comprehensive consultation prior to the operation. The patient is thoroughly informed about all details concerning the surgical procedure. The access points, the position of the implant, as well as the size and shape of the breast prosthesis are selected according to the patient’s anatomical shape. All pros and cons necessary for a decision are discussed with the patient.

Possible access points for inserting an implant into the breast are: through the skin fold under the breast, at the edge of the areola and through an incision in the armpit. The most common choice is through the incision under the breast. The reason for this is that the mammary gland is least affected by this approach (Fig. 1 right).

The implant may be placed either under the mammary gland (Fig. 1 middle) or under the pectoral muscle (Fig. 1 right).

The position of the implant under the muscle is chosen by women with very little fat tissue, as the muscle ensures better coverage of the implant. On the other hand, a more natural form of the mammary gland can be achieved by placing the implant under the mammary gland and above the muscle. This placement of the implant is only possible with a sufficient soft tissue mantle (subcutaneous fat tissue). The correct positioning of the implants is carried out with the patient in a half-seated position.

Choosing the “right” implant is very important. There are silicone-filled implants and salt-filled implants. These can be single or double lumen. The single-lumen implants are for so-called single augmentations and intended to remain in the body. Double-lumen implants are mostly used to compensate for asymmetry (differences in chest size). There are also implants with rough and smooth surfaces, round and anatomically shaped implants, which may have a low, medium or high profile. There are liquid silicone implants with a softer consistency and implants with more solid silicone (Fig. 2), which have a firmer consistency.

For safety reasons, silicone implants with solid silicone and a special interlinking of the fibers are recommended, as they prevent the silicone from leaking.

The right combination of these different elements will eventually yield the desired result. Most commonly used are anatomically shaped implants with a rough surface and cohesive gel, so-called “no-bleeding prostheses”, with a single chamber and of moderate length with high projection. The operation is performed under general anesthesia and as in-patient treatment (1-2 days).

The outpatient care lasts an additional 10 days. A specially fitted bra must be worn for a period of up to 3 months upon removal of the stitches. All sports activities should rest for at least 4 weeks.

The final result is not to be expected until after 12 weeks.

In addition to general surgical complications, a capsule fibrosis may occur (in 4-8% of cases). An incapacity for work for a period of 7 days is to be expected after the operation. The costs of a breast augmentation range between 6,000 and 7,500 euros.

BREAST REDUCTION

A normal adult breast weighs approx. 500 grams. A hyperplastic breast may well weigh 2 kg and more. It is not uncommon for voluminous breast growth (mammary hyperplasia) to occur during puberty. In most cases a hormonal surge or genetic predisposition are responsible. This may cause psychological stress manifesting itself in insecurity, social withdrawal and feelings of inferiority. The high weight of the breasts can lead to impairments during sport and leisure activities. Spinal and shoulder pains are also common.

Breast reduction is often covered by insurance. If the amount to be removed exceeds 500 grams, or if the reduction is one or, better yet, two cup sizes, the medical service of the health insurance company is usually rather accommodating – not, however, in cases of obesity. An expert opinion of the orthopedist, gynecologist or general practitioner may be advantageous.

The right time for breast reduction is after family planning. For younger/adolescent women, surgery is only allowed under certain strict conditions.

Once the decision has been made to perform the operation, a detailed consultation is held with the patient a few days prior to the operation. Preparing for a breast reduction is somewhat more complicated than for a breast augmentation. A mammography to exclude lumps in the breasts should be performed in any case.

The exact incision is discussed with the patient. The postoperative scars – depending on the size of the breast – should be barely visible.

In principle, an incision is made around the areola, vertically down to the breast fold, where an additional, horizontal incision is made (resulting in an inverted “T”). This operation, too, is performed under general anesthesia and as an in-patient procedure (at least 1-3 days).

Apart from the general surgical risks, complications that may arise include impaired sensitivity of the mammilla (nipple), irregular nipple shape, partial nipple loss, and asymmetry of the breasts. The procedure lasts 3-5 hours.

Post-operative outpatient care extends over a period of at least 14 days and should be administered by the surgeon himself. A general physical rest and the avoidance of excessive physical strain (sports) is prescribed for a period of 4 weeks.

The costs of the operation with in-patient treatment range between 7,000 and 9,000 euros, depending on the scope of the operation.

BREAST RETENTION

The procedure for a breast lift is similar to that of a breast reduction, so that the same conditions for intra-, pre- and post-operative care apply to a breast lift. A breast lift, however, is less complex than a breast reduction. Due to this procedure not being medically indicated, it is unfortunately in most cases not covered by health insurance. Compared to the incision during a breast reduction, as little tissue as possible is removed during the lifting procedure.

Sometimes a breast lift combined with a breast augmentation yields the best result.

The range of complications that may occur during a breast lift is similar but much smaller than that during a breast reduction. The postoperative recovery phase of this much gentler procedure is accordingly shorter.

NIPPLE CORRECTION

The appearance of the nipples is often the basis for considerations to intervene esthetically and surgically, especially in case of so-called “inverted nipples”, which are usually congenital but can also occur as a result of pregnancy and  which do not constitute a functional disorder.

The correction is relatively simple, the milk ducts are severed, and the new shape of the nipple is stabilized by means of a special suture technique.

This operation can be performed under local anesthesia and does not require in-patient treatment. Breastfeeding is no longer possible after this procedure. The patient is able to work again the next day. The complication rate is very low. This procedure costs approximately 2,500 euros.

RECONSTRUCTIVE BREAST SURGERY

There are many diseases, for instance the breast carcinoma, which may lead to partial or complete loss of the mammary gland. In such cases, plastic reconstructive surgery with its microsurgical techniques and free tissue transplantation may provide remedy. Reconstruction is possible both with autologous or with foreign tissue. Both techniques are sophisticated and yield esthetically pleasing results.

Reconstruction with autologous tissue is very complex, can take 7-8 hours and almost always yields a satisfactory result that lasts a lifetime. Most of the time, the procedure is covered by health insurance. If foreign tissue is used, the interventions are considerably less time-consuming (1.5-2.5 hours of surgery), but the results are also less reliable. In most cases, several procedures are necessary to achieve the desired result. The operating costs can amount to 15,000 euros.

Dr. med. Branislav Matejic
Specialist for Plastic and Esthetic Surgery
Specialist for Surgery / Hand surgery.