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UPDATE #1
What’s Plastic About
Plastic Surgery?

What's Plastic About Plastic Surgery?
Actually, quite a bit. But do you know why plastic surgery is called "plastic?" While most people think that it's because plastic materials (like silicone) are used in plastic surgery, the term was in use long before implants made of plastic were developed. Plastic actually refers to the strict definition of the word: "capable of being molded or of receiving form." Used in the sense of changing the position of skin and moving skin and tissue from one part of the body to another, this meaning of plastic came to be used for the materials we now call plastics, not the other way around. Plastic surgery itself is plastic: new developments, technologies, and techniques emerge on a regular basis. This first issue of the newsletter article will document and discuss five of the most significant trends in plastic surgery.

1) More surgery through smaller incisions, which means less scarring.
Liposuction is the best example of this trend. Virtually unknown thirty years ago, liposuction is now the most commonly performed cosmetic surgery in the United States. Using incisions that typically measure half an inch or less, nearly every part of the body can be recontoured. While the most common areas are the stomach, hips, and thighs for women, and the chest, stomach, and love handles for men (and the chin/neck for both!), it is also used on many other areas. Dramatic changes can be effected with only minimal "evidence" being left behind. Another example is the "transconjunctival lower lid blepharoplasty," which is the removal of fat bags under the eyes using small incisions placed inside the lower eyelid itself, leaving nothing visible on the skin. This procedure is often combined with laser resurfacing to tighten the skin. A third example is saline-filled breast implants. This implant is inserted empty and then filled once it's in place. Compared with silicone implants, which come pre-filled, a similarly sized saline implant can be inserted through a smaller incision, thereby leaving a smaller scar.

2) Younger patients having smaller procedures, and dividing one big procedure into several smaller ones
Instead of waiting until there would be the most dramatic changes, patients are undergoing procedures at an earlier age (i.e., a Maintenance philosophy). Aside from there being "less to do" on younger patients, the recovery tends to be easier. Less time is therefore lost from work and one's regular routine. Similarly, instead of combining several procedures into one big session, patients are more likely to have a long-range plan for what they want to do, and have things done as they "arise." Typically, this might be eyelid surgery in one's thirties or forties and a facelift in one's forties or early fifties, with liposuction of the chin, Botox, and Collagen injections in between.

3) The diminished role of the doctor as teacher
It used to be that the doctor was the patient's primary - if not only - source of medical information. While the doctor remains a key resource, the explosion of information available in books and magazine articles and particularly on the Internet has changed the way information is obtained. Patients routinely arrive at a consultation already knowing a lot about the procedure(s) they're interested in. This is really to everyone's advantage. Patients get a lot more out of a consultation when they already know the basics. That way, they can use the time they spend with the doctor to see how the generalities apply to them, to ask any specific questions they have, and, in another function of the Consultation, to better assess the doctor and his or her office staff. In brief, Sy Syms has it right: the ideal - for all involved - is the "educated consumer."

4) Newer anesthetics that facilitate outpatient procedures
In the past few years a new group of intravenous anesthetic agents have changed the way anesthesia can be administered. While typically described as deep intravenous sedation, these powerful but short-acting preparations allow people to be sedated to an appropriately deep level for the procedure itself but then to wake up relatively quickly. As an added benefit, they are associated with fewer side effects (such as nausea). Traditional general anesthesia is still an excellent - and often the best - choice, but the new anesthetics have facilitated another trend: more outpatient and ambulatory procedures in a hospital, surgicenter, or in a doctor's office. While there are advantages and disadvantages with all facilities in which plastic surgery is performed, the unmistakable trend is toward outpatient procedures. Smaller, outpatient facilities, including doctor's offices, offer a level of privacy and personalized, attentive care that can be difficult for larger facilities, such as hospitals, to provide. The changes in health care in general and the way hospitals are staffed and reimbursed have also contributed to this phenomenon.

5) Increased Safety
Advances in surgical technique and instrumentation as well as in monitoring capabilities and anesthesia have combined to make plastic surgery safer than ever before. For example, liposuction is now performed by first infusing a wetting solution that contains lidocaine (a local anesthetic that decreases the amount of anesthesia required) and epinephrine (which constricts the blood vessels and decreases bleeding). This combination allows more fat to be removed more safely than could be done previously when little or no fluid was injected before the surgery. At the same time, new anesthesia equipment allows more precise and careful monitoring of the patient during and after the surgery. An example is the pulse oximeter which, through a clip placed on a finger, uses light spectometry to measure the oxygen concentration in the blood. This sensitive instrument allows the anesthesia, particularly the type that is used commonly in plastic surgery, to be delivered more safely.

The plastic nature of plastic surgery has made the procedures safer and more effective than ever before. Like the lasers themselves, we can expect that plastic surgery will continue to evolve "at the speed of light."

Alan M. Engler, MD, FACS - Board Certified Plastic Surgeon
122 East 64th Street New York, NY 10065 USA
(212) 308-7000 alan.engler@gmail.com

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