The American Society of Plastic Surgeons explains Plastic Surgery can include both reconstructive and cosmetic procedures.1 Typically reconstructive surgery is considered medically necessary to restore function and normal appearance, and to correct deformities that are congenital, trauma related or created by medical conditions such as cancer. Cosmetic surgery is not considered medically necessary as it is performed to reshape and adjust normal anatomy to enhance appearance. Certain conditions can be considered either reconstructive or cosmetic depending on the patient’s specific situation. An example of this is rhinoplasty which may be performed to enhance the person’s appearance which is cosmetic but also may be necessary to restore normal breathing and appearance after a trauma such as a fracture which is reconstructive. Often rhinoplasty is performed with other procedures which involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When adjunctive procedures are performed that do not change the nasal shape or appearance, they do not meet the definition of rhinoplasty. Rhinoplasty performed to address functional abnormalities may inadvertently change the shape or appearance of the nose.
Ishii et al13 created clinical guidelines to provide evidence-based recommendations for the treatment of patients who are candidates for rhinoplasty. Rhinoplasty ranks among the most commonly performed cosmetic surgery in the United States. Rhinoplasty should be considered more than just for cosmetic reasons as it is often medically necessary to improve nasal respiration and relieve any congenital or acquired airway obstructions. While Rhinoplasty may be performed to address a functional abnormality, it may also change or enhance the appearance of the nose. Rhinoplasty is often performed with adjunctive procedures that involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When these accompanying procedures are performed without an impact on the nasal shape or appearance, they do not meet the definition of Rhinoplasty.
These guidelines were created by a Guideline Development Group that consisted of 16 members representing experts in plastic surgery, facial plastic and reconstructive surgery, otolaryngology, otology, rhinology, sleep medicine, psychiatric, advanced practice nursing, and consumer advocacy. Three literature searches were performed from May 2015 through December 2015 to identify clinical practice guidelines, systematic reviews, and randomized controlled trials. After all exclusion methods the literature resulted in 1 guideline, 22 systematic reviews, and 19 randomized controlled trials. This information was used to gather evidence, relevant treatments, and outcomes.
There were 10 evidence-based recommendations created based on Grade B and C quality of evidence with overall prevalence of benefit over harm. (1) Clinicians should ask all patients about their motivation for surgery and expectations and outcomes. (2) Candidates should be assessed for comorbid conditions that could impact surgery. (3) The rhinoplasty candidate should be evaluated for nasal airway obstruction during the preoperative assessment. (4) Candidates should be educated regarding what to expect after surgery and any potential complications. (5) Candidates should be counseled about the impact of surgery on nasal airway obstruction and how sleep apnea might affect perioperative management. (6) The patient should be educated about strategies to manage pain and discomfort after surgery. (7) Perioperative antibiotics for rhinoplasty should not be routinely prescribed for more than 24 hours after surgery. (8) Perioperative systemic steroids have the option to be administered to the rhinoplasty patient. (9) Packing should not be routinely used in the nasal cavity of rhinoplasty patients at the conclusion of surgery. (10) Clinicians should document patient satisfaction with nasal appearance and function at a minimum of 12 months after surgery.
Included within this guideline were validated patient-outcome tools used to perform functional assessments for rhinoplasty. These tools included Nasal Obstruction Septoplasty Effectiveness (NOSE) scale and Sino-Nasal Outcome Test (SNOT-22). Useful tools for evaluating the nasal septums and turbinates preoperatively included anterior rhinoscopy, nasal endoscopy, Cottle maneuver and modified Cottle maneuver. Anterior rhinoscopy is helpful for assessing the nasal septum and turbinates. For patient with no obvious cause for nasal obstruction using anterior rhinoscopy, nasal endoscopy can be valuable. Nasal endoscopy can be useful to evaluate the posterior septum, the ostiomeatel complex, any possible nasal polyps or purulent drainage, the posterior choanae, adenoidal hypertrophy, and the existence of any tumors. Static and dynamic inspection, palpation and the modified Cottle maneuver can be used to supplement physical examination for evaluating the internal nasal valve and external nasal valve for nasal valve collapse. For evaluating the extent of septal deviation, turbinate hypertrophy, and nasal deformity, imaging studies are not useful and should not be performed.
Simon and Sidle19 performed a literature review of surgical procedures used for augmenting the nasal airway. For patients presenting to otolaryngology clinics, the most common complaint is nasal obstruction. There are many different anatomical factors that can contribute to these obstructions and the feeling of decreased nasal airflow. Nasal septum deviation secondary to congenital, traumatic, or iatrogenic etiologies was the most common finding in patients with complaints of nasal obstructions. These authors too found that the NOSE scale or SNOT-22 test should be used to identify the patient’s complaint. The preoperative assessment ought to include anterior rhinoscopy for evaluating septal deviation, nasal endoscopy for any possible tumors, Cottle maneuvers and external dilators to assess and determine dynamic valve collapse and also trials of decongestants for evaluating if mucosal congestion is contributing to the nasal obstruction. There are several procedures used to improve these obstructions that fall under the functional rhinoplasty technique such as but not limited to Septoplasty, extracorporeal Septoplasty, and correction of caudal septal deviation.
Han et al23 developed a clinical consensus statement (CCS) in regards to septoplasty with or without inferior turbinate reduction. A panel was assembled of experts in otolaryngology who performed a systematic literature review to obtain important evidence to support the diagnosis, medical and surgical management of Septoplasty with or without inferior turbinate reduction. A deviated septum is one of the common reasons for nasal obstruction and may or may not involve hypertrophic inferior turbinates. Septoplasty and inferior turbinate reduction aim to improve the nasal airway in these cases. Septoplasty is also used as a supporting procedure to improve access and the function of the paranasal sinuses.
The authors noted that there were no clinical guidelines in regard to appropriate methods for diagnoses and treatment of nasal obstruction secondary to septal deviation and turbinate hypertrophy. Payers often require tests such as acoustic rhinometry/rhinomanometry, nasal endoscopy, photos, and imaging despite evidence-based literature prior to approving payment for septoplasty. The panel developed the CCS after evaluating the appropriateness of septoplasty with or without inferior turbinate reduction based on (1) systematic literature review; (2) establishment of active definitions of septoplasty and inferior turbinoplasty, intended scope of practice, and interested people for the consensus statement; (3) modified Delphi survey development and completion; (4) revising clinical statement repeatedly based on survey results; and (5) assembling data, analysis, and presentation.
The panel reached an agreement that nasal septoplasty is defined as a procedure used to correct a deviated nasal septum to improve nasal function, form, or both. Determining patients appropriate for septoplasty is based on symptomology and physical examination. The panel reached a strong consensus that anterior rhinoscopy, nasal endoscopy or both are adequate to determine septal deviation and can provide useful information prior to septoplasty. The panel did not determine acoustic rhinometry or rhinomanometry to be helpful in diagnosing septal deviation but can be helpful for patients whose primary issue is nasal obstruction. The panel agreed that photographic evidence is unneeded to confirm septal deviation. The group also determined a nasal steroid trial for 4 weeks prior to septoplasty was adequate conservative treatment.
Kaufman et al21 performed a literature review regarding various modalities for achieving a successful rhinoplasty for patient with cleft nasal deformity. The cleft nasal deformity presents as a difficult challenge in plastic surgery as it involves skin, mucosa, cartilage, and skeletal platform. Cleft lip nasal surgery can be divided into primary, intermediate, and secondary repairs. Early intervention can be beneficial for an earlier restoration of nasal shape with the increased chance for more symmetrical nasal growth. The primary rhinoplasty is performed with the intention to restore symmetry and reposition nasal structures so that deformities will not be exacerbated by further growth. Some patients may need to have intermediate rhinoplasty before reaching school age in order to achieve greater symmetry and to help avoid further growth deformities. The best approach for a secondary rhinoplasty surgery is to wait until basal growth is completed. The deformity is complex and should be addressed during multiple stages of the patient’s life to assist in reaching the best outcome.
Modica and colleagues14 conducted a study on a sample of 52 patients all followed by the Otolaryngology Unit of the University Palermo between January 2015 and January 2017. The purpose of the study was to determine if functional nasal surgery was effective in moderate to severe OSAS on improving CPAP compliance. The patients in the study all underwent different nasal surgeries (septoplasty, unblocking of lower turbinates, and FESS) and were evaluated 6 months after the surgery using the NOSE scale and evaluating CPAP usage. Most patients following surgery reported an improvement in the degree of obstruction to mild. The results showed by improving nasal function, CPAP usage increased from 2-3 hours a night to 6-8 hours a night with a reduction in CPAP pressure.
Reconstructive Breast Surgery: Removal of Breast Implants
The Food and Drug Administration (FDA)26 reviewed the risks of breast implants and the associated complications and adverse outcomes. The life of the implants and the chances of developing complications vary by person. Some of the complications listed by the FDA are breast pain and changes in sensation, scar tissue that can cause capsular contracture, rupture and deflation of the breast implant, and the development of different kinds of cancer such as non-Hodgkins lymphoma or breast cancer, systemic symptoms, infections, or connective tissue diseases.
The American Society of Plastic Surgeons (ASPS)9 notes female symptomatic breast hypertrophy has not only negative psychosocial indications but negative physical indications as well.9 Clinical guidelines were developed based on the evidence in 667 articles to support reduction mammoplasty for symptomatic breast hypertrophy. Symptomatic breast hypertrophy causes persistent neck and shoulder pain, grooving from brassiere straps that is painful, chronic rashes in the skin folds of the breast, and/or frequent headaches, backaches, and upper extremity peripheral neuropathies due to the increased volume and weight of hypertrophic breast tissue. There is no treatment for female breast hypertrophy that is long lasting and non-surgical. Orthotic brassieres may offer some relief but often cause increased discomfort through pressure from the straps. Reduction mammoplasty offers the best approach to relieving the physical symptoms of breast hypertrophy.
Lonie and colleagues27 conducted a literature search of the PubMed and Cochrane Library, Medline and SCOPUS databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. They included breast reduction, reduction mammoplasty, treatment outcomes, personal satisfaction, quality of life, questionnaire and instrument in their search terms. Pre-determined inclusion criteria by two authors resulted in 95 articles that were included. The results of the search were 95 articles met the inclusion criteria and represented 9,716 patients. Data was extracted from the included studies relating to demographics, surgical technique, questionnaires used and physical, psychological and aesthetic outcomes. Fifty-eight studies listed overall satisfaction as primary endpoint, including 5,867 patients. The authors inferred that in 90.3% of the studies, patients reported improvements in the vast majority of premorbid symptoms both physical and mental, stating a finding consistent with previous reviews of this subject.
The ASPS16 defines gynecomastia as “the presence of an abnormal proliferation of breast tissue in males”. Gynecomastia can be caused by a broad number of reasons that are either physiological or pathological. True gynecomastia is due to glandular breast tissue where as pseudogynecomastia the breast enlarges secondary to fat accumulation. Both fat and glandular tissue are present in mixed gynecomastia. During puberty gynecomastia is common but often regresses by 6 months to within 3 years of onset. Adult gynecomastia is correlated with increased age due to progressive underactive testicular function, increase in body fat and growth in the estrogen/androgen ratio. Gynecomastia is graded using a scale adapted from the McKinney and Simon, Hoffman and Kohn scale and grade I-IV. The ASPS recommends surgical treatment of gynecomastia to reconstruct the male chest contour and histological explanation of suspicious breast growths. Biopsy of breast tissue is advisable when malignancy is suspected. Surgical treatment is recommended for unilateral or bilateral grade III or IV gynecomastia that persists more than 3 to 4 months after pathological causes have been ruled out, after 3 to 4 months of failed medical treatment, and for pain and discomfort due to the enlargement and tightness of the hypertrophied breast.
Gestational gigantomastia is a rare condition distinguished by exaggerated, rapid, and often disabling enlargement of the breasts.28 It most often begins in the first trimester and generally occurs bilaterally. Rakislova and colleagues28 noted that less than 100 cases have been reported in literature and while it is benign, it can lead to serious complications and sometimes death. These authors describe a case study of a 30 year old HIV-positive female with no pertinent past medical history. The patient began having marked increased enlargement of both breasts at 8 to 10 weeks gestation. Initially she did not have pain but as it progressed she experienced burning pain and noticeable discomfort. She presented to the emergency room at 24 weeks gestation and was diagnosed with gestational gigantomastia. Surgical intervention was not recommended due to potential complication and the patient underwent treatment with Penicillin G for 10 days. Despite conservative treatment the ulcers continued to increase and caused heavy blood loss. The patient lost between 3 and 4 liters of blood. The patient received multiple blood tranfusions and despite treatment expired on the 13th hospital day.
Fletcher and colleagues29 conducted a case study on a 31 year old woman, gravida 5, para 4. She presented at 18 weeks gestation with bilateral breast swelling, erythema, and pain for the last 4 months. The patient was eventually hospitalized for her worsening breast pain and after diagnosis of gestational gigantomastia (GG) she was started on bromocriptine. Despite conservative treatment she developed spontaneous local hemorrhage in her left breast. Due to pain and to avoid further complications she underwent cesarean section at term. The patient continued bromocriptine but continued to have severe discomfort and underwent a breast reduction. GG can be significantly debilitating. Skin ulceration, necrosis, infection and hemorrhage can occur as well as sepsis, multiorgan failure, and death though rarely. During pregnancy, conservative management is preferred over breast reduction due to the risk of harm to the fetus. In cases of massive hemorrhage, ulceration, sepsis or necrosis surgical management should be pursued by either breast reduction or mastectomy. Due to the high chance of recurrence with future pregnancies it is recommended those planning future pregnancies undergo mastectomy.
Chellappan and Castro24 presented a case study where they performed electrocautery dermabrasion on a 62 year old male with severe rhinophyma. Rhinophyma is the most advanced stage of rosacea and is classified as Stage IV. During this stage the phymatous changes present with hyperplasia and/or ocular inflammation. Phymatous tissue enlarges over a period of time and should be treated in the early stages to prevent progression as more advanced stages have irreversible fibrotic changes. Extensive thickening of the tissue can obstruct external nasal valves making treatment of the rhinophyma medically necessary to alleviate respiratory issues. Challappan and Castro24 show in this case study support of using electrocautery and dermabrasion to remove hypertrophic skin and create a smooth contour. The patient had significant improvement in respiratory function and the patient’s skin returned to normal pigmentation, scab free four weeks following the procedure. This supports electrocautery dermabrasion as a mainstay of treatment allowing smooth contouring, efficient hemostasis and does not require multiple treatments.
Niamtu7 performed a review of the diagnosis and treatment of rhinophyma. Rhinophyma is the end process for severe rosacea and can be a debilitating problem both functionally and psychosocially. The most severe cases can affect breathing and even vision. Minor or early cases can be treated using a range of rosacea medications such as topical creams, sulfur based washes, antibiotics, Retin-A, and light based or photodynamic therapy. Medical or drug treatment in moderate to advanced cases is futile and surgical treatment is certain.
Clarós et al25 notes in their study that while no consensus concerning the treatment of rhinophyma has been reached, there are many different surgical procedures that have been proposed for the management of this disease. While rhinophyma is considered the final stage of rosacea, it is rare in the older population. This case study retrospectively looked at twelve cases over a 12 year period. These patients were treated with the classical dermabrasion technique with decortication and fibrin glue was applied topically to the skin surface. This technique promoted complete healing and patients reported improved quality of life with no recurrence.
The American Society of Plastic Surgeons31 outlines practice parameters that are focused on the surgical removal of excess skin and fat that occurs in obsess patients or remains following massive weight loss. There are numerous procedures and techniques developed to treat the imperfections that result from massive weight loss such as abdominoplasty, panniculectomy, circumferential lipectomy, torsoplasty, medial thigh lift, and breast reduction. The operative treatment for the correction of the imperfections will vary depending on the patient’s body type, fat deposition pattern, and the amount of weight loss.
Not only can imperfections from massive weight loss bring patients a dissatisfaction of appearance but it can affect functional abilities as well such as difficulty exercising, impaired ambulation, chronic pain, and hygiene difficulties. Dermatological issues such as uncontrolled intertrigo, infections and skin necrosis can also develop.
Practice parameters for patients who are preparing to undergo surgery for removal of excess skin and fat are screened and assessed preoperatively. This includes screening for depression, diabetes mellitus, gastroesophageal reflux disease (GERD), nutritional deficiencies if any, abdominal wall hernias, and preoperative lab and diagnostic testing.
Excess skin that remains after significant weight loss is nearly impossible to rectify with diet, weight loss or exercise. Non-surgical candidates are left with very few alternatives for treatment. Alternative treatments such as radiofrequency or ultrasound demonstrate minimal effect and result. Surgical candidates should maintain a stable weight for two to six months for body contouring. Those patients who have undergone bariatric surgery stable weight is usually reached at 12 to 18 months.
Sachs et al12 performed an overview of panniculectomy and some of the indications and clinical significance of performing the procedure. Panniculectomy is not a cosmetic procedure and must meet medically necessary criteria. The procedure is performed to remove the excess skin and fat incurred from weight gain. This can cause large overhanging abdominal skin known as a pannus which can sometimes cover the thighs, hips and knees. This excess can cause difficulty with daily activities and cause skin infections and rashes like intertrigo due to irritation and sweating. Typically, patients with skin conditions receive medical treatment with topical antifungals, corticosteroids, and antibiotics.
How far the pannus extends is graded 1 through 5. Grade 1 is the pannus reaching the mons pubis and grade 5 is the pannus extending to or past the knees. For a patient to qualify for a panniculectomy they usually must fail three months of medical treatment for intertrigo, and the pannus must hang below the level of the pubis, and confirmed with photography. A panniculectomy is performed to remove the excess skin and fat to relieve the associated symptoms and restore normal function.
Persons who experience dramatic weight loss also can have excess lower abdominal skin which hangs over the groin and pubic areas. This causes issues with walking, discomfort and skin irritation as well. Patients who have lost weight without surgery must maintain stable weight for at least 6 months prior to undergoing a panniculectomy. For those bariatric surgery patients, weight must remain stable for at least 18 months, including the most recent 6 months.
While there are many studies focused on clinical outcomes of abdominoplasty, there are few looking at the advantage of abdominal lipectomy.32 Abdominal lipectomy is performed to remove excess abdominal tissue where there is little to no abdominal wall undermining, and there is no gathering of abdominal muscle performed with exception to a ventral hernia. Semer et al32 performed a prospective outcome study on patient who underwent an abdominal lipectomy during a 12 month period from September 2004 to September 2005. Data was obtained at the preoperative visit, during surgery, and at the 1 week, 1 month, and 6 month visits postoperatively.
There are both major and minor complications that can occur with abdominal lipectomy. A major complication is possible rehospitalization or a subsequent operation is needed, whereas minor complications result in ongoing outpatient care. The authors administered the Short Form-36 Health Survey and the Multidimensional Body-Self Relations Questionnaire to 72 patients enrolled in the study, to assess perceived health, well-being and body image following abdominal lipectomy. The results of the study were that at the end of the 6 month follow-up period, data collected from 59 of 60 patients showed they were happy to have had the surgery. The authors found through the results of the study that abdominal lipectomy is a safe and effective treatment for correcting the symptoms from a lower abdominal pannus.