The American Society of Plastic Surgeons explained plastic surgery may be reconstructive or cosmetic procedures.1 Usually, reconstructive surgery is considered medically necessary to correct deformities created by congenital defects, trauma, or medical conditions. Cosmetic surgery is used to reshape or adjust parts of the anatomy to enhance the visual appearance and is usually considered not medically necessary. There are instances where these two subspecialties of plastic surgery overlap as there are certain conditions that can be deemed either reconstructive or cosmetic in nature. Rhinoplasty surgery is a good example as this procedure is usually performed to improve the appearance of the nose but the procedure may also be medically necessary to improve nasal breathing or restore a normal appearance after a traumatic injury such as a nasal fracture.
Chellappan and Castro13 performed a case report to support the use of electrocautery and dermabrasion as the mainstay of treatment for severe rhinophyma. Rhinophyma is classified as stage IV rosacea which is the most advanced stage. It is characterized by phymatous changes which presents with hypertrophic thickening with edema of the nasal pyramid skin. Treatment for this condition should begin in the early stages to prevent progression into the more advanced stages with irreversible fibrotic changes. Extensive thickening of the tissue can obstruct external nasal valves making treatment of the rhinophyma medically necessary to alleviate respiratory issues. The patient in this case report had a history of acne rosacea which progressed into severe rhinophyma causing major deformity and nasal obstruction. Electrocautery and dermabrasion were performed to remove hypertrophic skin and create a smooth contour which resulted in a substantial improvement in respiratory function. The patient’s skin returned to normal pigmentation and was scab-free four weeks after the procedure. This case report supports electrocautery dermabrasion as the mainstay of treatment which allows for smooth contouring, efficient hemostasis, and does not require multiple procedures.
Torresetti et al14 performed a case report and review of literature regarding treatment of disfiguring rhinophyma. Medical treatments such as antibiotics and retinoids are useful in the early stages in hopes of suppressing sebum secretion and treating any associated infections. The general consensus for treatment of rhinophyma remains the surgical removal of the thickened tissue either by full thickness excision or partial thickness excision. Partial thickness excision has been largely performed by many different procedures including dermabrasion. In the cases of infiltrating rhinophyma, such as rhinophyma with underlying skin cancer, total eradication is considered and usually requires flap coverage or skin grafts.
Clarós et al30 described their experience of rhinophyma based on a retrospective case study. Rhinophyma is considered the final stage of rosacea and a rare disease in the older population. There are many different surgical procedures that have been proposed for the management of this disease, but there has not been a consensus of which procedure “constitutes the gold standard." In this case study, twelve cases over a 12-year period were identified with patients of various ethnic origins, mean age of 71 years old and mostly male predominance. These patients reported a long history of rhinophyma with a mean duration of 10.75 years. The patients were treated with the classical dermabrasion technique with decortication and topical application of fibrin glue onto the skin surface to promote complete healing. “No recurrence was observed in this series and all the patients reported improved quality of life."
Sachs et al15 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 specific criteria to be medically necessary. This procedure is often performed on patients with large, overhanging abdominal skin known as a pannus which hangs down from the abdomen and sometimes covers the thighs, hips and knees. This excess skin and fat are often a result of weight gain. The pannus can become so large that it begins to interfere with activities of daily life and can cause skin infections and rashes such as intertrigo due to irritation and sweating. Typically, patients with skin conditions receive medical treatment such as topical antifungals, corticosteroids, and antibiotics.
There are different grades for the varying degrees of how far the pannus extends. Grade 1 is the pannus reaching the mons pubis, grade 5 is the pannus extending to or past the knees. Often for patients to qualify to have a panniculectomy they must fail three months of medical treatment for intertrigo, and the pannus must hang below the level of the pubis and be confirmed with photography. When a panniculectomy is performed, the excess fat and skin are removed to relieve the associated symptoms and restore normal function.
Patients who experienced dramatic weight loss can also develop excess lower abdominal skin which overhangs the groin and pubic areas causing issues with walking, discomfort and/or skin irritation as well. Patients, who have lost weight without surgery, must maintain stable weight for at least 6 months prior to having a panniculectomy. For bariatric surgery patients, weight must remain stable for at least 18 months, including the most recent 6 months.
The American Society of Plastic Surgeons16 outlined practice parameters that are focused on the surgical removal of excess skin and fat that occurs in obese patients or remains following massive weight loss. There are numerous procedures and techniques that have been developed to treat the defects associated with massive weight loss such as abdominoplasty, panniculectomy, circumferential lipectomy, torsoplasty, medial thigh lift, and breast reduction.
These practice parameters for patients who are preparing to undergo surgery for the removal of excess skin and fat include preoperative assessment and screening. This includes screening patients for depression, diabetes mellitus, gastroesophageal reflux disease (GERD), any nutritional deficiencies, abdominal wall hernias, and preoperative lab and diagnostic testing.
The excess skin that remains after significant weight loss is virtually impossible to correct or improve by exercise, diet, or further weight loss. Those patients who are not surgical candidates are left with very few alternative treatment options. Ideally, body contouring surgery is performed after weight loss has stabilized for two to six months. Post bariatric surgery patients usually reach a stable weight 12 to 18 months after surgery.
The operative treatment for the correction of the deformities associated with massive weight loss will vary depending on the patient’s body type, fat deposition pattern, and the amount of weight loss. These deformities can cause patients not only a dissatisfaction of appearance, but functional inabilities as well, such as difficulty exercising, impaired ambulation, chronic pain, inability to perform activities of daily living, and difficulty with hygiene. Dermatological issues such as uncontrolled intertrigo, infections and skin necrosis can develop also. Semer et al31 performed a prospective outcome study on patients who underwent an abdominal lipectomy during a 12-month period from September 2004 through September 2005. This is the first prospective outcome study of patients who have undergone reconstructive abdominal lipectomy as opposed to having a cosmetic abdominoplasty. Data was collected preoperatively, during surgery, and postoperatively at one-week, one-month, and six-month follow-up visits. There were 72 patients enrolled in the study with an age range from 21 to 68 with the majority of the patients being women. Fifty-eight of the patients had significant weight loss and maintained a stable weight for at least six months prior to surgery.
There were both major complications (requiring re-hospitalization or reoperation) and minor complications (requiring local outpatient care) post-operatively. The major complication rate was 5.6% and the minor complication rate was 27.8%. Four patients had major complications such as hematoma and wound breakdown/infection, both requiring reoperation. Twenty patients had minor complications such as seroma, infected seroma, and localized infection/minor wound breakdown.
There were two instruments selected for health-related quality-of-life measures, the Short Form–36 Health Survey (SF-36) and the Multidimensional Body-Self Relations Questionnaire (MBSRQ). These were administered at the preoperative visit to establish a baseline and again at the six-month postoperative visit to evaluate outcomes. At the end of the six-month follow-up period, data collected from 60 patients showed that 59 patients were happy to have had the surgery and one patient who was overall happy but would have preferred to have undergone a more extensive “cosmetic” procedure.
This study was initiated based on anecdotal evidence that there was a high major complication rate for this procedure, especially in patients who already had bariatric surgery; however, the data did not support this belief.
Reconstructive Breast Surgery: Removal of Breast Implants
The Food and Drug Administration (FDA)4 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. The FDA lists some of the complications such as breast pain, the formation of scar tissue which can cause capsular contracture, rupture and deflation of the breast implant, the development of different kinds of cancer such as non-Hodgkin’s lymphoma or breast cancer, systemic symptoms, infections, or connective tissue diseases. https://www.fda.gov/medical-devices/breast-implants/risks-and-complications-breast-implants
Breast reduction or surgical mastectomy for gynecomastia
Lonie and colleagues32 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. Search terms included were breast reduction, reduction mammoplasty, treatment outcomes personal satisfaction, quality of life, questionnaire and instrument. Pre-determined inclusion criteria by two authors included articles which addressed bilateral reduction mammoplasty, excluding symmetrizing and post-cancer, and reported patient satisfaction or quality of life based on outcome questionnaires. The search results were further restricted to English language articles. The literature search yielded 2,361 studies, only 95 met the inclusion criteria, representing 9,716 patients.32 (pg 433) Data was extracted from the included studies relating to demographics, surgical technique, questionnaires used and physical, psychological and aesthetic outcomes. Overall, the mean age was 37.8 years, body mass index (BMI) was 28.0, and combined tissue resection mass was 1,402.9 g. Fifty-eight studies listed overall satisfaction as primary endpoint, including 5,867 patients. Grouped data found overall satisfaction to be 90.3% (range, 67.6–100%). Of the studies investigated in the systematic review, a wide range of questionnaires for patient reported outcome measures, surgical technique and skin pattern excision and satisfaction were captured. The authors inferred that in almost all studies, patients reported improvements in the vast majority of premorbid symptoms both physical and mental health and stating a finding consistent with previous reviews of this subject.
Ngaage et al33 conducted a retrospective study of patient satisfaction survey and chart review of demographics, operative data and postoperative course including complications for patients undergoing reduction mammoplasty over a 12 year period at a single institution at the University of Maryland Medical Center from 2006 to 2013. Potential participants were identified using the CPT code 19318-reduction mammoplasty. Included in the study were patients with 5 or more years of post-reduction follow-up. Exclusion criteria were reductions related to Oncologic conditions, patients that were deceased or patients that did not have functional telephone numbers. The participants preoperative Body Mass Index (BMI) was classified according to the World Health Organization Clinical Guidelines adopted by the National Institute of Health. Patients were put into 4 categories based on BMI (normal [<25], overweight [25–29.9], obese [30–39.9], and morbidly obese [≥40]). Seventy patients met the inclusion criteria. Patient satisfaction was assessed using a customized survey which was administered over the phone. Only patients with complete medical records who participated in the survey were included. Median time from surgery to survey was 6 years. Based on a 5-point Likert scale of 1 to 5 with 5 being highest satisfaction, study participants were asked questions on long-term outcomes following reduction mammoplasty. The questions were related to satisfaction with the decision to have breast reduction, satisfaction of the results post breast reduction, symptoms prior to breast reduction, symptom relief post breast reduction, satisfaction with aesthetic result and bra size before and after breast reduction. Study limitations included memory recall bias, use of a non validated questionnaire, study recruitment of participants lost to incomplete medical records and low sample size overall. Previous studies reporting patient outcomes following reduction mammoplasty at different time points with findings of satisfaction stable in the immediate and short-term postoperative period leads the authors to believe this to be supported by the study finding of high overall and aesthetic satisfaction also present at 12 years after breast reduction. Consequently, demonstrating that reduction mammoplasty has a clinically important and robust benefit.
Rhinoplasty/Reconstructive Nasal Surgery
Ishii et al11 created clinical guidelines to provide evidence-based recommendations for the treatment of patients who are candidates for rhinoplasty surgery. Rhinoplasty ranks among the most commonly performed cosmetic surgery in the United States. Rhinoplasty should be considered more than just a cosmetic procedure as it is often performed as a medically necessary surgery to improve nasal respiration and relieve any airway obstructions that are either congenital or acquired. While rhinoplasty may be performed to address a functional abnormality, it may inadvertently change or enhance the appearance of the nose. Often rhinoplasty is performed with adjunctive procedures which involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When adjunctive 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 (GDG) that consisted of 16 members representing experts in plastic surgery, facial plastic and reconstructive surgery, otolaryngology, otology, rhinology, sleep medicine, psychiatry, advanced practice nursing, and consumer advocacy. There were three literature searches performed from May 2015 through December 2015 to identify clinical practice guidelines, systematic reviews, and randomized controlled trials. The information obtained during these searches 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 “preponderance of benefit over harm." (1) Clinicians should ask all patients about their motivation for surgery and expectations for 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 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 may 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 cosmetic and functional assessments for rhinoplasty. For cosmetic assessments, FACE-Q Rhinoplasty Instrument, Glasgow Benefit Inventory, and Rhinoplasty Outcome Evaluation were listed and for functional assessments, Nasal Obstruction Septoplasty Effectiveness (NOSE) scale and Sino-Nasal Outcome Test (SNOT-22) were also listed.
Kaufman et al17 performed a literature review regarding various modalities for achieving a successful rhinoplasty for patients 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 an intermediate rhinoplasty before reaching school age in order to achieve greater symmetry and to help avoid future growth deformities. The best approach to performing a secondary rhinoplasty is to wait until nasal growth has concluded. This deformity is a complex condition that should be addressed during multiple stages of the patient’s life to help achieve the best outcome.
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 a number of different anatomical factors that can contribute to these obstructions and the sensation of decreased nasal airflow. The most common finding in patients with complaints of nasal obstructions is a deviated nasal septum secondary to congenital, traumatic, or iatrogenic etiologies. 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.
Septoplasty is usually performed on patients that present with anatomic changes of the septum which may hinder the function of the nasal airway. Extracorporeal septoplasty is usually performed for the more severe deviations or loss of significant portions of the septum which require reconstruction. Caudal septal deviation usually requires treatment beyond traditional septoplasty as these deviations are important on both appearance and functional levels. The caudal septum provides essential structure of the nose and when there is any deviation in these structures, significant deformities may develop. “Previous epidemiological studies have revealed that the finding of a straight septum is present in only 42% of newborns and in adults, only 21%."19
De Sousa Michels et al27 performed a summary of data and theories on the association between nasal obstruction and obstructive sleep apnea syndrome (OSAS). There are many nose and pharynx abnormalities that can cause snoring and sleep apnea such as rhinitis, turbinate hypertrophy, nasal polyps, and septal deviation. The treatment options for nasal obstructions include nasal dilators, surgical intervention, and medical treatment such as topical corticosteroids and sympathomimetic decongestants.
In the context of this article, surgical interventions such as septoplasty, rhinoseptoplasty, functional endoscopic sinus surgery, turbinectomy, and nasal valve surgery appear to be good therapeutic options for patients with nasal obstructions and OSAS. There are patients that may benefit from surgery as an adjuvant treatment to improve the effectiveness of continuous positive airway pressure (CPAP).
“Over 50% of CPAP users complain of significant nasal symptoms, such as nasal congestion, rhinorrhea, nasal dryness, and sneezing, which may become more significant if the patient presents any structural abnormality of the nose.”27 Functional or anatomical abnormalities in the nasal cavity may cause patients discomfort and hinder adjustment to the CPAP due to the device requiring higher pressure titration in order to eliminate respiratory events. Studies have shown that patients that had nasal surgery showed a decrease in the levels of CPAP titration. This article has concluded that nasal surgery may be helpful in patients with obstructive sleep apnea (OSA) who do not tolerate CPAP therapy when there is a nasal obstruction present.
Rhee et al34 created a clinical consensus statement regarding the diagnosis and management of nasal valve compromise (NVC). “NVC is a distinct and primary cause of symptomatic nasal airway obstruction, yet there remain ambiguities and disparities in the diagnosis and management." The purpose of this clinical consensus statement was to help distinguish NVC from other disease processes that may cause nasal airway obstruction. An updated systematic review of literature was performed along with two rounds of surveys and conference calls with a panel of eight experts that was comprised based on their work in related fields and valued opinions. The survey covered the following categories: definition, history and physical examination, adjunctive tests, outcome measures, management, and coding. After reviewing the responses, targeted questions regarding NVC were formulated.
The categories of the survey that had the greatest percentage of consensus or near consensus were the definitions, history and physical examination, outcome measures and management. The categories with the larger percentage of no consensus were adjunctive tests and coding. The results of the surveys can be found in Tables 2-7.
After review, “the panel found that the literature consistently noted the benefit of surgical treatment of NVC, but the evidence relied mostly on uncontrolled studies."34 There was a strong disagreement that there is a gold standard test to diagnosis NVC. There was a general consensus that NVC is best evaluated with history and physical findings and that endoscopy and photography can be useful but are not always necessary. Also, the panel found that the use of nasal steroid medications may not be helpful for treating NVC in the absence of rhinitis and mechanical treatments such as stents may be useful in selected patients. “Surgical treatment is the primary mode of treatment of NVC.”34