Appearance is an important aspect of modern life. People today not only want to feel good inside; they also want to look good outside. To achieve this end, over a million American men and women elect to undergo cosmetic procedures performed by surgeons certified by the American Board of Plastic Surgery (ABPS) each year. The results are often dramatic and permanent, so it is important that the patient knows what to expect and that he or she chooses a surgeon wisely. Patients seeking advice on cosmetic procedures and referral to a plastic surgeon may turn first to their family physicians. The American Society of Plastic Surgeons (formerly the ASPRS) has prepared this monograph as a reference aid in counseling patients who are considering cosmetic surgery.

Cosmetic and Reconstructive Surgery: The Differences

Although the outward effects may be similar or even identical, the terms cosmetic and reconstructive surgery are not interchangeable. The plastic surgeon performs cosmetic surgery to reshape normal structures of the face or body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed to correct abnormalities of facial or body structures caused by congenital defects, developmental abnormalities, injuries, previous or concurrent surgeries, infection, tumors, or other disease. The purpose of reconstructive surgery is generally to improve function, but it may also be used to restore a normal appearance.

These distinctions have implications for insurance coverage. Nearly all insurance carriers cover reconstructive procedures for functional restoration but not those performed purely for cosmetic reasons. In general, the classification as cosmetic or reconstructive depends on the reason that the surgery is performed. For example, rhinoplasty to change the shape of the nose is considered cosmetic. However, rhinoplasty to restore the shape of the nose following traumatic deformity is reconstructive.

Corrective surgery to remove or minimize the effects of scarring usually provides cosmetic improvement. Insurance carriers, however, may recognize these procedures as reconstructive in nature because scars are abnormal formations that develop on the body as a result of injury or illness.

Origins of Cosmetic Surgery

Cosmetic surgical techniques originally evolved from reconstructive procedures, and some techniques are the same, whether they are used for cosmetic or reconstructive purposes.

Suction-assisted lipectomy, for example, commonly known as liposuction, is a procedure used to remove
lipomas (fatty tumors), defat flaps and remove fatty deposits in various reconstructive procedures, but it has a much wider application, however, as a cosmetic technique to streamline the body by suctioning away localized deposits of unwanted fat.

Many other procedures that today are more widely used to enhance appearance began as solutions to reconstructive problems. The relationship between the two types of procedures is so close that surgeons well-versed in reconstructive procedures are most likely also to have the background and training required for cosmetic surgery.

Cosmetic Surgery and Quality of Life

People with a good self-image tend to function effectively in their work, feel secure in their relationships, and interact positively with others. Self-image has other components, but one of the most important is appearance. Sometimes the correction of even a minor cosmetic defect can make a major positive change, substantially increasing feelings of well-being and self-worth.

Many people hold jobs where appearance is important in the workplace, even if the person is not a public figure. In any job that involves interaction with others, people are apt to be judged­at least in some degree­by the way they look. Often encounters are fleeting, so that first impressions count. At times of tenuous job security, people struggle to maintain whatever edge they can. For some, retaining a youthful and pleasing appearance may be their means of remaining competitive in a crowded marketplace.

Is Your Patient Asking the Right Questions?

As the primary care physician you can help provide patients with basic information to help them ask the right questions about how to research cosmetic surgery procedures they are considering. The following checklist outlines the facts that the patient should gather before making any decision about cosmetic surgery:

• What procedures are available for this characteristic and what do they entail?
• Does the procedure ordinarily require hospitalization or can it be done on an outpatient basis?
• What type of anesthesia is generally used? (local, general, epidural, other?)
• How much time is needed for recovery and when can normal activities be resumed?
• What sort of outcome can the patient reasonably expect?
• How long will the improvement last?
• What are the possible risks?
• Are there any special considerations that might influence the patient's decision on whether or not to have the procedure? (For example, some skin procedures require that the patient avoid sun exposure permanently; patients need to know this before they elect the surgery.)

Each procedure can be evaluated according to the same checklist. This makes it easy to compare procedures when several options are available.

Does Your Patient Have Realistic Goals?

During the course of this informational discussion, you have an excellent opportunity to assess the patient's status as a candidate for cosmetic surgery. It is important to learn not only what the patient expects from the surgery itself, but also what effects he/she anticipates the altered appearance will have on his or her life in general. A good surgical candidate has:

• realistic expectations of the surgery itself
• realistic expectations of the effect surgery will have on quality of life/lifestyle/relationships
• a good self-image, but a concern about a bothersome feature or a moderately diminished self-image due to the cosmetic defect
• an understanding of the risks
• realistic expectations of the duration of improvement (if improvement will not be permanent)

Unrealistic goals like finding a mate, salvaging a doomed relationship or achieving a promotion at work call into question the patient's suitability for any type of procedure, as does an expectation of surgical improvement beyond the realm of possibility. Also, although it is reasonable to hope for an improved self-image, a person whose ego is in crisis is not a good surgical candidate.

There are a number of warning signs that suggest that a patient may not be a suitable candidate for cosmetic surgery. These include:

• expectations of retarding aging itself
• expectations of an appearance enhanced beyond possibility
• unrealistic expectations of lifestyle/career/relation-ship effects
• unrealistic expectations of the duration of effects
• an unwillingness to learn the risks
• the patient is in crisis due to death of a loved one, divorce, loss of a job, or other major disrupting life event
• an unwillingness to change the behavior that led to the problem (e.g., a liposuction candidate who continues to overeat)
• an obsession with a very minor defect
• mental illness
• the patient is impossible to please (generally this can be inferred from prior behavior, such as
  ongoing or previous difficult relationships with staff)

What Should Your Patient Look For in a Plastic Surgeon?

It is important that patients be aware that some risks attend even minor cosmetic procedures and that there is no guarantee that the effects will be exactly as the patient envisioned. The best assurance the patient has for a reliable outcome is to choose an experienced plastic surgeon certified by the American Board of Plastic Surgery who has performed the procedure many times before. The plastic surgeon's specific training and experience make him/her knowledgeable about the best techniques for specific problems (and specific patients), and the plastic surgeon's familiarity with the various procedures helps reduce the risk of complications.

There are several referral sources for patients seeking a plastic surgeon. Patients often turn first to their primary care physicians for advice and referrals. The Plastic Surgery Information Service 1-888-4-PLASTIC (1-888-475-2784) can also provide names of qualified, plastic surgeons certified by the American Board of Plastic Surgery in the local area. Hospitals, doctors and nurses are other potential sources of referrals, as is a referral from a friend who has had plastic surgery and is pleased with the result. The Directory of Medical Specialists and the Compendium of Certified Medical Specialists are two directories that list plastic surgeons certified by the American Board of Plastic Surgery and give summaries of their training and experience.