Plastic surgery is defined as a surgical specialty dedicated to reconstruction of facial and body defects due to birth disorders, trauma, burns, and disease (ABCS, 2017). Correcting dysfunctional areas of the body by reconstruction is the intent of plastic surgery and of a plastic surgeon.
Plastic surgery deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, crania, and maxillofacial structures, hand, extremities, breast and trunk, and external genitalia (ACS, 2017). A plastic surgeon must have special knowledge and skill in order to design and perform surgery using grafts, flaps, free tissue transfer and replantation when necessary, in addition to managing complex wounds and tumor surgery (ACS, 2017). Medical advances in the field of plastic surgery include tissue techniques such as microvascular and craniomaxillofacial surgery, liposuction, and tissue transfer.
Craniomaxillofacial surgery involves reconstructing congenital and acquired deformities of the head, skill, face, neck, and jaws (Kim et al, 2015). Maxillofacial surgery depends on the supply and quality of available tissues and flap harvests. The tissues are used to replace and approximate bones, muscles, nerves, skin, and mucosa. Liposuction is also known as a fat removal procedure. This type of surgery removes excess deposits of fat to sculpt and improve the shape of a patient’s body (ABPS, 2017). Various types of liposuction techniques are available including tumescent, ultrasound assisted, laser assisted, and suction assisted. Tumescent is associated with an anesthetic that reduces the pain and bleeding that can occur during surgery. Ultrasound assisted liposuction uses ultrasound technology to degrade and loosen the targeted fatty tissue. Lasers are also used to loosen up the fatty tissue to allow for easier removal. Suction assisted liposuction uses a vacuum-like device to remove the excess fat.
Tissue Transfers
Tissue transfers are also known as flaps and are mainly accessed from deceased donor or transferred from one area of a patients’ body to the other. Tissue transfers provide a means for reconstructive surgeons to repair parts of the body and restore appearance, function and feeling. The most common reasons for patients to undergo tissue transfer or transplant is after treatment for cancer or after trauma, burn or injury (Hopkins, 2017). A plastic surgeon will remove skin, fat, muscle, nerve, and/or bone tissue from one part of the body and move it where it is needed. Arteries, veins, and sometimes nerves are then re-attached in the new location.
Tissue transfer may occur by various means. A local flap is a tissue that matches the size and shape of the area it is needed. Regional flaps are comprised of tissues taken from a nearby area and are often used to re-build large areas of vital structures including bones and nerves (Hopkins, 2017). A free tissue transfer is also known as a free flap, which refers to removal of tissue from an entirely different part of the body. Composite tissue transplantation is reconstructive transplant in an external feature or limb from one individual transferred to another (Hopkins, 2017). This type of surgery has not only been performed on limbs but also on abdominal walls.
These surgical techniques are as complicated as they sound. They require immense knowledge, skill, and training. Tissue engineering has allowed for significant improvements in reconstruction options for plastic surgeons. Tissue engineering is defined as the reconstitution of tissues and organs, in vitro, for use as model systems in basic and applied research or for use as grafts to replace damaged or diseased body parts or body functions (Kim et al, 2015). The successful identification and combination of tissue engineering, scaffold, progenitor cells, and physiologic signaling molecules has enabled the surgeon to design and recreate the missing tissue in its near natural form (Kim et al., 2015). Newly developed tissues allow plastic surgeons to restore the missing tissue with the same form and function it originally had.
Plastic Surgery vs. Cosmetic Surgery
Some may confuse plastic surgery with cosmetic surgery, however they are two different areas of specialization. A plastic surgeon may perform both cosmetic surgery and plastic surgery. The procedures, techniques, and principles of cosmetic surgery are entirely focused on enhancing a patient’s appearance (ABPS, 2017). Examples of cosmetic surgery include breast enhancements (augmentation, lift, reduction), facial contouring (rhinoplasty, chin, or cheek enhancement), facial rejuvenation (facelift, eyelift, neck lift, brow lift), body contouring (tummy tuck, liposuction, gynecomastia treatment), or skin rejuvenation (laser resurfacing, Botox, filler treatments).
Both cosmetic and plastic surgery may include the same surgical procedures. For example, a woman who is unhappy with her breasts may choose to undergo cosmetic surgery via a breast enhancement. A different woman, who perhaps has had a mastectomy, would undergo plastic surgery for breast reconstruction. Many plastic surgeons obtain additional training in order to perform cosmetic surgery in addition to plastic surgery. Additional examples of plastic surgery include burn repair surgery, congenital defect repair (cleft palate, extremity defect repair), lower extremity reconstruction, hand surgery, and scar revision surgery (ABPS, 2017).
The History of Plastic Surgery
Ancient Beginnings
The oldest cosmetic surgery practices may date back to Egypt in the third millennia BC, where early accounts describe rudimentary surgical procedures performed to repair facial trauma, including mandibular and nasal fractures (Docshop, 2017). According to Kim et.al (2015), plastic surgery began with an effort not to leave a scar on a face while treating a cut in 4000 B.C. The first recorded nose reconstruction was performed during the 5th century in India. Sushruta was an Indian healer in ancient India who was the first to mention that plastic surgeries were in existence in India during the 6th century B.C. (Robinson, 2015).
Sushruta Samhita is a Sanskrit text in encyclopedia form that was written by Sushruta, who lived between 600 and 400 BC. His writings include detailed descriptions of examinations, diagnoses, treatments, and procedures involving a variety of ailments, including procedures for reconstructing an earlobe using skin grafted from the cheek, as well as the process for repairing the nose by utilizing a pedicle flap from cheek or forehead tissue (Docshop, 2017). The text also documented the need for facial surgery was due to war battle injuries, although in some cases, the procedures were performed as penalties for crime (for example, amputations).
Beginnings of plastic surgery are also noted in the Greco-Roman era texts. In a text titled De Medicina, Aulus Cornelius Celsus discussed methods for reconstructing mutilated ears, lips, and noses that were similar to the techniques used by those in India, although it is not clear if the ancient Indians had interactions or shared information with the western Greeks and Romans (Docshop, 2017). Reconstructive surgery continued throughout the Middle Ages, with various texts citing blood circulation, tissue health, and bone reconstruction as areas of interest.
During the early Byzantine period, Oribasius, known as a royal physician, created a comprehensive 70-volume medical encyclopedia combining all previous medical knowledge which contained a section related to reconstructive principles. The text demonstrated reconstructive principles for repairing facial defects, using tensionless suture lines, and the importance of cartilage as an underlying support for the ear and nose (Docshop, 2017).
Byzantine Emperor Justinian II underwent nasal reconstruction after he was overthrown and his nose was mutilated so that his disfigurement would prevent him from reclaiming his title, and he did eventually return to power (Docshop, 2017). The fall of the Roman Empire and subsequent tribal wars prevented further medicinal advances and discoveries. Aside from minor advancements, such as a procedure to repair a cleft lip described in early tenth-century literature, the firm scientific foundations found in Greek, Roman, and Byzantine medicine had given way to mysticism. Pope Innocent III declared all surgical procedures were prohibited by Christianity and by Church law.
Renaissance Period
Despite the church extinguishing medical opportunities, Indian and Greco-Romans passed their teachings and principles down through generations. When Muslims conquered India in the tenth century, it is likely that Indian knowledge of facial reconstruction was brought back to Arabic culture and, from there, spread throughout Europe with the capture of Sicily during the ninth through twelfth centuries (Docshop, 2017).
The Renaissance period revived medical knowledge and practices and advances in science in technology. Basic standards of cleanliness and hygiene were incorporated, which, along with the advances in science, resulted in safer and more successful surgeries. In the 15th century, an illustrated Turkish-Islamic text entitled Imperial Surgery by Serafeddin Sabuncuoglu presented such procedures as maxillofacial surgery, eyelid surgery, and treatment for gynecomastia (enlarged male breasts) (Docshop, 2017). In fact, his method for correcting and reducing male breasts is the basic foundation for modern breast reductions and mammoplasty.
Modern Advances
Further advances in plastic surgery were made in the 19th century and spread throughout the western world. Two British surgeons observed an Indian brickmaker performing reconstruction of a man’s nose in India. They brought this knowledge back to Britain, and determined if a brickmaker could perform this reconstruction, then a surgeon could not only perform the same surgery but improve upon the procedure as well. The medical advances in anesthesia, knowledge of bodily systems, and antiseptic conditions allowed surgeons to perform a wider variety of procedures of increasing complexity – cleft lip repair, true skin grafts, and the first recorded instances of aesthetic nose reconstruction and breast augmentation (Docshop, 2017).
As with many other medical professions, the profession of plastic surgeons significantly developed in the 20th century, during the two World Wars and the Korean War. Due to medical advances, more soldiers survived injuries that previously would have been fatal; thus, the increased need for reconstructive surgery. Injured soldiers now required wound closure, skin grafting, and flap surgery (Kim et al, 2015). In 1923, the first modern rhinoplasty was performed in the United States (Robinson, 2015).
How to Become a Plastic Surgeon
Plastic surgeons shape and mold regions of the body like the ears, face, trunk, hands and other extremities, and they also repair congenital defects, such as malformed bone structure in hands for feet, or cleft palette (Study, 2017). As mentioned previously, there is a slight difference between plastic and cosmetic surgery, although the education and training is basically the same for a plastic surgeon and a cosmetic surgeon.
The foundation of surgical anatomy, physiology, pathology, and other basic sciences is fundamental to the specialty of plastic surgery (ACS, 2017). A competent plastic surgeon will have a unique combination of basic knowledge, surgical judgement, technical expertise, ethics, and interpersonal skills in order to achieve satisfactory patient relationships and problem resolution (ACS, 2017). Over a decade of education and training is required to become a plastic surgeon.
Extensive education and training is required to become a licensed plastic surgeon, but it does pay off in the end. Aspiring surgeons must complete up to a decade or more of education and training to enter this field, which includes earning a medical degree, gaining licensure and enrolling in residency and fellowship programs (Study, 2017). Some details of the plastic surgery profession from the Bureau of Labor Statistics can be found in the table below (Study, 2017).
Required Education
Doctor of Medicine (M.D.)
Other Requirements
Residency and fellowship
Licensure and Certification
Licensure required in all states; board certification in plastic surgery available
Job Growth (2014-2024)*
14% for all physicians and surgeons
Median Annual Salary (2016)**
$260,232 for plastic surgeons
A future plastic surgeon will get a bachelor’s degree in a pre-medical or science field such as biology or chemistry. An accredited medical school is the next step in the process in order to earn a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.). The first two years of medical school include classroom and laboratory requirements, and the last two years consist mainly of hands-on clinical experience in hospitals or other health care centers. Accreditation for education programs is through the Accreditation Council for Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada, or the American Dental Association.
Once medical school is successfully completed, five to six years of residency training is required. Typically, the first three years of surgery training is in general surgery and the final 2-3 years are in plastic surgery (Study, 2017). After residency is completed, examinations are required in order to become a licensed, practicing surgeon. Many aspiring plastic surgeons pursue a fellowship after their residency in order to obtain more specialized education and training, although it is not required in order to practice plastic surgery.
Medical school training includes special knowledge and skill in the design and transfer of flaps, in the transplantation of tissues, and in the replantation of structures are vital to these ends, as is skill in excisional surgery, in management of complex wounds, and in the use of alloplastic materials (ACS, 2017). Residency experiences allow for the student to develop their knowledge of arts and science and to develop into a competent, responsible plastic surgeon with high moral and ethical character capable of functioning as an independent surgeon (ACS, 2017).
All plastic surgeons are educated and trained in congenital problems of the head, neck and trunk, burn management, fluid replacement, breast surgery and other basic skills (Study, 2017). A fellowship program may specialize in a subfield of plastic surgery like hand, craniofacial or eyelid surgery, hair replacement or breast reconstruction (ACS, 2017). Regardless of specialization, a plastic surgeon can then be certified through the American Board of Plastic Surgery. Certification is not required to practice legally in the United States, but it is an option available to licensed plastic surgeons.
Being a Plastic Surgeon
Plastic surgeons describe their field as exciting, interesting, fulfilling, and diverse. From the tremendous variety of conditions that fall into the plastic surgeon's area of treatment expertise, to the flexibility of professional lifestyle, plastic surgery offers practitioners lifelong satisfaction in the practice of surgery (Study, 2017). While cosmetic surgery is perceived to be what fills a plastic surgeon’s day, for most practicing plastic surgeons, this is not the case. There is a tremendous diversity in the field of plastic surgery and options for specialized treatments.
Congenital, acquired, and traumatic problems are among the different fields of expertise, and within those fields are even more specialized areas such as cranio-maxillofacial surgery, microvascular surgery, hand surgery, and cosmetic surgery. This is not a comprehensive list of plastic surgery options, but just an example of the variety of patients and injuries a practicing plastic surgeon may experience.
Cranio-maxillofacial surgeons treat conditions or defects within bones of the face and skull, and any related tissue abnormalities. Microvascular surgeons move tissues from one location to another and reestablish blood supply and innervation to this tissue using an operating microscope and sutures that are finer than human hair (ACS, 2017). Hand surgeons treat congenital, acquired, and traumatic musculoskeletal problems of the hand and upper extremities, employing both plastic and orthopedic surgical techniques. Burn surgeons work as part of a large team that provides intensive care for burn-injured patients and treats both acute burn wounds and chronic scars. The goal of the cosmetic surgeon is to make changes in body shape or rejuvenate areas. A plastic surgeon can choose to limit a practice to one of these specialty or sub-specialty areas, or to practice plastic surgery in general. There is a tremendous amount of variety and diversity in the options a plastic surgeon may have.
Several factors are involved in this rapidly evolving field such as socio-economic development, changes in cultural norms, globalization and the effects of Western culture, advertising, media, and mental disorders (Nejadsarvari et al, 2016). Cosmetic surgery is different than most medical surgeries legally, because the objective is simply to “look better”, not to benefit in a medically therapeutic aspect. The increase in cosmetic surgery, which deals exclusively with human appearance, has raised the question of ethics and morals of cosmetic surgery.
Moral and Ethical Challenges
The desire for human beauty in human nature has long existed since the creation of the features (Nejadsarvari et al, 2016). Modification of appearances and surroundings is not a new concept. In America, one out of every 150 cases performs breast aesthetic surgery and research has shown that it is due to the way bodies (particularly female bodies) are portrayed in magazines, which creates new socially acceptable norms. In recent years, the abuses in medical ethics in plastic surgery have greatly increased, and high ethical questions are raised (Nejadsarvari et al, 2016).
One of the main concerns of certified plastic surgeons is cosmetic surgeries begin performed by non-licensed surgeons. Advertising and public deception also raise another ethical issue for plastic surgery. Today, in light of this trend, genuine human values are lost and false values, such as pride and ambition have been replaced (Nejadsarvari et al, 2016). In addition, many patients seeking cosmetic surgery have psychological factors, such as body dysmorphic disorder or low self-esteem, that is the basis for their desire for surgical options to improve their appearance.
Purely elective cosmetic surgery procedures may have long-term adverse effects on body function and health, which raises another ethical and moral issue for plastic or cosmetic surgeons. In addition, cosmetic surgery is purely for financial benefit of the surgeon. Although the justification can be made that the patient will feel better about themselves, it should be considered as to why the patient is unhappy with their appearance in the first place.
For any plastic surgeon, it is important to be aware of the ethical and moral challenges the profession in general faces as the field continues to grow. Cosmetic surgery may overshadow the true intention of plastic surgery, which is to provide victims of cancer, traumatic accidents, or congenital defects with a change to have full form and function of their body or area of their body. Patients of plastic surgeons have a chance at a greater quality of life using surgery to correct or improve their issue, and reconstructive surgery has allowed many victims the chance for a nearly full recovery.
While being a plastic surgeon can be challenging and demanding, it offers a wide range of options and exciting opportunities for those in the field. Plastic surgeons earn a nice salary and many are able to work flexible schedules and see a variety of patients.
Nasrin Nejadsarvari, N., Ebrahimi, A., Ebrahimi,A., and Hashem-Zade, H. Medical Ethics in Plastic Surgey: A Mini Review. World J Plast Surg. 2016 Sep; 5(3): 207–212.
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