What is Plastic Surgery?
Plastic surgery is broad surgical subspecialty that, unlike other surgical specialties, isn't confined to a single organ system. As a result, it is a technically demanding and naturally creative field that is constantly changing and re-inventing itself. Plastic surgeons treat pathologies that range from congenital anomalies to cancer, trauma and degenerative or autoimmune conditions. Additionally, plastic surgeons are inherent team players since they must constantly work alongside other specialties like general surgery, gynecology, neurosurgery, ophthalmology, oral surgery, orthopedic surgery otolaryngology and urology to reconstruct any anomalies or defects in the body.
Very few specialties in medicine offer the opportunity to be creative and innovative. This is why we love plastic surgery!
On this page, we provide a broad overview of the "scope of practice" in plastic surgery. Please click on the following categories to learn more about the various conditions that plastic surgeons may treat. As you can imagine, it is not all-encompassing. However, it offers a glimpse of what plastic surgeons do!
Aesthetic (Cosmetic) Surgery
As defined by the American Medical Association (AMA) in 1989, "Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem." Cosmetic or aesthetic surgery includes various rejuvenating procedures to treat structures of the face (e.g., facelift for age-related changes, rhinoplasty for a large nose, blepharoplasty for excess eyelid skin), as well as other parts of the body including but not limited to the breast (e.g., breast augmentation) and abdomen (e.g., abdominoplasty following pregnancy). The field also includes the use of various injectables, such as fillers and neurotoxins, to address asymmetries and age-related changes. Trainees are able to pursue further fellowship training in the field if they so desire.
Image: Sieber DA, Rohrich RJ. Finesse in Nasal Tip Refinement. Plast Reconstr Surg. Aug;140(2):277e-286e.
Hair transplantation is a surgical technique employed by plastic surgeons to transfer hair follicles from one part of the body, the donor site, to a deficient recipient site. This minimally invasive procedure may be used in areas of balding, or to restore eyelashes, eyebrows, pubic or chest hair. It can also be used to fill areas of scarring from prior injuries or surgeries. Trainees may have the opportunity to pursue this as an interest in various cosmetic centers across the country.
Image: Onda M, Igawa HH, Inoue K, Tanino R. Novel technique of follicular unit extraction hair transplantation with a powered punching device. Dermatol Surg. 2008 Dec;34(12):1683-8. doi: 10.1111/j.1524-4725.2008.34346.x. Epub 2008 Oct 13. PMID: 19018825.
Gender-affirming surgery is a surgical procedure by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their identified gender. This includes facial feminization or masculinization, breast augmentation or mastectomy, vaginoplasties and phalloplasties. Nguyen PD et al. demonstrated that trainees were prepared to address plastic surgery-related transgender concerns and felt that plastic surgeons are the most appropriate specialty referral for each type of gender-affirming surgery. Several fellowships in this field have recently become available to trainees seeking additional training.
Images: Chen K, et al. Facial Recognition Neural Networks Confirm Success of Facial Feminization Surgery. Plast Reconstr Surg. 2020 Jan;145(1):203-209. doi: 10.1097/PRS.0000000000006342.
Van Boerum MS et al. Chest and Facial Surgery for the Transgender patient. Transl Androl Urol. 2019;8(3):219-227.
Chen ML, Safa B. Single-Stage Phalloplasty. Urol Clin North Am 2019;46(4):567-580.
Hand/Upper Extremity Reconstruction
Plastic surgeons may care for both pediatric and adult patients with hand/upper extremity deformities related to traumatic, oncologic and congenital/syndromic etiologies. Traumatic cases may necessitate not only bony fixation, but possibly replantation of all or part of the hand and upper extremity. In addition, nerve and tendon repairs and transfers are important techniques for the restoration of sensation and function to the upper extremity. Trainees may pursue additional fellowship training in this field.
Image: Courtesy of Saïd Azoury, MD.
According to migraineresearchfoundation.org, nearly 1 in 4 US households includes someone with a migraine. Migraine pain can be debilitating and is instigated by the irritation of vessels, nerves and other soft tissues. Plastic surgeons can play a critical role in the treatment of migraines. Various novel treatment approaches have been developed, including endoscopic and direct surgical release of nerve triggers (such as the transpalpebral approach for anterior triggers).
Image: Gfrerer L, Maman DY, Tessler O, Austen WG Jr. Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes. Plast Reconstr Surg. 2014 Oct;134(4):771-778. doi: 10.1097/PRS.0000000000000507. PMID: 24945947.
Plastic surgeons perform nerve surgeries to treat a variety of conditions. Various applications of nerve surgery include brachial plexus surgery, facial reanimation, repair following traumatic injury, targeted muscle reinnervation and regenerative peripheral nerve interface. These various modalities aim to improve quality of life in patients with either congenital, acquired or traumatic nerve pathologies.
Image: Terzis JK, Konofaos P. Radial nerve injuries and outcomes: our experience. Plast Reconstr Surg. 2011 Feb;127(2):739-751. doi: 10.1097/PRS.0b013e3181fed7de. PMID: 20966815.
Head/Neck Surgical Oncology
Plastic surgeons may also care for cancers of the head/neck region including melanoma, squamous cell carcinoma and osteosarcomas. As one of the oldest subspecialties in plastic surgery, head/neck surgical oncology training teaches trainees not only the management of cancer but also the currently utilized innovative techniques used to reconstruction tumors defects that restore form (i.e., aesthetic) and function (i.e., swallowing, breathing, biting).
Image: Free Flaps. In: Cheney M, Hadlock T, ed. Facial Surgery. Plastic and Reconstructive. 1st Edition. Thieme; 2014. doi:10.1055/b-006-161012.
Melanoma/Cutaneous Malignancy Surgery
The surgical management of melanoma and other cutaneous malignancies falls within the skill sets of plastic and reconstructive surgeons. Patients may be referred to plastic surgeons for resection of these malignancies, in addition to the reconstruction of defects from head to toe.
Image: Azoury SC, Lange JR. Epidemiology, risk factors, prevention, and early detection of melanoma. Surg Clin North Am. 2014 Oct;94(5):945-62, vii. doi: 10.1016/j.suc.2014.07.013. Epub 2014 Aug 6. PMID: 25245960.
Cleft Lip/Palate Surgery
It is estimated that one in every seven hundred children will be born with a cleft lip or palate. If untreated, this condition can lead to feeding difficulties, ear infection, speech delay, breathing issues, not to mention psychosocial issues. Plastic surgeons are a critical component of the multidisciplinary care of these patients. Plastic surgery procedures include not only cleft lip and palate surgery, but also primary and revisional rhinoplasties. Some may also have the opportunity to participate in missions around the world treating underserved patients and communities.
Image: Courtesy of Saïd Azoury, MD.
Craniofacial surgeons partake in the care of both pediatric and adult patients with craniofacial deformities related to various antecedent etiologies, including traumatic, oncologic and congenital/syndromic. Techniques include ear and nose reconstruction with autologous and alloplastic materials, fracture fixation for maxillofacial fractures, skeletal reconstruction and cranial vault remodeling. Trainees may elect to pursue further training in this field.
Image: Swanson JW et al. An Algorithm for Managing Syndromic Craniosynostosis Using Posterior Vault Distraction Osteogenesis. Plast Reconstr Surg. 2016;137(5):829e-41e.
Dr. Paul Manson is widely considered a pioneer and father of facial trauma surgery. Patients presenting with facial trauma may have other concomitant serious injuries and plastic surgeons are involved in their overall care and management. This includes the management and repair of related soft tissue injuries and wounds, fracture stabilization, dental care and even microvascular replantation of facial parts in the cases of severe mutilating injuries.
Image: Luck JD et al. Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number Fixation Sites in Growing Children. Plast Reconstr Surg. 142(1):51e-60e.
Orthognathic surgery, also known as jaw surgery, corrects dentofacial anomalies of the upper (maxilla) and lower jaw (mandible). Correcting these irregularities realigns the jaws and teeth to improve not only a patient's "bite," but also their breathing and facial appearance. Surgeons who perform orthognathic surgery work closely with orthodontists and oral surgeons.
Image: Management of Developmental Dentofacial Deformities. In: Bentz M, Bauer B, Zuker R, ed. Principles & Practice of Pediatric Plastic Surgery. 2nd Edition. Thieme; 2016. doi:10.1055/b-006-161029.
Temporomandibular Joint Surgery
Patients with end-stage temporomandibular joint pathology present with restricted jaw function oftentimes require joint reconstruction to alleviate pain and improve function. The various methods used for reconstruction include costochondral grafts, alloplastic prostheses and vascularized free bone graft. Trainees will be exposed to these techniques when working with craniofacial and orthognathic surgeons.
Image: Tiongco RP, Hui A, Stern-Buchbinder Z, Stalder MW, St Hilaire H. Reconstruction of Bilateral Mandibular Condyles Using a Single Vascularized Fibula. Plast Reconstr Surg Glob Open. 2021 Jan 25;9(1):e3154. doi: 10.1097/GOX.0000000000003154. PMID: 33552802; PMCID: PMC7859325.
Plastic surgeons may a critical role in the multidisciplinary care of patients with breast cancer. Reconstructive options after breast cancer surgery include oncoplastic surgery following lumpectomy or implant-based or autologous reconstruction after mastectomy. The most common form of breast reconstruction in the United States is two-stage implant-based reconstruction, in which a tissue expander is first placed to expand the skin following mastectomy. After the tissue expander has been expanded sufficiently, a permanent implant is placed. Autologous reconstruction, however, is considered to be the gold standard in terms of recreating the natural breast shape and is most often achieved using free-flap transfer from the abdomen or, less commonly, from the buttocks or thighs.
Images: Implant Insertion. In: Cohen M, Thaller S, ed. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th Edition. Thieme; 2018. doi:10.1055/b-005-143642
Sultan SM, et al. Bipedicle-Conjoined Deep Inferior Epigastric Perforator Flaps for Unilateral Breast Reconstruction in Overweight and Obese Patients: Do the Benefits Outweigh the Risks? J Reconstr Microsurg. 2020; 36(05): 346-352. doi:10.1055/s-0040-1701209
According to the American Burn Association (ABA), over 450,000 serious burn injuries occur in the United States annually that require medical treatment. Plastic surgeons are integral to the care of both pediatric and adult patients suffering from burn injuries. Reconstructive techniques include skin grafting, the use of various biologic matrices, allografts, flaps and free tissue transfer.
Image: Glat PM, Davenport T. Current Techniques for Burn Reconstruction: Using Dehydrated Human Amnion/Chorion Membrane Allografts as an Adjunctive Treatment Along the Reconstructive Ladder. Ann Plast Surg. 2017 Feb;78(2 Suppl 1):S14-S18. doi: 10.1097/SAP.0000000000000980. PMID: 28079551.
Chest/Abdominal Wall Reconstruction
Complex reconstructive surgeries of the chest and abdomen are a common aspect of plastic surgery practice. With regards to the chest, plastic surgeons are often called upon to restore the chest wall following tumor resection. This may involve the use of mesh or rigid fixation for skeletal reconstruction depending on the size of the defect, as well as pedicled or free tissue coverage. For abdominal wall, plastic surgeons utilize an understanding of abdominal wall anatomy to manage complex and recurrent defects. This includes the component separation technique originally described by plastic surgeons, and various positioning of mesh on top, within or under the abdominal wall for reinforcing the repair.
Image: Azoury SC et al. Chest Wall Reconstruction: Evolution Over a Decade and Experience with a Novel Technique for Complex Defects. Annals of Plastic Surgery. 2016;76:231-237.
Microsurgery is a field of plastic surgery that involves the use of loupe or microscope magnification to anastomose small blood vessels (arteries and veins), nerves and lymphatics. Such techniques may be used in cases of free tissue transfer for cancer (i.e., for breast reconstruction) or trauma reconstruction or to treat lymphedema following oncologic resection. Trainees have the option of pursuing additional fellowship training in this field.
Image: Hsieh et al. Chang's Technique of Sequential End-toS-Side Microvascular Anastomosis. International Microsurgery Journal. 2017;1(1):4.
Lower Extremity Reconstruction
Orthopaedic surgeons often call upon plastic surgeons for reconstruction of the lower extremity. In fact, plastic surgeons play a critical role in the determination of whether limb salvage is a possibility. This requires an understanding of principles shared with orthopaedic surgery, such as wound management and fracture fixation, as well as locoregional flaps and microvascular techniques for soft tissue coverage. Such techniques have a role for defect reconstruction in the setting of trauma, tumor resection or chronic wounds.
Image: Courtesy of Saïd Azoury, MD.
Lymphedema affects nearly 250 million people worldwide. It can present as the primary pathology or can result from filariasis or, more commonly, lymph node dissection. Modern surgical techniques for lymphedema range from direct excision or liposuction to more complex procedures such as lymphovenous anastomosis and lymph node microvascular transfer. The goals of these treatment options is to lessen the long-term disability and functional impairment, while overall improving the quality of life.
Image: Schaverien, Mark V. M.B.Ch.B., M.Sc., M.Ed., M.D., P.G.Cert.(F.L.M.); Coroneos, Christopher J. M.D., M.Sc. Surgical Treatment of Lymphedema, Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 738-758 doi: 10.1097/PRS.0000000000005993.
Reconstruction for Mohs and Dermatological Surgery
Plastic surgeons are often called upon by their dermatology colleagues for reconstruction of defects from Mohs surgery for skin cancer, particularly those in cosmetically sensitive areas such as the face or hands. Reconstructive techniques range from local rotational, transposition and advancement flaps to pedicled and free-flaps. Plastic surgeons have the unique training to be able to problem-solve the reconstruction of defects from anywhere on the body.
Image: Courtesy of Saïd Azoury, MD.
Vascularized Composite Allotransplantation
In 1964, the first scientifically reported vascularized composite allotransplantation (VCA) occurred in Ecuador when a patient received a new hand. Now, the field of adult VCA has expanded to include uterine, face, scalp, larynx, abdominal wall and penile transplantation. Plastic surgeons are an integral part of the transplantation team. Plastic surgery residency training provides the necessary skills for those interested in VCA, including techniques of craniofacial, aesthetic, hand/extremity and microsurgery. Vascularized composite allotransplantation also expanded to the pediatric population when the world's first bilateral upper extremity replantation was performed in a child in 2015.
Image: Kantar RS et al. Facial Transplantation for an Irreparable Central and Lower Face Injury: A Modernized Approach to a Classic Challenge. Plastic and Reconstructive Surgery. 2019;144(2):264e-283e.