Session 1 : Background and definitions

Plastic surgery – Definition, principles and areas of convergence with æsthetic dermatology

Marcus Castro Ferreira
Professor and Chief,
Plastic Surgery Division Faculty of Medicine,
University of São Paulo, Brasil

In order to consider the current role of plastic surgery as a medical specialty and the overall development of æsthetics related to medicine and other health care areas, I must emphasize that the name æsthetic dermatology is not usual to the medical societies in most countries (in particular in Brazil).

Dermatology is a well known specialty, related mainly to medical pathologies and it can be practiced only by those certified by their specialist’s board. The problem would be the same if we have had this symposium dedicated to æsthetic surgery, area theoretically done only by plastic surgeons, many of them do today what it is being called here æsthetic dermatology.

In order to improve education and regulation in this new field , we have the option of using the name Aesthetic Medicine but not to consider it a specialty, just an area of special interest, inside the scope of different specialties, thus assuming it as a multidisciplinary area.

Aesthetic Medicine was introduced by us at the Faculty of Medicine of the University of São Paulo , as part of the optional curriculum in plastic surgery, to medical students and to residents and to post- graduated doctors.

There is not such area in the Department of Dermatology in our Medical School, a few doctors do some procedures but they do not use the name æsthetic dermatology.

After this introduction we may now concentrate on our topics for this meeting.

1- Updating of knowledge and methods for its acquisition

Plastic Surgery is a very old specialty, mostly related to the development of surgical techniques devoted to reconstruction of missing parts of the human surface .The more accepted definition, that issued by the American Society of Plastic Surgeons (1) informs that “Plastic Surgery is done in abnormal structures of the human body caused by congenital defects, trauma, tumors or other diseases in order to ameliorate function but also to bring the appearance to that considered normal”. Thus there is a clear æsthetic commitment of the specialty. They also add a provisional definition for æsthetic surgery “that made on normal structures in order to improve appearance”.

As it happens with any surgical specialty the surgeon is not a technician but a doctor that should use not only classical operations but also the lesser invasive procedures, as lasers and peelings for instance, and all the medical armentarium used by other clinical specialties, case of skin care techniques.

The doctor should use all treatments he learnt and was trained to perform, in order to solve that specific problem helping the patient.

The main focus of application of new technology, either surgical or medical should be directed to the improvement of the quality of life, and in this context, æsthetical concern is nowadays an important medical issue. The medicalization of the æsthetical care must be enhanced in order for the public to gain better control of what is being applied and developed.

In those aspects, plastic surgery has acted in order to improve better care for patients with æsthetic complaints.

Aesthetic surgery as a major part of plastic surgery was developed mostly after the second world war years and took the advantage that it still persists today, to be a liberal and private activity inside the environment dominated by insurance, public or private, that act as controllers of the traditional medical procedures, including the reconstructive part of plastic surgery.

In the last 50 years there was a clear distortion among plastic surgeons, who moved to the æsthetic area dedicating themselves only to æsthetic surgery and leaving reconstructive surgery for a minority of plastic surgeons. In Brazil, for example, among more than 4000 plastic surgeons enlisted in the Brazilian Society of Plastic Surgery, around 90% do just æsthetic surgery. In the last 10 years æsthetic medicine has been considered as a natural extension of the æsthetic surgery and other specialties as dermatology more recently discovered the economical potential of it.

In my country, the main appeal for residency in dermatology that we see nowadays is this æsthetic part. It is one of the most popular residencies in my medical school.

Plastic Surgery has been massively advertised by all media ways, it has become popular out of the medical environment and all of this helped to create an image that plastic surgery is just æsthetic. With the introduction of new procedures as botulinum toxin and other, plastic surgeons are viewed as beauty doctors. Medical societies are not controlling their practices, there is no scientific criterion to decide which product or operation is better or, at least, if they can fulfill what it was promised. (2) Patients are usually poorly informed about the results of the treatment.

What are the æsthetic problems that plastic surgery has been trying to solve in the last years as afflicting normal beings (in terms of appearance) and were, more recently, followed by dermatologists and other specialists?

First of all, signals of the passage of time, the aging, as inevitable as time, but always object of affliction by the humanity that psychologically consider youth superior to the old age. Rejuvenation has always been one favorite topic for intellectual discussion and desire.

Laser on burn sequellae. Effect of pulse-laser(DermapulsePL100®). Determine safety parameters. Evaluate patient’s satisfaction. (Isaac,C.et al,2006)

A second common problem and indication for æsthetic procedures was the body contour on breasts, abdomen, thighs and buttocks. Popularized as something indispensable for all women those procedures, surgical or medical can be provided to solve their necessities and reach their goal.

In what seems to have happened in recent years, the media has had a very important role. The public, and specially the women were induced to accept plastic surgery as an essential obligation that should be pursued to combat the effects of aging or, at least, to disguise the consequences; procedures of æsthetic medicine were considered to be a normal extension of this life style. It was taken as granted that surgeons and dermatologists could fulfill those expectations.

It is a sociological trend, it represents sometimes a social climb, in a word it is an object for consummation, more than a medical necessity. Similarly to the rejuvenation measures, advertising of perfection of form for those not so well built made those treatments an irresistible attraction.

In principle, there is nothing wrong with the desires and worries. However, I think it should be our concern as doctors and for us here one of our main motivations, to set directions and to discuss measures that can introduced in academic and medical organizations in order to control and better inform the public about æsthetic medicine.

As an unexpected and important development in plastic surgery we are seeing now the æsthetic concern is not limited to the so-called pure æsthetic cases anymore.

An important amount of patients, considered by classical definition, as deformed people, who were afflicted by burns, facial trauma, facial paralysis, tumor and so on were operated by plastic surgery as reconstructive cases but more and more they ask for complementary treatment aiming at result with better æsthetical quality. This is considered to be a booming area inside plastic surgery – the interface between æsthetic and reconstructive plastic surgery and up to now, has not been well addressed in medical meetings or through scientific publications.

Aesthetic Medicine has had a major role in its development and we included this interface in our medical division of the university hospital since the beginning of our æsthetic group activities, in 1995, in Sao Paulo.

Patients with facial burns were the first to be benefited from the use of peelings in order to improve facial scarring, followed by patients with facial palsy who, after sophisticated microsurgical transfers and function rehabilitation asked for improvement of their appearance that use could provide by botulinum toxin injections.

Fillers Adsorbable biomaterials. Autogenous fillers; Hyaluronic acid; Polilactic acid. (M.O de Campo Escuro 400x)

2- Answering the second question

“Approaches to implement this new specialty” and emphasizing that we do not consider it a specialty, we felt important to develop more centers in academic environment as we did in our university, in plastic surgery division or other in order to expose those new procedures to medical students and other specialty doctors.

The interface between æsthetic and reconstructive problems was, in the last 7 years, much developed by Dr Alessandra Salles, plastic surgeon, who started a clinic that provided the benefits of æsthetic medicine to a wider population usually without access to private offices. It was introduced also these new concepts to the medical school.

It is clear in my mind that to develop a serious area of æsthetic medicine, not only a commercial enterprise, we need a larger participation and discussion of all procedures in the medical schools. Medical students and residents should have more information about these new products, about results of clinical trials, problems and pitfalls that can arise with their use. Increased participation of private companies working together with the medical structures will leave away advertising media and fashion concepts that can undermine the benefits that we can offer to our patients.

We are doing such efforts in our medical school. Although it seems impossible to include in the basic medical curriculum it was possible to offer it to medical students as optional discipline and for that we use modern resources-there is a virtual discipline on Aesthetic Medicine, students learnt by Internet, there is no need for physical presence in classes. Information can be provided by those means but it lacks physical contact with patients, which can be offered only for small groups. For residents and specialists (even dermatologists were accepted) a capacitating course is being offered with more time for practical training including experience in peelings, fillers and toxin.

Medical societies may contribute to the development of this new area, mostly Plastic Surgery and Dermatology. Chapter exists in the Brazilian Society of Plastic Surgery but it needs a better background and a scientific basis of research.

Some scientific journals in the field of plastic surgery have increased their space to publish more articles on æsthetic medicine. Plastic and Reconstructive Surgery, well respected journal, is doing this and Aesthetic Plastic Surgery, formerly dedicated only to technical details of plastic surgery procedures is more recently increasing the number of published papers on the subject.

3- Priority research avenues

Aesthetic Medicine is not different from any other area of medical endeavor: the basic concepts like wound healing, blood supply and ischemia, tissue regeneration and repair, angiogenesis are also research lines for æsthetic medicine as the patients described here suffer from deviations of those physiological conditions.

Breast Cancer. Treatment and Reconstruction. Aæsthetic Concern

Apart from research with anti-aging that would change the human race as such, it seems that avoiding aging is not foreseen in a near future but we can study some basic functions of the cell using cell cultures.

At the Faculty of Medicine in Sao Paulo, in the last 10 years we developed projects using fibroblast cultures in order to study collagen production and influence of the Tgf and other physiological stimulus to the collagen production.

We were more interested in anomalous scar formation as it happens with keloid- scars an important æsthetic concern for patients with burn and other trauma sequels but it is clear that the fibroblasts taken from aged skin can also be studied using this research line.

Aesthetic medicine is currently receiving more attention from basic scientists working on stem cells as one of the sources of the so- called mesenchimal cell is the adypocite (fat tissue cell) derived from liposuction. Those cells can be prepared as adult stem cells to generate osteocytes, condrocytes and for us mostly interesting, fat cells again but in a more organized way, thus making possible the creation of new fat tissue. We will be pursuing this new avenue on the next year.

Conclusion

Answers for the three questions show that æsthetic medicine is already an important medical area from the business point of view and for the practitioner as financially interesting. It is lacking more scientific background and more solid knowledge on the effects and efficiency of the products. It lacks basically more evidence-based evaluation of the results with longer follow- up. This is not so simple to achieve but efforts should be made to implement them.

Discussion of all those aspects is an essential part of progress in this area. We had the opportunity to discuss it in Paris in 2005 (3) and I am here now to address again this subject.

Most commercial products have today good reputation but if they were considered just fashion creations they can loose their credit and be discarded as it happened with many luxury products in a recent past.

From the left to the right: M. Kopec, C. Beylet, G. Kaya, M.C. Cabelguenne, V. Gassia, J. Wolf and S. Gonzalez