In his latest online article, Mr Matthew James gives us his insights into cosmetic and reconstructive surgery. He talks about the difference between the two, how a patient can prepare for surgery, what’s involved in the procedure and how long the recovery is.

What is the difference between cosmetic and reconstructive facial plastic surgery?

Cosmetic surgery is typically associated with enhancing one's natural features, while reconstructive surgery is primarily focused on restoring what has been damaged. Facial damage can result from various factors, including congenital conditions, accidents, trauma, or infections, leading to disfigurement and scarring. Reconstructive procedures involve repairing and restoring the affected facial tissue. Often, skin from the cheek is a preferred source for reconstruction due to its abundance.

It's worth noting that the term "plastic surgery" is derived from the Greek word "plasticos," meaning to mold or shape tissues. Contrary to common misconceptions, it doesn't involve inserting plastic materials into the face. Plastic surgeons may use fillers or even a patient's own fat to enhance or modify facial features. Reconstructive surgery aims to address issues caused by tumours, trauma, infections, or congenital conditions, while cosmetic surgery involves improving one's appearance within the bounds of their natural features.

When discussing facial aging, it's helpful to consider it in three zones: the upper face (involving issues like brow descent and excess upper eyelid skin), the mid face (concerned with baggy or puffy lower eyelids), and the lower face (dealing with jowl formation and a loose neck). Cosmetic procedures can also address concerns such as prominent ears, which can have a significant impact on a person's self-esteem, especially in school or the workplace.

Another common cosmetic surgery is rhinoplasty, which is sought by individuals who wish to alter the shape of their nose. Given that the nose is a highly visible feature, dissatisfaction with its appearance often prompts people to seek rhinoplasty.

How does a patient prepare for both types of facial plastic surgery?

When it comes to patient preparation for surgery, the approach varies depending on the type of surgery being performed. In cases of trauma surgery or reconstructive surgery, patients may not have the opportunity to prepare due to unexpected incidents like infections or accidents. Consequently, preparation for reconstructive surgery is often not feasible because patients are typically dealing with issues such as tumour removal or accident-related injuries.

In contrast, when it comes to cosmetic surgery, there are specific measures that patients can take to enhance their post-operative healing process. Various techniques have been explored over the years to facilitate this. For instance, low-level laser therapy can be employed to improve blood circulation, while radiofrequency treatments can help condition and prepare the tissues for surgery. However, in most instances of facial surgery, extensive pre-surgical preparation isn't necessary because the skin possesses remarkable healing capabilities. Therefore, there isn't much that I typically advise my patients to do in advance of surgery.

Occasionally, there are exceptions. For example, if a patient has a history of cold sores and is undergoing significant facial surgery, I might prescribe acyclovir to prevent outbreaks. In cases like acne, it's advisable to have the condition under control before major surgery to minimise infection risks. Generally, most patients come to the clinic already well-prepared because they maintain good facial care, and there are no concerning issues. However, in recent times, I have incorporated K-laser therapy, a form of low-level laser therapy, which enhances blood supply to the tissue and may expedite healing, particularly in certain facelift and other surgical procedures.

What is involved in both types of procedures?

Let's explore the common elements between cosmetic and reconstructive surgery procedures. Essentially, surgery, whether cosmetic or reconstructive, shares fundamental principles. The core action performed by surgeons in both these procedures is the manipulation of skin.

In reconstructive surgery, the objective often revolves around filling a defect or addressing scar tissue. This process mirrors cosmetic surgery in many ways. Surgeons typically make incisions, lift the tissue, and then carefully suture it into the desired position. In essence, whether it's reconstructive or cosmetic surgery, the surgical steps are quite similar. The critical aspect that distinguishes the expertise of plastic surgeons lies in their ability to delicately handle the tissues. Years of training and experience have honed their skills in this regard. Handling tissue with precision is of paramount importance, as even the slightest damage to tissue can create opportunities for bacterial infection. When tissue is compromised, it can become a breeding ground for pathogens. Likewise, overly tight sutures can lead to tissue necrosis, which is another consideration.

To summarise, while cosmetic and reconstructive surgeries share many surgical techniques, the key differentiator lies in the surgeon's ability to handle tissue with extreme care. This skill is central to the practice of plastic surgery, especially in facial procedures.

How long is the recovery, and does it leave scars?

Let's discuss the recovery duration following both reconstructive and cosmetic surgery. To better understand this, it's helpful to break it down into phases. The facial skin possesses remarkable attributes, including a robust blood supply and a remarkable capacity for regeneration and repair. Most of the skin healing process on the face typically occurs within a week or two. This impressive healing ability is especially advantageous for practitioners of facial surgery because it facilitates rapid recovery and pleasing results. For example, if we consider a scenario involving tumour excision with a resultant defect, even in such cases, the skin tends to heal within one to two weeks. Even if the defect is a couple of centimetres in size, the skin has a remarkable capacity to close over and regenerate quickly.

In the context of procedures like facelift surgery, where incisions are made in front of and behind the ear, the skin is lifted, repositioned, and the underlying structures are tightened and sutured. Remarkably, within just one to two days, the skin naturally seals itself, becoming entirely waterproof. This means that patients can typically shower shortly after the surgery. Within one to two weeks, the skin becomes strong and resilient enough to allow patients to resume their regular daily activities. In certain cases, a substance called "artise," which is a fibre in tissue glue, is now being used. When lifting a layer of the face, it's essential to secure it back in place to prevent hematoma formation in the space. These tissue glues allow surgeons to attach the skin to the underlying muscle, reducing the risk of bruising or hematoma formation.

This advancement has notably improved the outcomes of facial surgeries. Drains are no longer commonly used in these surgeries, and patients can often return home on the same day of the procedure. The use of tissue glues also reduces tension on the suture line, minimising the risk of tissue damage. Overall, most facial healing occurs within one to two weeks, which can be surprising to patients. Many find it hard to believe that they can return to work so quickly after these procedures. The face's rapid and forgiving healing process is a significant advantage in facial surgery and contributes to positive outcomes.

What are the common facial procedures that you do?

Let's discuss the common facial procedures I perform. It's beneficial to categorise these procedures into the three facial zones: upper, mid, and lower.

In the upper facial zone, common procedures include brow lifts and upper eyelid blepharoplasty. Often, these can be combined, as drooping brows can contribute to hooded upper eyelids. Combining a blepharoplasty with either a direct brow lift or an endoscopic brow lift is a frequent approach.

Moving to the mid face, the primary concern often involves the lower eyelids. Issues like baggy lower lids, loose skin, and wrinkles around the eyes are common. Additionally, mid-face concerns may involve hollowing and descent. A facelift can restore mid-face volume, but we often enhance this effect with fat transfers. We take fat from the neck and inject it into the cheekbones for a natural and youthful appearance. Regarding lower eyelids, we address eye bags by re-draping them to reduce bulging and tighten the skin, securing it to the corner of the eye. Caution is crucial in eyelid surgery to prevent downward pulling of the eyelid. In the lower facial zone, facelifts are the most common procedure. Facelifts not only enhance the mandible's angle but also address concerns like turkey neck or a loose neck.

The classic facelift involves lifting the skin, tightening the underlying muscles, often above the nerve layer. Sometimes, we complement this with fat transfer to improve tissue quality. I refrain from performing deep-plane facelifts because, in my opinion, the potential risks of nerve damage outweigh the benefits. Safety is my top priority in cosmetic surgery. Patients seek improvements in their facial appearance without complications. Therefore, I prioritise safety above all else.

Prominent ears are another common issue, particularly in children who may undergo corrective surgery to prevent teasing at school. I don't perform extensive nose surgeries like rhinoplasty. On the non-surgical side, we offer treatments such as chemical peels to rejuvenate the skin's quality. Common options like botox and fillers are available, but I recommend caution with the recurrent use of fillers due to potential long-term issues. Instead, I prefer temporary filler use, followed by micro fat transfer if patients are satisfied with the results. In my practice, I don't heavily focus on laser resurfacing, but we have a clinic with experts in this area. Laser resurfacing is valuable for addressing issues like blemishes and spider nevi, as well as certain skin conditions.

Mr Matthew James is a distinguished plastic surgeon with over 20 years of experience. You can book an appointment with Mr James on his Top Doctors profile.