SETTING THE STANDARD

When we speak of the gold standard in plastic surgery, people immediately think of different procedures and operations or specific rejuvenating approaches. Ask five different plastic surgeons for the gold standard in our specialty, and you will likely get five different answers and they will likely all be correct in their own way. The gold standard as far as specific plastic surgery procedures are concerned have changed with time. But the key principles behind the care we provide our patients will always be part of our “gold standard.” I refer to knowledge, experience, safety, art and communication.

Regarding facial rejuvenation, many surgeons would look to the classic facelift as the gold standard. In this approach, extra skin is removed, the jowls are trimmed, fat is sculpted along the line of the mandible or jaw bone and banding in the neck is corrected. The underlying “muscular tissue,” or SMAS, is repositioned, and then tissue is re-draped to give a more youthful appearance with well-hidden scars. Although many patients will still benefit from this approach, so-called short-scar techniques have evolved to limit the scars, anesthesia requirements and downtime, with many of our patients benefiting from this approach. Taking this one step further, a number of patients undergo laser resurfacing, with Botox or filler injections and avoid surgery altogether and this often works quite well.

In the end, there is no one facial rejuvenator that is right for everyone, and the gold standard here is for the surgeon to use his expertise while considering patient safety to select the optimal approach for the individual before him. Communication skills also come into play so that the patient and surgeon arrive at the treatment decision together.

When I finished my residency training at Columbia-Presbyterian, the TRAM (transverse rectus abdominus myocutaneous) flap was the gold standard in breast reconstruction. In this operation following mastectomy, excess abdominal skin, fat and the underlying muscle were rotated through a pocket under the chest wall skin into the mastectomy site to reconstruct the breast. This operation could be done at the time of mastectomy or anytime afterward and allowed for a ptotic (or droopy), more natural-looking mature breast to be created, while at the same time giving the patient what was in essence a cosmetic abdominoplasty.

Over time, advances in implants and the introduction and widespread use of the acellular dermal matrix have significantly improved our capabilities in implant reconstruction. Paralleling this development, improvement in the technique of microsurgical reconstruction of the breast has led to muscle-preserving DIEP and other flaps that all can rival the appearance of the TRAM flap but have different postoperative recovery benefits.

My last example involves the development of rejuvenating eyelid surgery. Whereas the blepharoplasty used to consider removal of excess skin and fat, the approach has evolved to correcting the distribution of the eyelid fat rather than simply removing it. In the modern approach, fat is re-draped to eliminate the hollow area under the lower lid (the so-called tear trough), or fat or another filler can even be added to the lid to improve the contour. Again, the best approach for each patient has to be individualized for his or her particular needs.

Whatever approach you select, remember to choose a surgeon with knowledge and experience, one who puts your well-being first, has a keen artistic sense and is able to communicate effectively so you’ll both be happy.

For more information, email mrosenberg@plasticsurgeryweb.com.

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