What Are We Doing and Where Are We Going?

In the last hundred years aesthetic plastic surgery hasprogressed much, evolving from an almost casualpractice, as performed by Mrs. Noel in Paris, to be-come an important part of the great field of plasticsurgery. Everybody recognizes it to be a very glam-orous activity, an image no doubt inflated by themedia and by many surgeons’ egos. It is a big business.

Less evidently, the expansion has occurred mostlyoutside the traditional medical environment—bighospitals and medical schools—probably becauseaesthetic plastic surgery is not reimbursed by socialsystems or medical insurance. For that it is regardedas one of the last bastions of the so-called privatepractice—the service for fee, direct business with thepatient that most of us still envision as the right wayto practice medicine.

In this new millennium our subspeciality will facemany challenges and undoubtedly will grow andtransform to a degree that is impossible to foresee. Atthis point, however, two questions should be ad-dressed in order to provide a clearer scope for ourjournal.

The first question deals with the limits of aestheticplastic surgery—how to define it. The second ques-tion is how to evaluate the outcome of aestheticprocedures in a more scientific way.

Definitions of aesthetic plastic surgery are numer-ous, the most accepted being that of the ASPS,‘‘Aesthetic surgery is performed to reshape normalstructures of the body to improve the patient ap-pearance and self-esteem.’’ This is in contrast withreconstructive surgery which attempts to bring de-formed individuals to normalcy.

This distinction seems artificial and may not beuseful in the future. Apart from the fact that it isimpossible to define ‘‘normal,’’ we can name manyother occasions related to ‘‘reconstructive’’ or medi-cal situations where the aesthetic outcome is clearlyimportant: breast reconstruction, congenital cranio-facial anomalies, reanimation of facial paralysis, mi-crosurgical reconstruction of the face, facial burns,contour problems after gastroplasty-treated obesity.In both, plastic surgery is the method, but it is the

well-balanced appearance, or the aesthetic outcome,that is our focus.

Evaluation of the results of aesthetic plastic surgeryis another major problem that we should concernourselves with. Both this and our aesthetic goalshould be represented in this journal by an expandedvariety of articles and sections.

Manuscripts that present personal techniques,technical innovations, comparisons between diverseapproaches, and complication rates are, of course,important, but they relate only to our surgical per-spective. We need more papers that reflect what theother side feels—the patient’s perspective of the re-sults. Outcome studies must quantify psychologicalimprovements, gains in self-esteem, shifts in qualityof life, and differences in social performance.

Articles should report on result assessments doneby independent observers, with long-term followups.This will bring us closer to practicing ‘‘medicinebased on evidence.’’ Aesthetic procedures done onpatients deformed either congenitally or by acquiredphysical abnormalities, will be discussed more fre-quently.

Expansion of the horizons of aesthetic surgery willbring us back to where we belong—in medical andacademic circles. There I see a great future for aes-thetic surgery in which the challenges of plastic sur-gery will be correctly addressed and we will betteremploy our resources to restore deformed patientsand to improve the overall appearance of humanbeings.

Aesthetic plastic surgery should not be considereda peripheral or minor medical activity. On the con-trary, it deals with human dignity and deep, personalexpectations. For the benefit of the patients, theplastic surgeon will create beauty.

Marcus Castro FerreiraDivision of Plastic SurgeryUniversity of Sao Paulo

Av. Dr. Arnaldo, 455—Sala 1360Sao Paulo, Brazil

Email: mferrei@uol.com.br

Aesth. Plast. Surg. 27:5, 2003DOI: 10.1007/s00266-003-0001-5Online publication: 14 April 2003