Silicone  -  Silicone  chin Implants are one of the most commonly used implants for chin augmentation. They are soft, smooth, flexible and come in different shapes and sizes. They do not incorporate (stick) to the surrounding tissues, so the pocket must be made precisely. They usually stay in place, but may move, buckle and cause bone resorption where they contact the mandible in some cases. Since they are smooth, they can also be removed easily.


Polyethylene  -  Polyethylene  chin implants, brand name Medpor, are hard, porous, slightly flexible and come in various shapes and sizes. They do incorporate, as the surrounding tissues can grow into the pores of the material. This fixes the polyethylene chin implants in place, and provides a blood supply to help prevent infection. It also makes these implants much more difficult to remove.


Polytetrafluoroethylene  - Polytetrafluoroethylene, brand name  Gore-Tex , is used in plastic surgery and other operations is known by an abbreviation of its chemical name,  ePTFE  (expanded  polytetrafluoroethylene ) or Gore S.A.M. (subcutaneous augmentation material). [ 12 ]  Because ePTFE is flexible and soft but very strong, it is inserted during operations in trimmed sheets and carved blocks and held to the bone by  titanium  screws. But because the material is  porous , the force that really holds the implant in place is soft tissue and bone growing through and into the implant.


The above artificial materials are used in medicine because they are  biocompatible  and have a low incidence of causing problems inside the human body. They are abundant, FDA cleared and can be used "off-the-shelf", without a donor site injury to the recipient.


Acellular dermal matrix  - ADMs are another chin augmentation implant material. Commercially known as AlloDerm and known to physicians as acellular human cadaveric dermis, AlloDerm comes from tissue donors Just after death, technicians remove a layer of skin, remove the epidermis, and treat the remaining dermis with  antibiotics  and other substances to remove the donor's cells and  DNA  that would cause rejection. The  graft  that emerges is often used to cover chin implants.


Other implant materials include Supramid, a braided nonabsorbable synthetic suture material in polymer shell and Mersiline, a mesh-like material that provides a scaffold on the bone. [ 13 ]


Surgical chin augmentation  - The most common type of surgical chin augmentation uses a chin implant. There are many types of chin implants, and many are described in the previous section. Chin augmentation with a chin implant is usually a cosmetic procedure. An incision is made either under the chin or inside the  lower lip, a pocket is made and the implant placed into the pocket. Some chin implants are fixed to the mandible, while others are held in place by the pocket itself.


Another surgical chin augmentation uses the lower prominence of the mandible as the "implant." Known as a sliding genioplasty, the procedure involves cutting a horseshoe-shaped piece of bone from the lower border of the mandible known as an osteotomy. For chin augmentation, the piece of bone is advanced forward to increase to projection of the chin. The piece can also be recessed backward for a chin reduction. The new position is held in place with a titanium step plate using titanium screws. The bone segment can also be fixated with 26 or 27 gauge wires and IMF (wiring the jaw shut) for 3-4weeks. This type of surgery is usually performed by an  oral and maxillofacial surgeon  or a  plastic surgeon .


More involved Orthognathic Surgery may be required in cases where the chin is small and a significant overbite co-exist. While the procedures above may improve the cosmetic appearance of the chin, they will not improve dental occlusion.  Mandibular advancement surgery  can be used to correct the alignment of the teeth and improve the projection of the chin.


Non-surgical chin augmentation  - Another method of chin augmentation uses an injectable filler. Most fillers are temporary, with results lasting months to years. Common temporary fillers include  hyaluronic acid  and  calcium hydroxyapatite  preparations. Permanent fillers, like "free"   silicone , have fallen out of favor due to the risk of migration, chronic inflammation and infection, which can permanently disfigure the chin.


Clitoral hood reduction , also termed  clitoral hoodectomy , [ 1 ]   clitoral unhooding ,  clitoridotomy , [ 2 ] [ 3 ]  or (partial)  hoodectomy , is a  plastic surgery  procedure (a form of  vulvoplasty ) for reducing the size and the area of the  clitoral hood  in order to further expose the  glans  of the  clitoris .


It is usually performed as an elective cosmetic surgery meant to improve sexual satisfaction and to change the aesthetic appearance of the  vulva . The reduction of the clitoral hood usually is done together with a  labiaplasty  that reduces the  labia minora , and occasionally within a  vaginoplasty .


Though patient surveys have indicated satisfaction with the outcome of such procedures, the  American College of Obstetricians and Gynecologists  cautioned in 2007 that for this type of vaginal surgeries, which are not medically indicated, women should be informed about the lack of data on their efficacy and potential complications. [ 4 ]


The procedures for labiaplasty occasionally include a clitoral hood reduction. [ 5 ]  One technique for reducing the clitoral hood is the bilateral excision (cutting) of the prepuce tissues covering the clitoral glans, with especial attention to maintaining the glans in the midline. [ 6 ]  Another technique cuts away (excises) the redundant folds of clitoral prepuce tissue, with incisions parallel to the long axis of the clitoris. [ 7 ]


Clitoral hood reduction can be included in the extended wedge resection labiaplasty technique, wherein the extension of the exterior wedge sections is applied to reducing the prepuce tissues of the clitoral glans. Yet, occasionally excess prepuce-skin, in the center of the clitoral hood, is removed with separate incisions. [ 8 ]


Studies have reported a high rate of patient satisfaction with the aesthetic changes to the  vulvo-vaginal complex  after labioplasty, and a low incidence rate of medical complications. [ 6 ] [ 8 ] [ 9 ] [ 5 ]  The study  Aesthetic Labia Minora and Clitoral Hood Reduction using Extended Central Wedge Resection  (2008) reported that of a 407-woman cohort, 98 per cent were satisfied with the labial reduction outcomes; that the average patient satisfaction score was 9.2 points on a 10-point scale; that 95 per cent of the women experienced reduced pudendal discomfort; that 93 per cent of the women experienced improved  self esteem ; that 71 per cent experienced improved sexual functioning; that 0.6 per cent (one woman) reported lessened sexual functioning; and that 4.4 per cent of the women experienced medical complications. [ 8 ]  The study  Expectations and Experience of Labial Reduction: A Qualitative Study  (2007) reported that the women who underwent labiaplasty had great expectations for the elimination of pubic discomfort and pain, improved cosmetic appearance of the  vulva , and improved sexual functioning. Most of the women experienced improved  self esteem ; yet the study also reported that formal psychological counselling before the surgical operation about what to expect and what not to expect from a labia minora and clitoral prepuce reduction procedure might better serve the prospective patient by assisting her in establishing realistic expectations for her genital beauty and mental health after such a procedure. [ 10 ] [ 11 ]


Partial or total hoodectomy is classified by the  World Health Organization  as  female genital mutilation  (FGM) Type 1A. [ 12 ]  However, this classification is criticised as being "overly-simplified" and "culturally insensitive" by some. They argue that hoodectomy is no different than male  circumcision , which is  legally permitted in most countries , and is often less invasive in practice. [ 13 ]


The  American College of Obstetricians and Gynecologists  (ACOG) published  Committee Opinion No. 378: Vaginal "Rejuvenation" and Cosmetic Vaginal Procedures  (2007), the college's formal policy statement of opposition to the  commercial misrepresentations  of labiaplasty, and associated vaginoplastic procedures, as medically "accepted and routine surgical practices". The ACOG doubts the medical safety and the therapeutic efficacy of the surgical techniques and procedures for performing vaginoplastic operations such as labiaplasty,  vaginal rejuvenation , the designer vagina, revirgination, and  G-spot amplification , and recommends that women seeking such genitoplastic surgeries must be fully informed, with the available surgical-safety statistics, of the potential health risks of surgical-wound  infection , of  pudendal nerve  damage (resulting in either an insensitive or an over-sensitive vulva), of  dyspareunia  (painful coitus), of tissue adhesions ( epidermoid cysts ), and of painful scars. [ 4 ]


The dorsal nerves of the clitoris travel above the clitoris along the clitoral body. Permanent injury to these nerves can occur with clitoral hood reductions. [ 14 ]


Clitoridectomy  or  clitorectomy  is the  surgical  removal, reduction, or partial removal of the  clitoris . [ 1 ]  It is rarely used as a therapeutic medical procedure, such as when  cancer  has developed in or spread to the clitoris. Commonly, non-medical removal of the clitoris is performed during  female genital mutilation . [ 2 ]


A clitoridectomy is often done to remove  malignancy  or  necrosis  of the clitoris. This is sometimes done along with a radical complete  vulvectomy . Surgery may also become necessary due to therapeutic  radiation treatments  to the pelvic area. [ 3 ]


Removal of the clitoris may be due to malignancy or trauma. [ 3 ] [ 4 ]


Female infants born with a  46,XX  genotype but have a clitoris size affected by  congenital adrenal hyperplasia  and are treated surgically with  vaginoplasty  that often reduces the size of the clitoris without its total removal. The atypical size of the clitoris is due to an endocrine imbalance in utero. [ 1 ] [ 5 ]  Other reasons for the surgery include issues involving  microphallism  and those who have  Müllerian agenesis . Treatments on children raise human rights concerns. [ 6 ]


Clitoridectomy surgical techniques are used to remove an invasive malignancy that extends to the clitoris. Standard surgical procedures are followed in these cases. This includes evaluation and  biopsy . Other factors that will affect the technique selected are age, other existing medical conditions, and obesity. Other considerations are the probability of extended hospital care and the development of infection at the surgical site. [ 3 ]


The surgery proceeds with the use of  general anesthesia , and prior to the vulvectomy/clitoridectomy an inguinal  lymphadenectomy  is first done. The extent of the surgical site extends 1 to 2 cm (0.39 to 0.79 in) beyond the boundaries of malignancy. Superficial  lymph nodes  may also need to be removed. If the malignancy is present in any  muscles  in the region, then the affected muscle tissue is also removed. In some cases, the surgeon is able to preserve the clitoris despite extensive malignancy. The cancerous tissue is removed and the incision is closed. [ 3 ]


Post-operative care may employ the use of suction drainage to allow the deeper tissues to heal toward the surface. Follow-up after surgery includes the stripping of the drainage device to prevent blockage. A typical hospital stay can last up to two weeks. The site of the surgery is left unbandaged to allow for frequent examination. [ 3 ]


Complications can include the development of  lymphedema ; not removing the saphenous vein during the surgery can help prevent this. In some instances, the buildup of fluid can be reduced through methods such as foot elevation,  diuretic  medication, and wearing  compression stockings . [ 3 ]


In a clitoridectomy for infants with a  clitoromegaly , the clitoris is often reduced instead of removed. The surgeon cuts the shaft of the elongated phallus and sews the  glans  and preserved nerves back onto the stump. In a less common surgery called clitoral recession, the surgeon hides the clitoral shaft under a fold of skin so only the glans remains visible. [ 7 ]


While much  feminist  scholarship has described clitoridectomy as a practice aimed at controlling women's sexuality, the historic emergence of the practice in ancient European and Middle Eastern cultures may also have derived from ideas about what a normal female genitalia should look like and the policing of boundaries between the sexes. [ 8 ]


In the seventeenth century, anatomists remained divided on whether a clitoris was a normal female organ, with some arguing that it was an abnormality in female development and, if large enough to be visible, it should always be removed at birth. [ 9 ]  In the 19th century, a clitoridectomy was thought by some to curb  female masturbation ; until the late 19th century, masturbation  was thought by many  to be unhealthy or immoral. [ 10 ]   Isaac Baker Brown  (1812–1873), an English gynaecologist who was president of the  Medical Society of London   believed that the "unnatural irritation" of the clitoris caused  epilepsy ,  hysteria , and  mania , and he worked "to remove [it] whenever he had the opportunity of doing so", according to his obituary in the  Medical Times and Gazette .  Peter Lewis Allen  writes that Brown's views caused outrage, and he died penniless after being expelled from the  Obstetrical Society . [ 11 ]


Occasionally, in American and English medicine of the nineteenth century,  circumcision  was done as a cure for insanity. Some believed that  mental and emotional disorders  were related to female reproductive organs and that removing the clitoris would cure the neurosis. This treatment was discontinued in 1867. [ 12 ]


Aesthetics  may determine clitoral norms. A lack of ambiguity of the genitalia is seen as necessary in the  assignment of a sex  to infants and therefore whether a child's genitalia is normal, but what is considered ambiguous or normal can vary from person to person. [ 13 ]


Sexual behavior is another reason for clitoridectomies. Author Sarah Rodriguez stated that the history of medical textbooks has indirectly created accepted ideas about the female body. Medical and gynecological textbooks are also at fault in the way that the clitoris is described in comparison to a male's  penis . The importance and originality of a female's clitoris is underscored because it is seen as "a less significant organ, since anatomy texts compared the penis and the clitoris in only one direction." Rodriguez said that a male's penis created the framework of the sexual organ. [ 14 ]


Not all historical examples of clitoral surgeries should be assumed to be clitoridectomy (removal of the clitoris). In the nineteen thirties, the French psychoanalyst  Marie Bonaparte  studied African clitoral surgical practices and showed that these often involved removal of the clitoral hood, not the clitoris. She also had a surgery done to her own clitoris by the Viennese surgeon Dr Halban, which entailed cutting the  suspensory ligament of the clitoris  to permit it to sit closer to her vaginal opening. These sorts of clitoral surgeries, contrary to reducing women's sexual pleasure, actually appear aimed at making coitus more pleasurable for women, though it is unclear if that is ever their actual outcome. [ 15 ]


Clitoridectomies are the most common form of female genital mutilation. The  World Health Organization  (WHO) estimates that clitoridectomies have been performed on 200 million girls and women that are currently alive. The regions that most clitoridectomies take place are Asia, the Middle East and west, north and east Africa. The practice also exists in migrants originating from these regions. Most of the surgeries are for cultural or religious reasons. [ 16 ]


Clitoridectomy of people with conditions such as  congenital adrenal hyperplasia  that cause a clitoromegaly is controversial when it takes place during childhood or under duress. Many women who were exposed to such treatment have reported loss of physical sensation in the affected area, and loss of  autonomy . [ 17 ] [ 18 ]  In recent years, multiple human rights institutions have criticized early surgical management of such characteristics. [ 19 ] [ 20 ] [ 21 ]


In 2013, it was disclosed in a medical journal that four unnamed elite female athletes from developing countries were subjected to gonadectomies and partial clitoridectomies after  testosterone testing  revealed that they had an  intersex  variation or disorder of sex development. [ 22 ] [ 23 ]  In April 2016, the  United Nations Special Rapporteur  on health, Dainius Pūras, condemned this treatment as a form of genital mutilation "in the absence of symptoms or health issues warranting those procedures." [ 24 ]


Clitoroplasty  is a type of  plastic surgery  involving the  clitoris . It encompasses several procedures, including clitoral reduction, clitoral reconstruction, and the creation of a neoclitoris in male-to-female  gender-affirming surgery . These surgeries aim to retain or restore sensation and function in the clitoris, often employing  nerve-sparing techniques .


Clitoral reconstruction  is surgery to restore the function and structure of the clitoris. Examples of clitoral reconstruction include its use to mitigate  congenital malformation  or repair damage caused by  female genital mutilation . [ 1 ] [ 2 ]


Clitoral reconstruction after female genital mutilation involves surgery to expose the remaining deep structures of the clitoris. As of 2023 [update] , there was little evidence for the therapeutic effectiveness of this procedure. [ 3 ]


Clitoral reduction  is the surgical reduction in size of the clitoris, used to treat  clitoromegaly . Unlike  clitoridectomy , the amputation of part of the clitoris, commonly considered a form of  female genital mutilation , modern clitoral reduction surgery aims to preserve sensation and function through the use of nerve-sparing  microsurgical  techniques. [ 4 ] [ 5 ] [ 6 ]


It should be distinguished from  clitoral hood reduction , an operation on the  clitoral hood  in which the clitoris itself is not damaged.


During  male-to-female gender-affirming surgery , a neoclitoris is made from the tissue of the  glans penis . [ 7 ]


In  female-to-male gender-affirming surgery ,  metoidioplasty  is an operation in which the clitoris is repositioned to create a  neophallus . [ 8 ]


Contour threads  are used in cosmetic/ plastic surgery  to vertically lift facial tissues that have dropped ("ptosed") or become sunken with age. The " ptosis " or descent of facial tissues with  aging  is a universal phenomenon to which much cosmetic facial surgery is directed.


Strands of 2/0  Prolene  monofilament thread, with little notches cut into their sides, are placed in the subcutaneous plane under the ptosed facial skin. These are anchored under secure points in  fronto-occipitalis  and  temporalis  tissues. Dropped or "ptosed" facial skin is then elevated onto the barbed threads, and stay elevated because of the barbs. Thus the patient gets a "facelift [ 1 ] ", without any scalpel work and without any removal of skin.


In the event that a patient is unhappy with the results, the threads can be readily removed and the patient's face thence returns to its position prior to treatment. [ 2 ]  Thus, Contour threads have negligible permanent "biological cost", as the effect is reversible. Effects last for a number of years, quoted as 2–5 years, after which time the positive effect is gradually lost and the patient's face returns to its state prior to treatment. [ citation needed ]


Cosmetic camouflage  is the application of  make-up   creams  and/or powders to conceal colour or contour irregularities or abnormalities of the face or body. It offers an answer to solve all related skin problems  such as Congenital origin, Traumatic origin and Dermatological origin ( angiomas, couperose, redness, teleangectasy, vitiligo, skin dyschromia, sunspots, senile spots, acne, results of burns, stretch-mark, scars, bruises, blue stains, eye sockets, tattoos). Furthermore, cosmetic camouflage solves  the psychological problems that a skin imperfection is sometimes able to provoke, it allows to rediscover its own beauty and to return with serenity to its own social life.
Cosmetic camouflage creams were first developed by  plastic surgeons  during  World War II  to cover the massive burns received by  fighter pilots . Nowadays, men, women and children can use cosmetic camouflage. [ 1 ] [ 2 ]


Cosmetic camouflage is also called camouflage makeup, cover makeup, or corrective makeup.


In the United States, a  craniofacial surgery fellowship  is a one-year program that prepares plastic surgeons to perform cosmetic, dental, and  craniofacial surgery  as well as the clinical application used in relevant medical procedures. The fellowship allows plastic surgeons to learn how to reconstruct and reshape the faces and heads of infants and children with facial anomalies, as well as those with traumatic injuries or cancer. [ 1 ]


To be eligible for craniofacial surgery fellowship, the candidate must have graduated from an accredited craniofacial surgery residency program (as defined in the American Society of Craniofacial Surgeons standards) and be in possession of a letter of recommendation from a person who has experienced a craniofacial surgery procedure with the surgeon. [ 2 ]  If the applicant is from another country, they should have completed the  ECFMG  examination or the  USMLE  and should be qualified for clinical activities. [ 3 ]


This article relating to education in the United States is a  stub . You can help Wikipedia by  expanding it .


Culture of cosmetic surgery  is a set of attitudes and behavior regarding making changes to one's appearance via  plastic surgery .  World War I  left thousands of soldiers with unprecedented levels of facial damage, creating a massive need for reconstructive surgery.  Harold Gillies  of  New Zealand  developed methods to restore function and structure to the faces of soldiers and these processes rapidly gained popularity. During the 1940s and 50s, personal appearance became more emphasized in the  United States . As  beauty standards  changed, new products and techniques were developed to meet those demands.


World War I left thousands of soldiers with unprecedented levels of facial damage; trench warfare and progressive weapons lead to massive amounts of death and destruction. Explosions and rapid gunfire left those who survived with horribly disfigured faces, creating a dire demand for medical intervention. Dr. Harold Gillies of New Zealand developed and tested methods to restore function and structure to the faces of soldiers, such as taking cartilage or skin from an easily concealed part of the patient's body and using it to reform the injured area. Due to the thousands of soldiers in need of immediate medical attention, there were no shortage of willing trial subjects. Gillies based his work on methods that had been developed previously, but were never intended for such drastic application. He improved upon these efforts and, when combined with anaesthesia and sedating medication, found his techniques rapidly gaining in popularity. [ 1 ]  The call for doctors able to perform facial reconstruction grew rapidly and received national attention. Dr. Varaztad Kazanjian became the first recognized post-war plastic surgery specialist at Harvard Medical School. [ 2 ]  Years after the war ended, the supply of patients in need of life-saving facial reconstruction was steadily reducing. As such, surgeons were able to take on less dire cases, such as industrial accidents or other injuries. Techniques and procedures became more advanced and public knowledge of them grew.


Throughout the 1940s and 50s fashion and personal appearance was emphasized more strongly in the United States; both world wars were over and years in the past, and normalcy was returning to the average American household. As ideas about what was considered beautiful changed, services, products, and techniques were developed to help consumers meet those standards if they so chose. Women felt pressure to be symmetrical, have smooth skin, and be slim yet curvy in all the right places. Being too thin was equated with being fragile and sickly, but being too large suggested poor self-care. [ 3 ]  The emphasize on  bust-waist-hip measurements  grew, with Miss America's proclaimed ideal in the 1950s being 36–24–36. [ 3 ]  Despite the physical risks they carry, corsets and waist-trainers returned to popularity during this time to help women achieve the "hourglass figure" that was so sought after. While fitted dresses and push-up bras were readily available, some women chose to undergo surgery to enhance their bodies. The rate of breast augmentation operations soared in the 1960s, and a decade later rates of anorexia-nervosa hit record highs. In the 1970s breast reduction surgery became more prevalent, as well as reduction of the thighs and buttocks. These surgeries were newly developed and experimental; some common unintended outcomes were numbness, loss of range of motion, and infection. At the same time, women were anxious to look youthful as they age in order to "keep their men". Suffering from poor self-image also became reason to improve one's appearance via surgery. Working women believed that good looks help secure or advance their livelihoods. Studies have shown that attractive individuals receive higher earnings and faster promotions than unattractive people across professions. In addition, people from different ethnic groups, such as Black, Asian and Jewish women, struggled to look more like other Americans and sought  WASP  noses and breasts as seen in  Playboy  magazines. [ 4 ] [ 5 ]


Many people who have plastic surgery in today's era choose to do so because of their mental state and lack of confidence in their own bodies. [ citation needed ]  Instead of working to accept and love what they look like as they are, millions of people turn to getting something changed about themselves instead because it requires less mental/ emotional work and is readily available. One example of this is people with eating disorders; a person who has body dysmorphia may try and get surgery in order to feel that they are skinnier than they already are. The major problem with this is that many eating disorder patients are not overweight, so this surgery will not be helpful to their physical health or appearance. These patients expect to come out of the operation room looking like a new person, and they believe that they will be able to feel confident in this new body. [ 6 ]  This can happen to certain people, but for the majority of people with these diagnoses, the surgery will not be able to change their mindset. These patients need therapy and mental treatments, so a physical surgery will be a waste of time and money. Besides eating disorder patients, a large number of people who choose to undergo plastic surgery are victims of anxiety, depression, or other mental illnesses. These people, just like an eating disorder patient, falsely believe the surgery will fix their mental state. These patients deserve to get mental health treatments because the surgery will most likely not be able to change their mindsets. However, cosmetic surgery can have profoundly wonderful affects for the transgender community and those who have significant facial damage. Trans folk who choose to have surgery so their physical form aligns more closely with their gender identity often feel more comfortable in their own skin and are able to see their external figure the way they want to see it, giving a marginalized and under-recognized group a significant amount of power back over their own lives. Burn victims and other patients who have experienced significant facial deformation also benefit psychologically from plastic surgery; victims of an accident or attack commonly feel much of their power has been taken away, and having a plethora of surgical procedures available to them may make the healing process easier. These procedures are intended to restore normalcy to people who have had traumatic experiences, and help them lead as normal of a life as possible.


Plastic surgery started to become commonly used during the world wars in order to help soldiers and veterans who were injured. Surgeons used skin grafts to reshape faces that had been impacted by bombs and bullets. [ 7 ]  After, plastic surgery became mainstream in the 1950s for American women to change themselves as beauty standards were changing. Most popular were, and is the third most popular today, rhinoplasties, which is a reconstruction of the nose.  Over the course of the 1900s American beauty standards became more narrow and created a rigid definition of beauty, which made these procedures more common in order to be seen as fitting into the definition of beauty. [ 3 ]   Today, many procedure can be done to meet society's definition of beauty and media and research has found the most common procedures sought out each year. The most popular procedure performed in 2018 were breast augmentations, followed by liposuction, nose reshaping, eyelid surgery, and tummy tucks. [ 8 ]  These procedures have become less invasive and more available as plastic surgeons expand their services and accessibility. These procedures are still expensive, but there are recently more ways to gets parts covered by health insurances. The criteria for medical intervention in contemporary society can be as simple as disliking the appearance of that part of the body; cosmetic surgery is the only medical specialty where the patient decides what is wrong with her and what the course of treatment will be. The prevalence of cosmetic surgery in the United States can make it feel less like a choice and more like a medical need; advertisements in everyday media, worship of celebrities who transform their bodies, and constant critique of the natural female form can suggest that there is something innately wrong or flawed about the way one looks, and surgical intervention is required to "fix" these issues.


A  custom-made medical device , commonly referred to as a  custom-made device  ( CMD ) (Canada, the European Union, the United Kingdom) or a  custom device  (United States), is a  medical device  designed and manufactured for the sole use of a particular patient. Examples of custom-made medical devices include  auricular splints ,  dentures ,  orthodontic appliances ,  orthotics  and  prostheses .


There is no globally agreed definition, but a custom-made medical device can be broadly defined as a medical device that has been designed and manufactured in accordance with a prescription from an appropriately qualified person for the sole use of a particular patient to meet their specific needs. Mass-produced medical devices that have been adapted for specific patient requirements such as customised wheelchairs, hearing aids, and spectacle frames do not typically fall within the definition of a custom-made medical device.


The requirements of sections 360d and 360e of this title shall not apply to a device that—


(A) is created or modified to comply with the order of an individual physician or dentist (or any other specially qualified person designated under regulations promulgated by the Secretary after an opportunity for an oral hearing);


(B) to comply with an order described in subparagraph (A), necessarily deviates from an otherwise applicable performance standard under section 360d of this title or requirement under section 360e of this title;


(C) is not generally available in the United States in finished form through labeling or advertising by the manufacturer, importer, or distributor for commercial distribution;


(D) is designed to treat a unique pathology or physiological condition that no other device is domestically available to treat;


(E)(i) is intended to meet the special needs of such physician or dentist (or other specially qualified person so designated) in the course of the professional practice of such physician or dentist (or other specially qualified person so designated); or


(ii) is intended for use by an individual patient named in such order of such physician or dentist (or other specially qualified person so designated);


(F) is assembled from components or manufactured and finished on a case-by-case basis to accommodate the unique needs of individuals described in clause (i) or (ii) of subparagraph (E); and


(G) may have common, standardized design characteristics, chemical and material compositions, and manufacturing processes as commercially distributed devices.


(2) Limitations


Paragraph (1) shall apply to a device only if—


(A) such device is for the purpose of treating a sufficiently rare condition, such that conducting clinical investigations on such device would be impractical;


(B) production of such device under paragraph (1) is limited to no more than 5 units per year of a particular device type, provided that such replication otherwise complies with this section; and


(C) the manufacturer of such device notifies the Secretary on an annual basis, in a manner prescribed by the Secretary, of the manufacture of such device.


Depending on the jurisdiction, custom-made medical devices can be  prescribed  by various  healthcare professionals  working within numerous  medical specialties  such as dentists,  hearing aid dispensers ,  ocularists/orbital prosthetists ,  orthotists ,  medical practitioners/physicians  and  prosthetists . Manufacturers of custom-made medical devices include  anaplastologists ,  audiologists ,
 clinical dental technicians/dental prosthetists/denturists ,  dental assistants / dental nurses ,  dental technicians , dentists,  ocularists/orbital prosthetists ,  ophthalmologists ,  optometrists ,  orthopaedic shoe fitters ,  orthopedic technicians ,  orthotists  and  prosthetists . [ 7 ]


In Australia manufacturers of custom-made medical devices are exempt from registering with the Australian Register of Therapeutic Goods (ARTG). Manufacturers of custom-made medical devices cannot advertise such devices directly to patients and are required to:


In Canada, custom-made medical devices are subject to Part 2 of the Medical Devices Regulations ( SOR /98-282) [ 2 ]  under the  Food and Drugs Act . Serious adverse incidents with medical devices must be  reported  to  Health Canada  within 72 hours. [ citation needed ]


Custom-made devices manufactured in the European Union are subject to  Regulation (EU) 2017/745 (Medical Device Regulation [EU MDR]) , [ 4 ]  which replaced and  repealed   Directive 93/42/EEC (Medical Devices Directive [MDD]) . [ 9 ]  Under the MDD, manufacturers of custom-made devices were required to follow the relevant Essential Requirements set out in Annex I and the procedure set out in Annex VIII. [ citation needed ]


The EU MDR was published on 5 April 2017, came into force on 25 May 2017 and, following a three-year transition period, was expected to replace and repeal the MDD on 26 May 2020. But on 23 April 2020, Regulation (EU) 2020/561 was adopted which deferred the full implementation of the EU MDR for one year until 26 May 2021 so that efforts could be concentrated on the response to the  coronavirus disease 2019 (COVID-19) pandemic . Under the EU MDR, manufacturers of custom-made devices are required to:


Custom-made devices are not required to carry the  CE marking .


In the UK manufacturers of custom-made devices are required to register with the  Medicines and Healthcare products Regulatory Agency . Until the UK  left the European Union  on 31 January 2020, custom-made devices were governed by the MDD, which was given effect in UK law by The Medical Devices Regulations 2002 (Statutory Instrument 2002/618 [UK MDR 2002] [ 5 ] ). Immediately after the UK's departure, the UK entered an 11-month  implementation period (IP) , during which EU law continued to apply.


In preparation for the UK's departure from the EU, the EU MDR was essentially transposed into The Medical Devices (Amendment etc.) (EU Exit) Regulations 2019, (Statutory Instrument 2019/791 [UK MDR 2019]), an amendment of the UK MDR 2002 [ 11 ] ) and was expected to be fully implemented on exit day. The UK MDR 2002 was further amended by The Medical Devices (Amendment etc.) (EU Exit) Regulations 2020 (Statutory Instrument 2020/1478 [UK MDR 2020] [ 12 ] ), which removed the provisions of the EU MDR and substituted 'exit day' for 'IP completion day'.


In Great Britain medical devices can conform to either the UK MDR 2002 (as amended) or the EU MDR until 30 June 2023.  Northern Ireland  remains in line with EU law under the terms of the  Protocol on Ireland/Northern Ireland . [ 13 ]


Custom-made devices are not required to carry the  CE marking  or the  UK Conformity Assessed (UKCA) marking . [ citation needed ]


Custom devices are subject to requirements including labelling ( 21 CFR  Part 801),  reporting  (21 CFR Part 803), corrections and removals (21 CFR Part 806), registration and listing (21 CFR Part 807) and  quality systems regulation  (21 CFR 820). Manufacturers of custom devices are obligated to submit an annual report of custom devices to the  Food and Drug Administration  but are exempt from Premarket Approval (PMA) requirements and conformance to mandatory performance standards. [ 14 ]


Dermabrasion  is a type of surgical skin planing, generally with the goal of removing  acne , scarring and other skin or tissue irregularities, typically performed in a professional medical setting by a  dermatologist  or  plastic surgeon  trained specifically in this procedure. Dermabrasion has been practiced for many years (before the advent of lasers) and involves the controlled deeper  abrasion  (wearing away) of the upper to mid layers of the  skin  with any variety of strong abrasive devices including a wire brush, diamond wheel or fraise, sterilized sandpaper, salt crystals or other mechanical means.


Dermabrasion procedures are surgical, invasive procedures that typically require a  local anaesthetic . Often, they are performed in surgical suites or in professional medical centers. Since the procedure can typically remove the top to deeper layers of the epidermis and extend into the  reticular dermis , there is always minor skin bleeding. The procedure carries risks of scarring, skin discoloration, infections and facial herpes virus ( cold sore ) reactivation. In aggressive dermabrasion cases, there is often tremendous skin bleeding and spray during the procedure that has to be controlled with pressure. Afterward, the skin is normally very red and raw-looking. Depending on the level of skin removal with dermabrasion, it takes an average of 7–30 days for the skin to fully heal ( re-epithelialize ). Often, the procedure is performed for deeper acne scarring and deep surgical scars. Dermabrasion is currently rarely practiced and there are very few doctors who are trained and still perform this surgery. Dermabrasion has largely been replaced by technologies including lasers,  CO 2  or  Erbium:YAG   laser . Laser technologies carry the advantage of little to no bleeding and are often less operator dependent than dermabrasion.


The purpose of surgical dermabrasion is to help diminish the appearance of deeper scars and skin imperfections. Often, the goal is to smooth the skin and, in the process, remove small scars (as from acne), uneven skin tone from scars or  birthmarks , sun damage,  tattoos , age spots,  Stretch marks   [ citation needed ]  or fine  wrinkles . [ 1 ]


Dermabrasion is a mechanical surgical skin planing method which has remained popular partially because it may afford an overall lower cost and may provide similar or superior results as newer laser methods for certain skin conditions. [ 2 ]


Microdermabrasion is a light cosmetic procedure that uses a mechanical medium for  exfoliation  to remove the outermost layer of dead  skin cells  from the  epidermis . Most commonly, microdermabrasion uses two parts: an exfoliating material such as crystals or diamond flakes, and a machine-based suction to gently lift up the skin during exfoliation. It is a non-invasive procedure and may be performed in-office by a trained  skin care  professional. [ 3 ]  It may also be performed at home using a variety of products which are designed to mechanically exfoliate the skin. Many salon machines and home-use machines use adjustable  suction  to improve the efficacy of the abrasion tool.


Microdermabrasion is considered a relatively simple, easy, painless and non-invasive skin rejuvenation procedure. Typically there are no needles or anesthetics required for microdermabrasion. The vacuum pressure and speed are adjusted depending on the sensitivity and tolerance of the skin. [ citation needed ]  Microdermabrasion is often compared to the feeling of a cat licking the skin - a rough but gentle texture.  Typical microdermabrasion sessions can last anywhere from 5 to 60 minutes. Minimal to no recovery time is required after microdermabrasion and most people immediately return to daily activity after a session. Makeup and non-irritating creams can usually be applied within a few hours or right after microdermabrasion. Since there is an often immediate increased minor skin sensitivity after microdermabrasion, irritating products such as  glycolic acids ,  Alpha Hydroxy Acids ,  Retinoid  products or fragranced creams and lotions are typically avoided right after the procedure. [ citation needed ]


Traditionally, a "crystal" microdermabrasion system includes a pump, a connecting tube, a hand piece, and a vacuum. While the pump creates a high-pressure stream of inert crystals (aluminum oxide, magnesium oxide, sodium chloride, or sodium bicarbonate) to abrade the skin, the vacuum removes the crystals and exfoliated skin cells. Alternatively, the inert crystals can be replaced by a roughened surface of the tip in the diamond microdermabrasion system. [ 4 ]


Unlike the older crystal microdermabrasion system, the diamond microdermabrasion does not produce particles from crystals that may be inhaled into patients' nose or blown into the eyes. Hence, diamond microdermabrasion is regarded as having higher safety for use on areas around the eyes and lips. Generally, the slower the movement of the microdermabrasion handpiece against the skin and the greater the numbers of passes over the skin, the deeper the skin treatment. [ citation needed ]


One of the safest methods of microdermabrasion involves the use of corundum or aluminum oxide crystals suspended in an antioxidant cream.   This version of microdermabrasion is generally the most cost efficient as it involves the use of a small handheld skincare tool instead of expensive equipment used by a salon.  This method of microdermabrasion rose to popularity in the early 2000s and is widely available today.


Often called "microderm" for short, microdermabrasion is a procedure to help exfoliate or temporarily remove a few of the top layers of the skin called the stratum corneum. Much like brushing one's teeth, microdermabrasion helps to gently remove skin "plaque" and skin debris. [ citation needed ]  Since human skin typically regenerates at approximately 30-day intervals, skin improvement with microdermabrasion is temporary and needs to be repeated at average intervals of two - four weeks for continued improvement.  Multiple treatments in combination with sunscreen, sun avoidance and skin care creams yield best results.


Dermabrasion is generally used to refer to a true surgical procedure that aggressively abrades away the top to mid layers of the skin. The term microdermabrasion generally refers to a non-surgical procedure that abrades less deeply than dermabrasion. Although the mechanism of the two procedures is similar, the difference in the depth of the abrasion results in different recovery times. Dermabrasion recovery time may take as much as several weeks to several months whereas microdermabrasion recovery time may be as little as one to two days. [ 5 ]  After microdermabrasion, skin will be much more sensitive to sun exposure. It is best to keep out of the sun and wear sunscreen at all times after the procedure. [ citation needed ]


Microdermabrasion may be performed to help diminish the appearance of superficial  hyperpigmentation  or  photo-damage  (sunburn), as well as diminish fine lines, wrinkles, acne and shallow acne scars. A further benefit of microdermabrasion is enhanced skin penetration by skin creams and serums. Removing dead skin (stratum corneum of the epidermis) will aid in the penetration of skin care products and medications by up to 10-50%. The controlled skin exfoliation afforded by microdermabrasion will allow make-up and self-tanning products to go on much more smoothly. [ 6 ]


Microdermabrasion treatment carries minimal to very few possible side effects or complications. However, some patients may experience temporary mild dryness, sun sensitivity and rarely temporary bruising or scratches in the area of skin treated. [ citation needed ]


The first microdermabrasion unit was developed in  Italy  in 1985, using small inert  aluminium oxide  crystals to abrade the skin. In 1986, other European markets had introduced the technology which was immediately adopted by physicians for mechanical exfoliation. There were 10 microdermabrasion units on the market in Europe by the end of 1992. In 1996,  Mattioli Engineering  partnered with one of the Italian designed machines and started working towards meeting FDA requirements for the USA. By the end of 1996, the  Food and Drug Administration | (FDA) issued the first approval letter for microdermabrasion machines. In January 1997, the first microderm machine was being sold and marketed in the US. The diamond tip was introduced in 1999 and the bristle tip brush was introduced in 2005. [ 7 ]  The first standard vacuum based microdermabrasion system called Vacubrasion was introduced in 2012 in the US and world markets, and provides diamond tip exfoliation and suction. Vacubrasion's patented air regulator delivery system was designed and underwent extensive testing by US dermatologists and physicians. Its straightforward design revolutionized microdermabrasion to permit use of almost any type of suction source (primarily retail brand vacuums with a 1.25 in (31.8 mm) standard round hose such as Eureka, Stanley vacuums) with a non-disposable, attached electroplated fine diamond abrasive tip. While traditional, older crystal based microdermabrasion and home microdermabrasion systems are sometimes fraught with clogging issues and potential loss of suction, the crystal-free Vacubrasion systems utilize a universal, larger and more powerful suction source that avoids many of these issues. [ 8 ]


Microdermabrasion has evolved from  rocks , stones and  shells  to  crystals , particle-free diamond tips and particle-free bristle tips. Once the desired amount of exfoliation has been reached, some microdermabrasion units will then spray or infuse a skin enhancing solution into the skin. Since microderm essentially manually removes limited layers of the stratum corneum (dead layers of the outer layer of the skin), any serum or topical product applied in any fashion to the skin following microdermabrasion will potentially have a greater opportunity for penetration into the skin.


Microdermabrasion crystals are typically made of a very fine, abrasive material like  aluminum oxide . Other inert microderm crystals include magnesium oxide, sodium chloride, and sodium bicarbonate. All ultra-fine white crystals are disposable and should be discarded after each use. The microdermabrasion vacuum removes the crystals and exfoliated skin cells. Inhalation of crystals should be avoided and masks are sometimes worn by the operator doing the treatment. Ocular injury may occur if crystals are inadvertently sprayed in the eye or if crystals remain around the eye and cause a corneal abrasion. There are some possible concerns of inhalation exposure and basic safety precautions should be taken. Patient goggles or eye shields, as well as operator face masks are recommended when treating with crystal based systems. Alternatively, microderm crystals can be safely replaced by the roughened surface of a diamond tip microdermabrasion system. The newer diamond based systems like Vacubrasion utilize a fine  diamond dust  that is essentially electroplated onto a stainless steel round tip that comes in contact with the skin.


A  dermatome  is a  surgical instrument  for producing thin slices of  skin  from a donor area, for use in  skin grafts . One of its main applications is for reconstituting skin areas damaged by third degree  burns  or  trauma .


Dermatomes can be operated either manually or electrically. The first drum dermatomes, developed in the 1930s, were manually operated. Afterwards, dermatomes which were operated by air pressure, such as the Brown dermatome, achieved higher speed and precision. Electrical dermatomes are better for cutting out thinner and longer strips of skin with a more homogeneous thickness.


Those are manual dermatomes and the term  knife  or  scalpel  is used to describe them. Their disadvantages are harvesting of grafts with irregular edges and grafts of variable thickness. Their operator has to be experienced in their use for optimal results. [ 1 ]


There are several types of dermatomes, usually named after their inventor.


An  escharotomy  is a surgical procedure used to treat full-thickness (third-degree) circumferential  burns . In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed  eschar . Following a full-thickness burn, as the underlying tissues are rehydrated, they become constricted due to the eschar's loss of elasticity, leading to impaired circulation distal to the wound. An escharotomy can be performed as a prophylactic measure as well as to release pressure, facilitate circulation and combat burn-induced  compartment syndrome .


An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below.  Due to the residual pressure, the incision will often widen substantially.


Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death. If ischemia (poor blood flow) persists for over six hours, then the irreversible process of muscle necrosis will begin. [ 1 ]


The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. Due to the primarily diaphragmatic breathing done by children, anterior burns may be enough to warrant an escharotomy. [ 2 ]  Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.


Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise.


Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following:


Neurovascular integrity should similarly be monitored frequently and in a scheduled manner. Capillary refilling time,  Doppler signals , pulse oximetry, and sensation distal to the burned area should be checked every hour. [ 4 ]  Limb deep compartment pressures should be checked initially to establish a baseline. Subsequently, any increase in capillary refill time, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures. Compartment pressures greater than 30 mm Hg should be treated by immediate decompression via escharotomy and  fasciotomy , if needed. [ 3 ]


During an escharotomy the patient is often sedated despite the insensible eschar. The burnt skin is incised down to the subcutaneous fat and into the healthy skin (up to 1 cm). The incisions should be deep enough to release all restrictive effects from the eschar. The operation can be performed on the trunk, limbs, or neck, all while avoiding critical nerves, veins, and vessels. [ 2 ]  Following the operation the wounds are dressed primarily with an absorbent, antimicrobial material, then wrapped lightly in a bandage. Elevation (if possible) and observation are encouraged. [ 4 ]


Ethnic plastic surgery , or  ethnic modification , refers to the types of  plastic surgery  performed frequently due to certain racial or ethnic traits, or with the intention of making one's appearance more similar or less similar to people of a particular  race  or  ethnicity . [ 1 ]  Popular procedures which may have an ethnically motivated component are  rhinoplasties  (nose jobs) and  blepharoplasties  (double eyelid surgeries). [ 2 ]


Michael Jackson 's  plastic surgery  has been discussed in the context of ethnic plastic surgery. [ 3 ]  In her book,  Venus Envy: A History of Cosmetic Surgery , Elizabeth Haiken devotes a chapter to "The Michael Jackson Factor" presenting " Black ,  Asian , and  Jewish  women who seek  WASP  noses and  Playboy  breasts. They are caught in the vexed immigrants' dilemma of struggling not only to  keep up with the Joneses  but to look like them, too." [ 4 ]


Plastic surgeons Chuma J. Chike-Obi, M.D., Kofi Boahene, M.D., and Anthony E. Brissett, M.D., F.A.C.S. distinguish between motivations of aesthetics and racial transformation for patients of African descent seeking plastic surgery. In their opinion, "Patients whose desired surgical outcomes result in racial transformation should be educated about the potential risks of this objective, and these requests should generally be discouraged." [ 5 ]


Feminist scholars have split views on the subject.  Christine Overall , professor of philosophy at  Queen's University at Kingston , has written that personal racial transformation, or as she puts it "transracialism", belongs to a larger class of personal surgical interventions. This larger class includes  transsexual  identity change,  body art ,  cosmetic surgery ,  Munchhausen syndrome , and  labiaplasty . Her basic thesis is that the arguments against the ethical nature of racial transformation (e.g. "it's not possible", "betrayal of group identity", "reinforces oppression", etc.) stand or fall with the ethical arguments related to transsexual change. [ 6 ]   Cressida Heyes , professor of Philosophy of Gender and Sexuality at the  University of Alberta , disagrees with Overall's schema. Heyes feels that racial transformation is fundamentally different from gender transformation since race is also determined by ancestry, personal cultural history and societal definitions. Hence ethical considerations of transracial surgery are different from ethical considerations in transsexual surgery. [ 7 ]


In the  South Park  episode " Mr. Garrison's Fancy New Vagina " Kyle undergoes an ethnic plastic surgery called "negroplasty" to qualify for the basketball team.


In the 2008 movie  Tropic Thunder , Kirk Lazarus goes through a controversial surgery to make his skin darker to play an African-American soldier.


Eyebrow restoration  is a  surgical procedure  to reposition the  eyebrow .  With advancing age, a common occurrence is descent of the eyebrow, or  brow ptosis . A similar condition is  eyelid ptosis . Eyebrow repositioning is a commonly performed procedure in  cosmetic surgery .  The brow is repositioned, optimally, for the wishes of the patient as well as to correct the descent.


The procedure may be performed either  open  (through a standard or modified coronal incision) which allows for partial or complete  ablation  of  corrugator supercilii musclesto  avoid any need for them in the future but still allow for facial expression, or closed when an  endoscopic  approach is employed albeit with shorter long-term results.  In the very young, eyebrow position may be modified with injection of paralytics but only to a limited extent.  Lateral injection into a portion of the  orbicularis  muscle can elevate the lateral brow to some extent.  Generally, injection of paralytics into the forehead will cause a descent of the brow and thus brow position can be tailored by selective injection of paralytic agents, again, to a limited extent.  Significant change in position or posture of the brow generally requires a surgical procedure to accomplish the desired goals.


Another purpose of this procedure is to customize the appearance of the eyebrows.


It was originally intended for  burn victims  and patients of illnesses that prevent hair from growing in the eyebrow region. Eyebrow restoration surgeries - or transplants - have since evolved into a cosmetic procedure favored by people wishing to have perfect eyebrows.


Some traditional  hair restoration  surgeons offer eyebrow restorations as well. Both procedures should be only performed by certified surgeons who specialize in hair and eyebrow transplantation.


The most popular hair and eyebrow restoration surgery technique is  follicular unit transplantation , which involves the removal of donor follicles from the back of the patient's head where hair tends to be more permanent. The most advanced form of follicular unit surgery is with the robotic system. Once removed, the "donor area" is then stitched back up with no visible scarring. The donor follicles are then transplanted into the "problem areas" of the patient's scalp.


Eyebrow transplants are designed to restore growing hair to eyebrows that are overly thin, scarred, or completely missing. The absence of hair can be due to genetics, prior  electrolysis  or  laser hair removal , over-plucking,  thyroid  or other hormonal abnormalities, or trauma due to surgery, burns or other types of accidents.


The donor hairs come from the scalp which, when transplanted into the eyebrows, continue to grow for a lifetime and therefore need to be trimmed typically once a month. To provide a natural appearance, the hairs are transplanted primarily one and occasionally two at a time, the natural way eyebrow hairs grow. This is a very delicate procedure, requiring perfect placement of these hairs into tiny half-millimeter incisions that are angled at just the right direction and positioned to mimic natural growth. The use of all-microscopically dissected  grafts  allows their placement into the smallest possible incisions so as to minimize scarring and damage to already existing hairs.


A procedure typically involves the placement of 50 to as many as 325 hairs into each eyebrow, depending upon the existing amount of hair and the desired size and density. Performed usually under a mild oral  sedative , the two-hour procedure is essentially painless, as is the recovery period.


For the first two to four days after the procedure, tiny crusts form around each transplanted hair. By three to five days, other than some occasional mild pinkness which fades out by the first week, patients are able to return to normal activities without any sign of having had a procedure.  Sutures  that are placed in the donor area are removed at one week. The transplanted hairs fall out at around two weeks, then start to regrow at three months, and continue to grow for a lifetime. [ 1 ] [ unreliable medical source? ]


Facial Autologous Muscular Injection  is also known as  Fat Autograft Muscular Injection , as  Autologous Fat Injection , as  Micro-lipoinjection , as  Fat Transfer   and as  Facial Autologous Mesenchymal Integration , abbreviated as  FAMI . The technique is a non-incisional pan-facial rejuvenation procedure using the patient's own stem cells from fat deposits. [ 1 ]  FAMI is an Adult stem cell procedure used to address the loss of volume in the face due to aging or surgery repair in restoring facial muscles, bone surfaces and very deep fat pads. [ 2 ]
The procedure involves removing adult stem cells of fatty tissue from lower body, and refining it to be able to re-inject living adipose stem cells into specific areas of the face without incision. FAMI is an outpatient procedure and an alternative to artificial fillers, blepharoplasty or various face lifts. [ 3 ] [ 4 ]  The procedure does not require general anesthesia and risks of an allergic reaction are minimal due to the use of the patient's own tissue used as the facial injection. [ 5 ]


Fat transplantation procedures have been in use for decades to restore volume to the face, and as a result, various techniques have been developed over the years. [ 6 ]  Facial autologous muscular injection (FAMI) was developed from 1996 by Roger E. Amar M.D., a French plastic surgeon. [ 6 ] [ 7 ]  Roger  Amar is the founder and director of the AMARCLINIC which hosts the FAMI international Academy in  Marbella ,  Spain . [ 8 ]  FAMI was introduced to the  United States  in 2001, [ 6 ]  and in 2010 in London UK. The FAMI procedure differs from other fat transplantation procedures in that it takes the patient's facial vascular paths into account while using their own fatty tissue to address the loss of volume in the face without having to make incisions. [ citation needed ]


Facial autologous muscular injections are performed to  rejuvenate  the face of the patient and reduce the appearance of the natural effects of aging. The procedure can also be used to improve unsatisfactory results from other procedures such as a face-lift surgery. Indications include depressions or hollows across the face from aging, trauma or previous surgery as well as sagging jowls due to loss of volume in the upper face.


FAMI can be used in combination with surgery below the jawline to address the look of sagging necks and skeletonized faces, or faces that exhibit extreme skinny structures characterized by  infraorbital  hollowness usually due to weight loss. [ 3 ]


Facial autologous muscular injections are procedures that target deep multiplane  autologous  fat. FAMI consists of an autograft of adult stem cells in order to rebuild muscles and bones. [ 9 ]  The adult stem cells are taken from an area of fatty tissue in a separate area of the body, typically from the patient's hip, knee or abdomen. The collected fat and stem cells are concentrated and refined. [ 10 ]  The stem cells are then re-injected into the muscles of the face. Specifically, the injections are made in close proximity or within the muscles responsible for facial expression. [ 2 ] [ 6 ] [ 11 ]


By reconstructing the structures of the face with one's own adult stemcells, FAMI rejuvenates the patient's face with restored volume to the facial muscles and bones. [ 9 ]   FAMI procedures are not surgical, they are  outpatient procedures  that do not require the use of a scalpel or incisions, rather specially designed disposable  cannulas  that follow skull curvatures are used to transfer and place the fatty tissue around the face. [ 4 ]


The results of the procedure are long-lasting, or relatively permanent due to the use of natural tissue rather than fillers and also because the injections are made to facial expression muscles and improve graft retention. Because it is a non-incisional procedure, facial autologous muscular injections are scar-less and results appear natural. [ 12 ] [ 13 ]


FAMI procedures are non-surgical and done as outpatient procedure outside of a hospital. The procedure is  minimally invasive and does not require the use of general  anesthesia , however, local anesthesia is used to block the patient from feeling pain or discomfort. Complications from facial autologous muscular injections are very rare. From the 2011 Advanced Techniques in Liposuction and Fat Transfer report, it was noted that in 726 cases over 14 years there were no reports of complications such as cytosteatonecrosis,  pseudocyst  formation, infections or other issues. [ citation needed ]


Facial implants  are used to enhance certain features of the face. The  surgery  may be  elective , or needed as the result of prior surgery on the face. Each involves placing  synthetic  materials deep under the  subcutaneous tissue  and onto the underlying  bone . A  maxillofacial  or  plastic surgeon  uses them to aesthetically improve facial contours,  proportion  and correct imbalances caused by  injury  or  hereditary traits . However, in cases that require  orthognathic osteotomies , those should be done before any implants are considered.


In most cases, facial implant surgery is completed on an  outpatient  basis in a hospital, a surgeon's office or a surgical center. A  local anesthesia  or  oral sedative  may be used, or the patient may be put to sleep during the procedure using  general anesthesia .


The most commonly used implants are:


Less commonly used implants are:


Fat removal procedures  are used mostly in  cosmetic surgery  with the intention of removing unwanted  adipose tissue . The procedure may be invasive, as with  liposuction , [ 1 ]  or noninvasive using  laser therapy ,  radiofrequency ,  ultrasound  or cold ( cryoablation  or cryolipolysis) to reduce fat, sometimes in combination with injections. [ 2 ] [ 3 ]


Fat is sometimes removed from one location to another on a person in an  autograft , such as in some  breast reconstruction  and  breast augmentation  procedures. [ 4 ]  These techniques are distinct from  bariatric surgery , which aims to treat  obesity  by minimizing food consumption or by interfering with the absorption of food during  digestion , and from  injection lipolysis , which relies solely on injections marketed as causing  lipolysis . [ 2 ]


Liposuction  is a type of  cosmetic surgery  that removes  fat  from the human body in an attempt to change its shape. [ 5 ]  Evidence does not support an effect on weight beyond a couple of months and it does not appear to affect  obesity  related problems. [ 6 ] [ 7 ]  In the United States it is the most commonly done cosmetic surgery. [ 8 ] [ 9 ]


Serious complications include  deep vein thrombosis ,  organ perforation , bleeding, and  infection . [ 10 ]  Death occurs in about one per ten thousand cases. [ 11 ]


The procedure may be performed under general, regional, or local  anesthesia  and involves using a cannula and negative pressure (suction) to suck out fat. [ 8 ]  It is believed to work best on individuals of normal or near normal weight and good skin elasticity. [ 8 ]


Post operational downtime can last anywhere from 2 – 4 weeks to 3 full months for patients to fully heal and be able to resume normal activities. [ 12 ]


Focused thermal ultrasound techniques work by raising the tissue temperature up to 48 °C, [ 13 ]  resulting in coagulative necrosis of adipocytes, with sparing of vessels and nerves. Passive heating of the skin may also induce collagen remodeling. [ 14 ] [ 15 ] [ 16 ]


Hydrolipoclasy  is a technique that is being studied as an alternative to  liposuction . [ 17 ]  It involves injecting a  hypotonic solution  into an area of fat and then subjecting it to  ultrasound  waves. [ 17 ]


Low level laser light reduces the stability of  adipocyte  cell membranes, allowing cells to release their stores of fat without damaging the cell. [ 18 ]


Cryolipolysis is the removal of fat by freezing. [ 19 ] [ 20 ] [ 21 ]  It involves controlled application of  cooling  within the temperature range of −11 to +5 °C (+12.2 to +41 °F) for the localized reduction of  fat  deposits, intended to reshape the contours of the body. [ 19 ] [ 20 ]  The degree of exposure to cooling causes  cell death  of  subcutaneous fat  tissue, without apparent damage to the overlying  skin . [ 20 ] [ 22 ]  It appears primarily applicable to limited discrete fat bulges. [ 19 ] [ 20 ] [ 23 ]


Adverse effects  include transient local redness, bruising and  numbness  of the skin, and these are expected to subside. [ 20 ] [ 23 ]  Typically, sensory deficits (numbness) will subside within a month. The effect on peripheral nerves was investigated and failed to show permanent detrimental results. [ 22 ]


Another adverse effect is paradoxical adipose hypertrophy (PAH) which causes fat tissue to grow larger rather than become reduced in size as a consequence of the procedure. [ 24 ] [ 25 ]  Supermodel  Linda Evangelista  has initiated legal action for damage caused by PAH. [ 26 ] [ 27 ]  Some studies indicate that PAH side effects are common on a per-patient basis, since a typical patient receives multiple treatments. [ 28 ]


Based on the premise that fat cells are more easily damaged by cooling than skin cells (such as  popsicle panniculitis ), cryolipolysis was developed to apply low temperatures to tissue via thermal conduction. [ 29 ]  In order to avoid  frostbite , a specific temperature level and exposure are determined, such as 45 minutes at −10 °C (14 °F). [ 20 ] [ 30 ]  While the process is not fully understood, it appears that fatty tissue that is cooled below body temperature, but above freezing, undergoes localized cell death (" apoptosis ") followed by a local inflammatory response that gradually over the course of several months results in a reduction of the fatty tissue layer. [ 20 ] [ 22 ] [ 30 ]


Typical cost per treatment area varies depending on location. Price in the US ranges from $750 to $1,500, [ 31 ]  with UK prices about £750 per area to be treated and in India, the Coolsculpting cost typically ranges from ₹60,000 to ₹115,000. [ 32 ]  In the U.S., the CoolSculpting procedure is FDA-cleared for the treatment of visible fat bulges in the  submental area , thigh, abdomen and flank, along with bra fat, back fat, underneath the  buttocks , and upper arm. [ 21 ]


Injection lipolysis is a procedure that reduces localized subcutaneous fat deposits, most commonly submental fat ( double chin ). This technique involves the injection of lipolytic substances, such as  deoxycholic acid  (branded as Kybella in the United States), directly into the targeted fat tissue. Deoxycholic acid is a naturally occurring  bile acid  that aids in the breakdown and absorption of dietary fat. When injected into subcutaneous fat, it causes the dissolution of the fat cell membranes, causing them to die. The destroyed fat cells are then gradually eliminated by the body's natural metabolic processes over the following weeks. [ 33 ] [ 34 ]  While the procedure is generally considered safe when performed by a qualified healthcare professional, potential side effects may include swelling, bruising, numbness, and rarely, nerve injury in the treated area. [ 33 ] [ 34 ] [ 35 ]


In 2010, Zerona, another low-level laser treatment, was cleared for marketing by the FDA as an infrared lamp. [ 36 ]  Zeltiq obtained FDA marketing clearance for  cryolipolysis  of the flanks, and in 2012 received marketing clearance for cryolipolysis of the abdomen. [ 20 ]  This treatment has also been cleared for the treatment of the upper arm, back fat, bra fat, banana roll, submental area, and thighs. [ 37 ]


Various lipolysis techniques including injection lipolysis, RF, laser, ultrasound, and cryolipolysis were forbidden in France by a decree of the French Public Health Authority in 2011. The decree was revised in 2012, distinguishing invasive techniques, which remain forbidden, from permitted non-invasive techniques; laser, RF, ultrasound and cryolipolysis that did not penetrate the skin became legal, and injection lipolysis and  mesotherapy  remained illegal.  Laser devices that involve inserting the probe through the skin transcutaneously but do not suck out the liquefied material are also prohibited. Surgeons are permitted to perform surgical liposuction techniques using laser-assisted lipolysis so long as suction is performed. [ 38 ] [ 39 ]


Flap surgery  is a technique in  plastic  and  reconstructive surgery  where  tissue  with an intact  blood supply  is lifted from a donor site and moved to a recipient site. Flaps are distinct from  grafts , which do not have an intact blood supply and relies on the growth of new blood vessels. Flaps are done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, wound contraction is to be avoided or to rebuild more complex anatomic structures like breasts or jaws. [ 1 ] [ 2 ]  Flaps may also carry with them tissues such as muscle and bone that may be useful in the ultimate reconstruction.


Flap surgery is a technique essential to  plastic  and  reconstructive surgery . A flap is defined as tissue that can be moved to another site and has its own  blood supply . This is in comparison to a  skin graft  which does not have its own blood supply and relies on  vascularization  from the recipient site. [ 2 ]  Flaps have many uses in  wound healing  and are used when wounds are large, complex, or need tissue of various types and bulk for successful closure and function. [ 2 ]


Flaps can contain many different combination of layers of tissue, from skin to bone (see  § Classification ). The main goal of a flap is to maintain blood flow to tissue to maintain survival, and understanding the anatomy in flap design is key to a successful flap surgery. [ 2 ]


Flaps may include skin in their construction. Skin is important for many reasons, but namely its role in  thermoregulation ,  immune function , and blood supply aid in flap survival. [ 2 ]  The skin can be divided into three main layers: the  epidermis ,  dermis , and  subcutaneous tissue . Blood is mainly supplied to the skin by two networks of blood vessels. The deep network lies between the dermis and the subcutaneous tissue, while the shallow network lies within the papillary layer of the dermis. [ 3 ]  The epidermis is supplied by diffusion from this shallow network and both networks are supplied by  collaterals , and by perforating arteries that bring blood from deeper layers either between muscles (septocutaneous perforators) or through muscles (musculocutaneous perforators). [ 2 ]


This robust and redundant blood supply is important in flap surgery, [ 2 ]  because flaps are cut off from other blood vessels when it is raised and removed from its surrounding native tissue. [ 2 ]  The remaining blood supply must then keep the tissue alive until additional blood supply can be formed through  angiogenesis . [ 4 ]


The  angiosome  is a concept first coined by Ian Taylor in 1987. [ 5 ]  It is a three-dimensional region of tissue that is supplied by a single artery and can include skin, soft tissue, and bone. [ 5 ] [ 6 ]  Adjacent angiosomes are connected by narrower choke vessels, and multiple angiosomes can be supplied by a single artery. Knowledge of these supply arteries and their associated angiosomes is useful in planning the location, size, and shape of a flap. [ 4 ]


Flaps can be fundamentally classified by their mechanism of movement, the types of tissues present, or by their blood supply. [ 2 ]  The surgeon generally chooses the least complex type that will achieve the desired effect via a concept known as the  reconstructive ladder . [ 7 ] [ 8 ]


Flaps can be classified by the content of the tissue within them.


Classification based on blood supply to the flap:


Anyone who is unstable for surgery should not undergo flap surgery. As with most surgeries, people who are sicker may have more difficulties with  wound healing , which include individuals with  comorbidities  such as  diabetes ,  smoking ,  immunosuppression , and  vascular disease . [ 15 ] [ 16 ]


The risks of flap surgery include infection,  wound breakdown ,  fluid accumulation ,  bleeding , damage to nearby structures, and  scarring . [ 10 ]  The most notable risk in this procedure is flap death, where the flap loses blood supply. The loss of blood can be due to many reasons, but is commonly due to tension on the vascular supply and insufficient blood flow to the end segments of the flap. [ 10 ]  This can sometimes be fixed with another surgery or using additional methods of healing in the reconstructive ladder. [ 17 ]


As with healing of any wound, healing of a flap maintains the same process of wound healing. There are four stages to wound healing:  hemostasis ,  inflammation ,  proliferation , and  remodeling , all of which can take up to a year to complete. [ 18 ] [ 2 ]


Following flap surgery, the biggest risk in recovery is flap death. Flap failure is an uncommon occurrence but does happen. The reported flap failure rate in free flaps is less than 5%. [ 19 ]  The most commonly cause is by  venous insufficiency  consisting of 54% of all causes. [ 19 ]  Venous insufficiency is commonly caused by a  venous thrombus  within the first 2 days following surgery. [ 19 ] [ 18 ]  After the immediate postoperative risk, the flap will continue to heal adhering to the stages of normal wound healing and will take over 3 months for an incision to be at 80% tensile strength compared to normal tissue. [ 18 ]


Skin flaps are an essential part of a surgeon's toolbox in plastic surgery. It is part of the reconstructive ladder. [ 17 ]  The first known reports of surgical flaps originated in 600 BC in India by  Sushruta  where the tilemakers' caste would reconstruct noses using regional flaps due to the practice of nose amputations as a form of legal punishment. [ 20 ] [ 17 ]  The next description of flap surgery comes from Celsus, an ancient Roman who described the advancement of skin flaps from 25 BC to 50 AD. [ 20 ] [ 17 ]  In the 15th century,  Gaspare Tagliacozzi , an Italian surgeon, helped develop the "Italian method" for nasal reconstruction, a delayed pedicle skin graft, where the skin from the arm would be attached to the nose for many months to create the reconstruction, first printed in the 1597 book  De Curtorum Chirurgia per Insitionem . [ 21 ]  The Italian method was rediscovered in 1800 by German surgeon  Carl Ferdinand von Graefe . [ 22 ]  Major advancements in modern plastic surgery are mostly attributed to  Harold Gillies , who pioneered facial reconstruction during World War I using pedicled tube flaps on patients like  Walter Yeo , and the development of the  walking-stalk skin flap  by Gilles' cousin  Archibald McIndoe  in 1930. [ 20 ] [ 23 ]


Advancements continued in flap surgery. With the introduction of the  operating microscope , microvascular surgery advancements allowed for the anastomosis of blood vessels. [ 12 ]  This led to the ability of free tissue transfers, and in 1958 Bernard Seidenberg transferred a part of the  jejunum  to the  esophagus  to remove a  cancer . [ 12 ] [ 24 ]  Modern advancements in flap surgeries have continued since this time and are now commonly used in many procedures. [ 12 ]


Foreskin restoration  or  foreskin reconstruction  refers to the process of recreating the  foreskin  of the  penis , which has been removed by  circumcision  or injury.  Foreskin restoration is primarily accomplished by stretching the residual skin of the penis, but  surgical  methods also exist. Restoration creates a facsimile of the foreskin, but specialized tissues removed during circumcision cannot be reclaimed.  Some forms of restoration involve only partial regeneration in instances of a  high-cut  wherein the circumcisee feels that the circumciser removed too much skin and that there is not enough skin for erections to be comfortable. [ 1 ]


In the  Greco-Roman world , uncircumcised  genitals , including the  foreskin , were considered a sign of beauty,  civility , and masculinity. [ 2 ]   In  Classical Greek and Roman societies  (8th century BC to 6th century AD), exposure of the glans was considered disgusting and improper, and did not conform to the  Hellenistic  ideal of gymnastic nudity. [ 2 ]  Men with short foreskins would wear the  kynodesme  to prevent exposure. [ 3 ]  As a consequence of this  social stigma , an early form of foreskin restoration known as  epispasm  was practiced among some  Jews  in  Ancient Rome  (8th century BC to 5th century AD). [ 4 ]


Foreskin restoration is of ancient origin and dates back to the  Alexandrian Empire  (333 BC). Males participated in the gymnasium nude and because the  Greeks  did not practice circumcision anyone who was circumcised was socially shunned. Hellenized Jews stopped circumcising their sons to avoid persecution and so they could participate in the gymnasium. Some Jews at this time attempted to restore their foreskins. This caused conflict within Second Temple Judaism, some Jews viewed circumcision as an essential part of the Jewish identity (1 Maccabees 1:15). [ 5 ]  Following the death of Alexander, Judea and the Levant was part of the  Seleucid Empire  under  Antiochus Epiphanes  (175-164 BC). Antiochus outlawed the Jewish practice of circumcision, both 1st and 2nd Maccabees records Jewish mothers being put to death for circumcising their sons (1:60-61 and 6:10 respectively). [ 6 ]  Some Jews during Antiochus' persecution sought to undo their circumcision. [ 7 ]  Within the 1st century A.D., there was still some forms of foreskin restoration being sought after (1 Corinthians 7:18). During the third  Jewish-Roman Wars  (AD 132–135), the Romans had renamed Jerusalem as Aelia Capitolian and may have banned circumcision; however, Roman sources from the period only mention  castration  and say nothing about banning circumcision. During the  Bar Kokhba  revolt, there is Rabbinic evidence that records, Jews who had removed their circumcision (meaning that foreskin restoration was still being practiced) they were recircumcised, voluntarily or by force. [ 8 ]  Again, during  World War II , some  European Jews  sought foreskin restoration to avoid  Nazi persecution . [ 9 ]


Non-surgical foreskin restoration, accomplished through  tissue expansion , is the more commonly used method. [ 10 ]


Tissue expansion has long been known to stimulate  mitosis , and research shows that regenerated human tissues have the attributes of the original tissue. [ 11 ]


During restoration via tissue expansion, the remaining penile skin is pulled forward over the glans, and  tension  is maintained either manually or through the aid of a  foreskin restoration device . [ 12 ]


Surgical methods of foreskin restoration, known as foreskin reconstruction, usually involve a method of  grafting  skin onto the  distal  portion of the penile shaft. The grafted skin is typically taken from the  scrotum , which contains the same  smooth muscle  (known as  dartos fascia ) as does the skin of the penis. One method involves a four-stage procedure in which the penile shaft is buried in the scrotum for a period of time. [ 13 ]


Restoration creates a facsimile of the  prepuce , but specialized tissues removed during circumcision cannot be reclaimed. [ medical citation needed ]  Surgical procedures exist to reduce the size of the opening once restoration is complete (as depicted in the image above), [ 14 ]  or it can be alleviated through a longer commitment to the skin expansion regime to allow more skin to collect at the tip. [ 15 ]


The natural foreskin is composed of smooth dartos muscle tissue (called the  peripenic muscle [ 16 ] ), large blood vessels, extensive innervation, outer skin, and inner mucosa. [ 17 ]


The process of foreskin restoration seeks to regenerate some of the tissue removed by circumcision, as well as provide coverage of the glans.  According to research, the foreskin comprises over half of the skin and mucosa of the human penis. [ 18 ]


In a survey restorers reported restoration; increased their sexual pleasure for 69% and improved their relationship for 25%  [ 19 ]


Various groups have been founded since the late 20th century, especially in  North America  where circumcision has been routinely performed on infants. In 1989, the  National Organization of Restoring Men  (NORM) was founded as a non-profit support group for men undertaking foreskin restoration. In 1991, the group UNCircumcising Information and Resource Centers (UNCIRC) was formed, [ 20 ]  which was incorporated into NORM in 1994. [ 21 ]  NORM chapters have been founded throughout the United States, as well as in Canada, the United Kingdom, Australia, New Zealand, and Germany. In France, there are two associations about this. The " Association contre la Mutilation des Enfants " AME (association against child mutilation), and more recently " Droit au Corps " (right to the body). [ 22 ]


Circumcised  barbarians , along with any others who revealed the  glans penis , were the butt of ribald  humor . For  Greek art  portrays the foreskin, often drawn in meticulous detail, as an emblem of male beauty; and children with congenitally short foreskins were sometimes subjected to a treatment, known as  epispasm , that was aimed at elongation.


The terms  free flap ,  free autologous tissue transfer  and  microvascular free tissue transfer  are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect.  "Free" implies that the tissue is completely detached from its blood supply at the original location ("donor site") and then transferred to another location ("recipient site") and the circulation in the tissue re-established by  anastomosis of artery(s) and vein(s) .  This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the  tissue  with blood.


Various types of tissue may be transferred as a "free flap" including skin and fat, muscle, nerve, bone, cartilage (or any combination of these),  lymph nodes  and intestinal segments.  An example of "free flap" could be a "free toe transfer" in which the great toe or the second toe is transferred to the hand to reconstruct a thumb. [ 1 ]


For all "free flaps", the blood supply is reconstituted using  microsurgical techniques  to reconnect the artery (brings blood into the flap) and vein (allows blood to flow out of the flap).


Free  autologous  tissue transfer is performed by many surgical specialties.


Free flaps are used to reconstruct tissue defects. Particularly when postoperative radiotherapy is indicated, vascularized free tissue is preferred over non-vascularized free tissue.


Breast reconstruction:


Hand reconstruction:


Head and Neck reconstruction:


When reconstructing complex head and neck defects, the reconstruction often requires bone and soft tissue from a distant donor site to be harvested. Functional reconstruction in the head and neck area often requires reconstruction of the oral cavity, the jawbone and the dental occlusion. Type of defects include:


The most common serious complication of a free flap is loss of the venous outflow (e.g. a clot forms in the vein that drains the blood from the flap). Loss of arterial supply is serious too and both will cause  necrosis  (death) of the flap. Close monitoring of the flap both by nurses and by the surgeon is mandatory following the completion of the operation. [ 2 ] [ 3 ]  If detected early, loss of either the venous or arterial blood supply may be corrected by operative intervention. Many times an implantable Doppler probe or other devices can be installed during surgery to provide better monitoring in the post-operative period. The Doppler probe can be removed before discharge from the hospital.


Usually the harvest of a "free flap" is performed in such a fashion to cause the least amount of disability. Despite this some disability may occur following removal of this tissue from the "donor site".


Other complications/sequalae which may occur with any surgery are also possible, including infection and pain.


Genitoplasty  is  plastic surgery  to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from  cancer treatment , or congenital disorders, endocrine conditions, or they may be cosmetic. [ 1 ]


Genitoplasty surgery includes the following:


The grafts used in genitalplasty can be an  allogenic , an  autograft , a  xenograft , or an  autologous  material. [ 13 ]


Genital reconstruction surgery can correct  prolapse  of the  urinary bladder  into the vagina and protrusion of the rectum into the vagina. [ 2 ]  Female infants born with a  46,XX  genotype but have genitalia affected by  congenital adrenal hyperplasia  may undergo the surgical creation of a vagina. [ citation needed ]  Vaginoplasty is commonly used to treat women with the congenital absence of the vagina. [ 3 ]  Other reasons for the surgery are to treat adrenal hyperplasia, microphallus, Mayer-Rokitansky-Kustner disorder and for women who have had a vaginectomy after malignancy or trauma. Reconstructive and corrective vaginal surgery restores or creates the vagina. [ 11 ]


Surgeries to modify the cosmetic appearance of infants' and children's genitals  are controversial due to their  human rights implications . There is no clinical consensus about necessity, timing, indications or evaluation. [ 14 ]


A  ghost surgery  is a surgery in which the person who performs the operation, the "ghost surgeon" or "ghost doctor", is not the surgeon that was hired for and is credited with the operation. The ghost doctor substitutes the hired surgeon while the patient is unconscious from  anesthesia . [ 1 ] [ 2 ]  Ghost doctors are often unlicensed and unqualified to perform the operations they are hired for. [ 1 ] [ 3 ]  Ghost surgery is widely considered to be unethical. [ 4 ]


Today, ghost surgery is particularly common in the  South Korean cosmetic surgery industry , in which it is "rampant." [ 3 ]


The term "ghost surgery" was originally used to refer to qualified surgeons performing operations in the place of the unqualified physicians credited with the operation. [ 5 ] [ 6 ]  By the late 1970s, following multiple highly publicized cases of medical equipment  salesmen  participating in surgery, it came to refer to multiple kinds of scenarios in which one individual substitutes the officially credited surgeon in an operation. [ 5 ] [ 7 ]


The Lifflander Report, a 1978 investigation commissioned by Speaker of the State Assembly of New York  Stanley Steingut , found that 50-95% of surgeries in teaching hospitals were performed by  residents  under supervision, rather than by the lead surgeon. The report concluded that this generally does not decrease the quality of care, and is necessary for medical students to gain experience. However, patients typically do not understand and are not properly notified of the extent to which persons besides the lead surgeon will participate in the surgery. [ 4 ] [ 7 ]


Ghost surgery has continued as a practice into the present day; most reports of ghost surgery in the United States involve associates or residents performing operations to a greater extent than the patient consented to. [ 8 ] [ 9 ]


In  South Korea , ghost surgery boomed in the 2010s with the increase in demand for  plastic surgery , following the government's promotion of  medical tourism . Ghost surgeries allow surgeons to double-book operations and otherwise maximize the number of patients they accept. [ 2 ]  Reports of ghost surgery in South Korea often involve dentists, nurses, or salespeople. One former ghost doctor reported that most substitutes were dentists. [ 1 ] [ 2 ] [ 3 ]


As ghost surgeries are untracked, it is unclear how common they are. Patients typically discover a ghost surgery took place after undergoing an unsuccessful operation. [ 8 ] [ 9 ]


Hospital records from  Parkland Hospital  in 2007-2008 showed that there were 161 surgeries in which residents operated for some time without supervision. Of these surgeries, 18% of the time the surgeon was not present for any part of the operation. Overall, across these surgeries, the surgeon was absent from 83% of the total operating time. [ 10 ]


Ghost surgeries are "rampant" in the South Korean cosmetic surgery industry today, and are increasingly common nationwide in other areas such as spinal surgeries. [ 1 ] [ 2 ] [ 3 ]  The Korean Society of Plastic Surgeons estimated that there were about 100,000 victims of ghost surgery in South Korea between 2008 and 2014. About five patients died during ghost surgeries in South Korea between 2014 and 2022. [ 2 ]


In 1975, William MacKay, the general sales manager of a prosthetics company, participated in the bone surgery of Franklin Mirando at the request of the lead surgeons, David Lipton and Harold Massoff. [ 7 ] [ 11 ]  MacKay had never gone to high school and had no medical training, but was interested in surgery; by the time of Mirando's operation, he had been frequently involved in surgical procedures, especially in those where prosthetics his company sold were involved. [ 7 ] [ 12 ]


MacKay was present for Mirando's operation while his hip was replaced, using equipment from his company. [ 12 ]  Feeling that his advice was being ignored by Lipton and Massoff, he left to go golfing, but was called back to the operating room by Lipton and Massoff when it was discovered the implant had come loose. [ 12 ] [ 13 ]  MacKay spent three and a half hours operating. [ 7 ]  It was later found that medical records had been manipulated to remove evidence of MacKay's participation in the operation. [ 12 ]


Mirando, who had been permanently crippled by the 10-hour operation, filed a $2 million malpractice suit against Lipton, Massoff, and Smithtown General Hospital; the case was settled out of court for $1 million in 1980. [ 11 ] [ 13 ]  He stated that he was unaware of MacKay's involvement when suing and that he filed the suit because the surgery had only worsened his condition. [ 13 ]


Lipton and Massoff were indicted for allowing a non-licensed person to practice medicine and for manipulation of medical records, but charges were dropped in 1978, after the District Attorney spearheading the investigation was defeated for re-election. [ 12 ] [ 13 ]


In October 2016, university student Kwon Dae-hee died from excessive bleeding after undergoing a jawline surgery partially conducted by a ghost doctor. [ 1 ] [ 2 ] [ 14 ]


Kwon had been bullied in high school for his chin shape and was insecure about his appearance; he booked his cosmetic surgery after seeing an ad for Center A, a well-known cosmetic surgery clinic in Seoul at the time. His family was not aware of the surgery until Kwon's subsequent hospitalization. [ 1 ] [ 14 ]


After reviewing  CCTV  footage of the surgery, Kwon's mother found that much of the operation took place with a general doctor, rather than the hired surgeon, in charge, and portions of the operation were performed by nursing assistants with neither doctor nor surgeon present. [ 1 ] [ 2 ]  The hired surgeon, who had been explicitly advertised as performing surgeries from start to finish, was carrying out operations on multiple patients at the same time. [ 15 ]


After the surgery, both doctors went home. Kwon lost over 3.5 liters of blood, over three times the amount later reported by the medical staff; the unsupervised assistants had to mop the bloodied floor over a dozen times. [ 1 ] [ 14 ]  Kwon was transferred to the hospital that night, and died seven weeks later. [ 1 ]


Kwon's family won 430 million  won  in damages against the clinic in 2019. [ 1 ]  The surgeon in the case was sentenced in 2021 to three years of prison for involuntary manslaughter. [ 2 ]


Following Kwon's death, his mother protested regularly in front of the  Korea National Assembly Proceeding Hall  to call for a bill, sometimes known as the "Kwon Dae-hee bill", that mandates the installation of security cameras in operating rooms. [ 1 ] [ 16 ]  The bill was passed in August 2021, in part due to the public response to Kwon's death. [ 14 ] [ 16 ]  The bill received objections from doctors, hospitals and medical groups, including the  Korean Medical Association , claiming that the cameras in the operating rooms would undermine trust in doctors, violate patient privacy and discourage doctors from taking risks to save lives. A poll by the Anti‑Corruption and Civil Rights Commission found that 97.9% of respondents supported the bill. [ 16 ]


Ghost surgery was included in the plot of  Squid Game . [ 17 ]


Glanuloplasty  is  plastic surgery  carried out on a  glans .  Typical examples include correcting a  hypospadias  on the  penis , [ 1 ]  or attempting to restore a  clitoris  mutilated by  female genital cutting .


Hair removal  is the deliberate removal of  body hair  or head  hair . This process is also known as  epilation  or  depilation .


Hair is a common feature of the human body, exhibiting considerable variation in thickness and length across different populations. Hair becomes more visible during and after  puberty . Additionally, men typically exhibit thicker and more conspicuous body hair than women. [ 1 ]
Both males and females have visible body hair on the  head ,  eyebrows ,  eyelashes ,  armpits ,  genital area ,  arms , and  legs . Males and some females may also have thicker hair growth on their  face ,  abdomen ,  back ,  buttocks ,  anus ,  areola ,  chest ,  nostrils , and  ears . Hair does not generally grow on the  lips , back of the ear, the underside of the  hands  or  feet , or on certain areas of the  genitalia .


Hair removal may be practiced for cultural,  aesthetic ,  hygienic , sexual, medical, or religious reasons. Forms of hair removal have been practiced in almost all human cultures since at least the  Neolithic  era. The methods used to remove hair have varied in different times and regions.


The term "depilation" is derived from the  Medieval Latin  "depilatio," which in turn is derived from the  Latin  "depilare," a word formed from the prefix "de-" and the root "pilus," meaning "hair."