British  physicians travelled to India to see  rhinoplasties  being performed by Indian methods. [ 18 ] [ 19 ]  Reports on Indian rhinoplasty performed by a  Kumhar  (potter)  vaidya  were published in the  Gentleman's Magazine  by 1794. [ 18 ]   Joseph Constantine Carpue  spent 20 years in India studying local plastic surgery methods. [ 18 ]  Carpue was able to perform the first major surgery in the  Western world  in the year 1815. [ 20 ]  Instruments described in the  Sushruta Samhita  were further modified in the Western world. [ 20 ]


In 1465, Sabuncu's book, description, and classification of  hypospadias  were more informative and up to date. Localization of the  urethral meatus  was described in detail.  Sabuncuoglu  also detailed the description and classification of ambiguous genitalia. In mid-15th-century Europe, Heinrich von Pfolspeundt described a process "to make a new nose for one who lacks it entirely, and the dogs have devoured it" by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not  until the 19th and 20th centuries  that such surgery became common.


In 1814, Joseph Carpue successfully performed an operative procedure on a  British military  officer who had lost his nose to the toxic effects of  mercury  treatments. In 1818, German surgeon  Carl Ferdinand von Graefe  published his major work entitled  Rhinoplastik . Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap.


The first American plastic surgeon was  John Peter Mettauer , who, in 1827, performed the first  cleft palate  operation with instruments that he designed himself.


Johann Friedrich Dieffenbach  specialized in  skin transplantation  and early plastic surgery. His work in  rhinoplastic  and  maxillofacial  surgery established many modern techniques of  reconstructive surgery . In 1845, Dieffenbach wrote a comprehensive text on rhinoplasty, titled  Operative Chirurgie , and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose. Dieffenbach has been called the "father of plastic surgery". [ 21 ] [ 22 ]


Another case of plastic surgery for nose reconstruction from 1884 at  Bellevue Hospital  was described in  Scientific American . [ 23 ]


In 1891, American  otorhinolaryngologist  John Roe presented an example of his work: a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses. In 1896,  James Israel , a  urological  surgeon from Germany, and in 1889 George Monks of the United States each described the successful use of  heterogeneous  free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German  orthopaedic -trained  surgeon , published his first account of reduction rhinoplasty. In 1910,  Alexander Ostroumov , the Russian  pharmacist , and perfume and cosmetics manufacturer, founded a unique plastic surgery department in his Moscow Institute of Medical Cosmetics. [ 24 ]  In 1928, Jacques Joseph published  Nasenplastik und Sonstige Gesichtsplastik . [ 25 ]


The development of weapons such as  machine guns  and  explosive shells  during  World War I  created trench warfare, which led to a rapid increase in the number of mutilations to the faces and the heads of soldiers because the trenches mainly offered protection to the body. The surgeons, who were not prepared for these injuries, were even less prepared for a large number of injuries and had to react quickly and intelligently to treat the greatest number. Facial injuries were hard to treat on the front line and, because of the sanitary conditions, many infections could occur. Sometimes, some stitches were made on a jagged wound without considering the amount of flesh that had been lost, so the resulting scars were hideous and disfigured soldiers. Some of the wounded had severe injuries and the stitches were not sufficient so some became blind, or were left with gaping holes instead of their nose.  Harold Gillies , scared by the number of new facial injuries and the lack of good surgical techniques, decided to dedicate an entire hospital to the reconstruction of facial injuries as fully as possible. He took into account the psychological dimension. Gillies introduced  skin grafts  to the treatments of soldiers, so they would be less horrified by looking at themselves in the mirror. [ 26 ] [ 27 ] [ 28 ]


It is the multidisciplinary approach to the treatment of facial lesions, bringing together  plastic surgeons , dental surgeons, technicians, and specialized nurses, which has made it possible to develop techniques leading to the reconstruction of injured faces. Gillies identified the need to advance the specialty of maxillofacial surgery which would be directly dedicated to the management of war wounds at this time. He developed a new technique using rotational and transposition flaps but also bone grafts from the ribs and tibia to reconstruct facial defects caused by the weapons during the war. Gillies experimented with this technique so he knew that he had to start by moving back healthy tissue to its normal position and then he would be able to fill with tissue from another place on the body of the soldier. One of the most successful techniques in skin grafting had the aim of not completely severing the connection to the body. It was possible by releasing and lifting a flap of skin from the wound. The flap of skin, still connected to the donor site, would then be swung over the site of the wound, allowing the maintenance of physical connection and ensuring that blood is supplied to the skin, increasing the chances of the skin graft being accepted by the body. At this time, we [ who? ]  assisted also to improving in treating infections also meant that important injuries had become survivable mostly thanks to the new technique of Gillies. Some soldiers arrived at the hospital of Gillies without noses, chins, cheekbones, or even eyes. But for them, the most important trauma was psychological. [ 29 ] [ 30 ]


The father of modern plastic surgery is generally considered to have been Sir  Harold Gillies . A New Zealand  otolaryngologist  working in London, he developed many of the techniques of modern facial surgery in caring for soldiers with disfiguring facial injuries during the  First World War . [ 31 ]


During  World War I , he worked as a medical minder with the  Royal Army Medical Corps . After working with the French  oral and maxillofacial surgeon   Hippolyte Morestin  on skin grafts, he persuaded the army's chief surgeon,  Arbuthnot-Lane , to establish a facial injury ward at the  Cambridge Military Hospital ,  Aldershot , later upgraded to a new hospital for facial repairs at  Sidcup  in 1917. There Gillies and his colleagues developed many techniques of plastic surgery; more than 11,000 operations were performed on more than 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds). [ 32 ]  After the war, Gillies developed a private practice with  Rainsford Mowlem , including many famous patients, and travelled extensively to promote his advanced techniques worldwide.


In 1930, Gillies' cousin,  Archibald McIndoe , joined the practice and became committed to plastic surgery. When  World War II  broke out, plastic surgery provision was largely divided between the different services of the  armed forces , and Gillies and his team were split up. Gillies himself was sent to  Rooksdown House  near  Basingstoke , which became the principal army plastic surgery unit; Tommy Kilner (who had worked with Gillies during the First World War, and who now has a surgical instrument named after him, the kilner cheek retractor) went to Queen Mary's Hospital, Roehampton; and Mowlem went to St Albans. McIndoe, consultant to the RAF, moved to the recently rebuilt  Queen Victoria Hospital  in  East Grinstead ,  Sussex , and founded a Centre for Plastic and Jaw Surgery. There, he treated very deep burns, and serious facial disfigurement, such as loss of eyelids, typical of those caused to aircrew by burning fuel. [ 33 ]


McIndoe is often recognized for not only developing new techniques for treating badly burned faces and hands but also for recognising the importance of the  rehabilitation  of the casualties and particularly of social reintegration back into normal life. He disposed of the "convalescent uniforms" and let the patients use their service uniforms instead. With the help of two friends, Neville and Elaine Blond, he also convinced the locals to support the patients and invite them to their homes. McIndoe kept referring to them as "his boys" and the staff called him "The Boss" or "The Maestro". [ 34 ]


His other important work included the development of the  walking-stalk skin graft , and the discovery that immersion in  saline  promoted healing as well as improving survival rates for patients with extensive burns—this was a  serendipitous  discovery drawn from observation of differential healing rates in pilots who had come down on land and in the sea. His radical, experimental treatments led to the formation of the  Guinea Pig Club  at  Queen Victoria Hospital , Sussex. Among the better-known members of his "club" were  Richard Hillary ,  Bill Foxley  and  Jimmy Edwards . [ 35 ]


Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by  American Board of Plastic Surgery . [ 36 ]  Subdisciplines of plastic surgery may include:


Aesthetic surgery is a central component of plastic surgery and includes facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance. [ 37 ]


Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed. [ 38 ]


Craniofacial surgery  is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, microtia, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with reconstructive surgeries after trauma or cancer and revision surgeries along with orthognathic surgery and facial feminization surgery. Craniofacial surgery is an important part of all plastic surgery training programs. Further training and subspecialisation is obtained via a craniofacial fellowship. Craniofacial surgery is also practiced by  maxillofacial surgeons .


Ethnic plastic surgery  is plastic surgery performed to change ethnic attributes, often considered used as a way of "passing".


Hand surgery  is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. The hand surgery field is also practiced by  orthopedic surgeons  and  general surgeons . Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough. There have been cases of surgery on women's hands in order to correct perceived flaws to create the perfect engagement ring photo. [ 39 ]


Microsurgery  is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery.


Children often face medical issues very different from the experiences of an adult patient. Many  birth defects  or syndromes present at birth are best treated in childhood, and  pediatric  plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include  craniofacial anomalies , Syndactyly [ 40 ]  (webbing of the fingers and toes), Polydactyly (excess fingers and toes at birth), cleft lip and palate, and congenital hand deformities.


Plastic surgery performed on an incarcerated population in order to affect their  recidivism  rate, a practice instituted in the early 20th century that lasted until the mid-1990s. Separate from surgery performed for medical need.


In plastic surgery, the transfer of skin tissue ( skin grafting ) is a very common procedure. Skin grafts can be derived from the recipient or donors:


Usually, good results would be expected from plastic surgery that emphasize careful planning of incisions so that they fall within the line of natural skin folds or lines, appropriate choice of  wound closure , use of best available suture materials, and early removal of exposed sutures so that the wound is held closed by buried sutures. [ original research? ] [ 41 ]


Cosmetic surgery is a voluntary or elective surgery that is performed on normal parts of the body with the only purpose of improving a person's appearance or removing signs of aging. Some cosmetic surgeries such as breast reduction are also functional and can help to relieve symptoms of discomfort such as back ache or neck ache. Cosmetic surgeries are also undertaken following breast cancer and mastectomy to recreate the natural breast shape which has been lost during the process of removing the cancer. In 2014, nearly 16 million cosmetic procedures were performed in the United States alone. [ 42 ]  The number of cosmetic procedures performed in the United States has almost doubled since the start of the century. 92% of cosmetic procedures were performed on women in 2014, up from 88% in 2001. [ 43 ]  15.6 million cosmetic procedures were performed in 2020, with the five most common surgeries being  rhinoplasties ,  blepharoplasties ,  rhytidectomies ,  liposuctions , and  breast augmentation . Breast augmentation continues to be one of the top 5 cosmetic surgical procedures and has been since 2006.  Silicone  implants were used in 84% and saline implants in 16% of all breast augmentations in 2020. [ 44 ]  The  American Society for Aesthetic Plastic Surgery  looked at the statistics for 34 different cosmetic procedures. Nineteen of the procedures were surgical, such as rhinoplasties or rhytidectomies. The nonsurgical procedures included  botox  and  laser hair removal . In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p. 5). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p. 12). [ 45 ]


In 1949, 15,000 Americans underwent cosmetic surgery procedures and by 1969 [ 46 ]  this number rose to almost half a million people. [ 47 ]  The  American Society of Plastic Surgeons  estimates that more than 333,000 cosmetic procedures were performed on patients 18 years of age or younger in the US in 2005 compared to approx. 14,000 in 1996. In 2018, more than 226,994 patients between the ages of 13 and 19 underwent plastic surgery compared to just over 218,900 patients in the same age group in 2010. [ 46 ] [ 48 ]  Concerns about young people undergoing plastic surgery include the financial burden of additional surgical procedures needed to correct problems after the initial cosmetic surgery, long-term health complications from plastic surgery, and unaddressed mental health issues that may have led to surgery. [ 49 ]  The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans, Asian Americans and Hispanic Americans as well as Caucasian Americans. In Asia, cosmetic surgery has become more popular, and countries such as China and India have become Asia's biggest cosmetic surgery markets. [ 50 ]  South Korea is also rising in popularity in Asian and Western countries due to their expertise in facial bone surgeries (see  cosmetic surgery in South Korea ). [ 51 ]


Plastic surgery is increasing slowly, rising 115% from 2000 to 2015. "According to the annual plastic surgery procedural statistics, there were 15.9 million surgical and minimally-invasive cosmetic procedures performed in the United States in 2015, a 2 percent increase over 2014." [ 52 ]  A study from 2021 found that requests for cosmetic procedures had increased significantly since the beginning of the COVID-19 pandemic, possibly due to the increase in  videoconferencing ; [ 53 ]  cited estimates include a 10% increase in the United States and a 20% increase in France. [ 54 ]


The most popular aesthetic/cosmetic procedures include:


In 2015, the most popular surgeries were botox, liposuction, blepharoplasties, breast implants, rhynoplasties, and rhytidectomies. [ 63 ]  According to the 2020 Plastic Surgery Statistics Report, which is published by the American Society of Plastic Surgeons, the most surgical procedure performed in the U.S. was rhinoplasty (nose reshaping) accounting for 15.2% of all cosmetic surgical procedures that year, followed by blepharoplasty (eyelid surgery), which accounted for 14% of all procedures. The third most populous procedure was rhytidectomy (facelift) (10% of all procedures), then liposuction (9.1% of all procedures). [ 64 ]


All surgery has risks. Common complications of cosmetic surgery includes  hematoma ,  nerve injury ,  infection ,  scarring ,  implant failure  and  end organ damage . [ 65 ] [ 66 ]   Breast implants  can have many  complications , including rupture. In a study of his 4761 augmentation mammaplasty patients, Eisenberg reported that overfilling saline breast implants 10–13% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. [ 67 ]  In 2011 FDA stated that one in five patients who received implants for breast augmentation will need them removed within 10 years of implantation. [ 68 ]


Although media and advertising do play a large role in influencing many people's lives, such as by making people believe plastic surgery to be an acceptable course to change one's identity to their liking, [ 69 ]  researchers believe that plastic surgery obsession is linked to psychological disorders such as  body dysmorphic disorder . [ 70 ]  There exists a correlation between those with BDD and the predilection toward cosmetic plastic surgery in order to correct a perceived defect in their appearance. [ 71 ]


BDD is a disorder resulting in the individual becoming "preoccupied with what they regard as defects in their bodies or faces". Alternatively, where there is a slight physical anomaly, then the person's concern is markedly excessive. [ 71 ]  While 2% of people have body dysmorphic disorder in the United States, 15% of patients seeing a dermatologist and cosmetic surgeons have the disorder. Half of the patients with the disorder who have cosmetic surgery performed are not pleased with the aesthetic outcome. BDD can lead to suicide in some people with the condition. While many with BDD seek cosmetic surgery, the procedures do not treat BDD, and can ultimately worsen the problem. The psychological root of the problem is usually unidentified; therefore causing the treatment to be even more difficult. Some say that the fixation or obsession with correction of the area could be a sub-disorder such as anorexia or muscle dysmorphia. [ 72 ]  The increased use of body and facial reshaping applications such as  Snapchat  and  Facetune  have been identified as potential triggers of BDD. Recently, a phenomenon referred to as ' Snapchat dysmorphia ' has appeared to describe people who request surgery to resemble the edited version of themselves as they appear through Snapchat filters. [ 73 ]  In response to the detrimental trend, Instagram banned all augmented reality (AR) filters that depict or promote cosmetic surgery. [ 74 ]


In some cases, people whose physicians refuse to perform any further surgeries, have turned to " do it yourself " plastic surgery, injecting themselves and facing extreme safety risks. [ 75 ]


Alarplasty  (or, less commonly,  alaplasty ) is a  plastic surgery  procedure in which a wedge of the  wing of the nose  is removed in order to alter the shape of the  nostrils . [ 1 ] [ 2 ]  Alarplasty may be used to increase or decrease the width of the nostrils, for either cosmetic or functional reasons. [ 3 ] [ 4 ]  In humans it may also make the nose perceptibly narrower. [ 3 ]


Temporary  swelling  is a common consequence of alarplasty. [ 3 ]


Alloplasty  is a  surgical procedure  performed to substitute and repair defects within the body with the use of  synthetic material . [ 1 ]  It can also be performed in order to bridge  wounds . [ 1 ]  The process of undergoing alloplasty involves the construction of an alloplastic  graft  through the use of computed tomography ( CT ), rapid  prototyping  and "the use of computer-assisted virtual model surgery." [ 1 ]  Each alloplastic graft is individually constructed and customised according to the patient's defect to address their personal health issue. [ 2 ]  Alloplasty can be applied in the form of reconstructive surgery. An example where alloplasty is applied in  reconstructive surgery  is in aiding cranial defects. [ 3 ]  The insertion and fixation of alloplastic implants can also be applied in cosmetic enhancement and augmentation. [ 4 ]  Since the inception of alloplasty, it has been proposed that it could be a viable alternative to other forms of transplants. The  biocompatibility  and customisation of alloplastic implants and grafts provides a method that may be suitable for both minor and major medical cases that may have more limitations in surgical approach. Although there has been evidence that alloplasty is a viable method for repairing and substituting defects, there are disadvantages including suitability of patient bone quality and quantity for long term implant stability, possibility of rejection of the alloplastic implant, injuring surrounding nerves, cost of procedure and long recovery times. [ 5 ] [ 6 ] [ 7 ] [ 8 ]  Complications can also occur from inadequate engineering of alloplastic implants and grafts, and poor implant fixation to bone. These include infection, inflammatory reactions, the fracture of alloplastic implants and prostheses, loosening of implants or reduced or complete loss of osseointegration. [ 6 ] [ 9 ]


Generally, alloplasty requires resource-intensive preparation including a computed tomography (CT) scan of the patient. Following the CT scan, computer-assisted design technology such as interactive virtual surgical planning software, is used to design a surgical simulation. The surgical simulation produced can be utilised to manipulate the 3D CT model to "preplan the resection, design cutting guides, and choose the appropriate stock prosthesis size". [ 1 ]  To further improve the safety and outcomes of alloplasty, additive manufacturing technology such as the use of rapid prototyping, fabricates stereolithographic models and cutting guides to be used in the operating room to improve surgical performance. [ 1 ] [ 9 ]


Prior to the surgical procedure, the alloplastic implant that will be used to repair or substitute the patients defect is designed to be biocompatible with the patient's specific body tissue. [ 2 ] [ 6 ]  The purpose and longevity of the alloplastic implant is also taken into account when considering the materials that are used to create the implant and the structure in order to be able to fixate the implant into the body safely and securely. [ 4 ]  Preventative measures taken to minimise infection include alloplastic implants being thoroughly sterilised through the administration of antibiotics, the implant acting as an antibiotic carrier. The administration of an antibiotic above the minimum biofilm eradication concentration can act as a protective barrier to bacterial adhesion but can also eradicate biofilm remnants. [ 6 ]  Another preventative measure to minimise infection is topical antiseptic cleaning in the area of operation. Patients prior to surgical procedure are to be placed on strict hygiene programs to minimise the production of harmful bacteria that may cause infection. Infection can delay the surgical procedure of the alloplastic implant which would cause the patient to further endure the disadvantages of their defect. [ 2 ]


After completion of surgical preparation and the creation of a final stock prosthesis, the commencement of the surgical procedure, alloplasty, begins. Alloplasty is performed with the use of anaesthesia. The type of anaesthesia is dependent upon the location of the insertion of the alloplastic implant and the severity of the patient's case, but commonly general anaesthetic and local anaesthetic are utilised. General anaesthetic is applied in major cases but for minor cases, the patient is put under local anaesthetic and intravenous sedation. Once the patient is under anaesthetic, surgeons make the appropriate dissections to insert and stabilise the alloplastic implants. [ 2 ]  Post-surgery the patient is monitored over a period of time to identify whether the implant has successfully repaired or substituted the defect of concern, and if infection is present. [ 10 ]


Alloplastic implants are  osteoconductive  and can bridge wounds by osseointegration. [ 6 ] [ 11 ]  After the initial insertion of an alloplastic implant, the implant acts as a guide and pathway for the continuum of bone and tissue reproduction. The alloplastic implant becomes more stabilised and integrated into the surrounding bone as bone production progresses, fixating the implant. [ 8 ]  Initially the method to fixate alloplastic implants is by using miniplates and screws to directly attach the implant to the bone to mechanically stabilise it. [ 1 ] [ 2 ]  In alloplastic surgeries that involve smaller implants, the screw themselves can be used as implants. For example, dental implants can be found in the form of screws. There are two type of screw designs that are suitable as dental implants, screw-root form and plateau-root form designed screws. The two screw designs have different osseointegration outcomes, longevity and healing processes. The screw-root form design is directly threaded into bone and has macroscopic retentive elements for initial bone fixation. A direct connection between bone and the implant provides high initial stability. Over time, screw-root form designs experience bone resorption and "bone modelling and remodelling at the bone to implant interface". [ 9 ]


Plateau-root form designed implants have a different healing process to screw-root form designs. The plateau-root form design has a woven bone formation. In the 0-3 month bone healing phase, osseointegration occurs by intramembranous ossification. Intramembranous ossification provides greater stabilisation and a more significant role in peri-implant bone healing around plateau-root form implants than screw-root form designed implants. [ 9 ]


Miniscrews are another type of implant that can be used to anchor and intrude hard surfaces, such as teeth. This type of implant can stabilise intrusive movement to a certain extent with a varying percentage of relapse of intrusion. Advantages of miniscrews are that they are easily inserted and removed, cheaper compared to other implants, are flexible in regards to insertion sites and cause a lower level of discomfort for the patient. Miniscrews are also able to provide stability without flap surgery and has a "short healing period and immediate loading". [ 12 ]


The approach for the fixation of alloplastic implants will be dependent upon the circumstance of the surgical operation and the required stability of the implant. Some patients will require a combination of approaches. The approach taken to surgically fixate an alloplastic implant can also because of the type of synthetic material that the implant is made of to suit its purposes. [ 2 ]  The alloplastic implant must also be biocompatible with the hosts tissues by being "non-toxic, non-allergenic, non-carcinogenic and non-inflammatory". [ 13 ]


Alloplasty is a method for synthetic implants to be inserted into the body to aid physical and mental function. [ 3 ] [ 14 ]  The procedure can be performed to reconstruct defects such as cranial defects. [ 15 ]  A common synthetic material used in the production of alloplastic grafts for craniotomy is heat-cure polymethyl methacrylate resin due to being nonconductive, radiolucent, light in weight and is easily modified to smoothly mould to the shape of the skull. [ 10 ]  The non-conduciveness and biocompatibility of polymethyl methacrylate resin and alloplastic materials in general, provides the ability for alloplastic implants to be used in aiding brain defects that may have been caused by decompressive craniectomy. [ 3 ] [ 10 ]  Porous titanium implants can also be used to correct calvarial defects such as "subdural hematoma and meningioma". [ 16 ]  Implants promote bone formation in osseous defects created by trauma or surgical intervention. [ 6 ]  Custom stock prosthetic implants reconstruct the cranial defects where the skull is too fragmented to be recovered or where bone has become infected and is required to be replaced. [ 3 ] [ 6 ]  Cranial implants are placed and secured through surgical stabilisation using surgical wires, mini plates and screws to fill gaps in the bone of the skull, called the bone flap. [ 10 ]  The conduct of alloplasty on the cranium restores lost or deficient use of the brain through the repair of mechanical defects, but is also able to provide fixations for cosmetic purposes to restore natural anatomy. [ 2 ] [ 3 ]


Alloplastic implants can be used in cosmetic facial surgery to restore volume in areas of the face and "can be serviced or removed without maximally invasive surgery". [ 4 ]  Implants ideally are "nonantigenic, durable, non-toxic and resistant to infection". [ 17 ]  Cosmetic enhancement can be desired for multiple reasons including the physical changes associated with ageing. The continuous change in facial structure and need for volume restoration due to ageing requires implants that can be easily replaced, cost effective, permanent if desired and a reversible procedure. Silicone implants can provide a three-dimensional (3D) augmentation when anchored to the facial skeleton with screws. Implants made from silicone are able to be replaced and reversed in procedure as the silicone is not integrated into skin tissue but is surrounded by a dense and fibrous tissue capsule. Other materials alloplastic implants are made of for cosmetic enhancement include "expanded polytetrafluorethylene and porous polyethylene" which are all biocompatible". [ 4 ] [ 17 ]


Facial implants that are left immobilised and that create pressure against bone can cause bone resorption. For example, chin implants that are immobilised create pressure on the anterior mandible which can cause an increase in bone resorption. Facial implants that are placed in a supraperiosteal plane centrally and subperiosteal plane laterally minimise bone resorption. The supraperiosteal plane placement of the implant minimises the degree of contact to the bone as the implant is immobilised and the subperiosteal plane has lateral pockets that fixate the implant. Chin implants can also be fixated and equally remove pressure from bone through the use of screw fixation. [ 18 ]


A disadvantage of alloplasty is that there are certain requirements for a patient to have long term stability of an alloplastic implant. [ 9 ]  This can be dependent upon age and health conditions of the patient. The patient must have sufficient maintenance of alveolar bone structure and minimise alveolar bone loss. For example, the removal of teeth results in accelerated loss of facial bone with the alveolar bone receding, resorbing and then disappearing. In the span of 2–3 years, patients can experience 40-60% of alveolar bone loss. Severe bone and tissue loss can make it difficult for the proceeding with alloplasty as procedural plans about regenerating bone through alloplastic implants become more complex. [ 13 ]


Another disadvantage with alloplasty is that alloplastic grafts and implants can cause inflammation or be completely rejected by the body and needs to be removed. [ 8 ] [ 19 ]  Alloplasty as a form of reconstructive surgery can be expensive. [ 15 ]  The need to remove and replace a rejected alloplastic graft or implant increases costs for the patient and prolongs the time the patient must endure the defect of concern. For patients that are successful with alloplasty, may experience long recovery times. This is because the patient's body needs to adapt to the foreign material and integrate the alloplastic implant or graft with its surrounding tissue. [ 5 ] [ 19 ]


The surgical technique of alloplasty if completed incorrectly can cause significant and irreversible damage to surrounding nerves by the improper placement of osteotomy. For example, in osteoplastic genioplasty, the risk of injuring a mental nerve is high. If the mental nerve injured or damaged, the lower lip and front of the chin can perceptually feel numb. [ 5 ]


Although evidence gathered by case-by-case studies have proposed that alloplasty is a viable alternative to other forms of transplants, there can be complications. [ 2 ] [ 3 ] [ 6 ]  Alloplastic implants that are not thoroughly sanitised can be contaminated. Contaminated implants attached to a surface in the body creates an enclosed slimy matrix called biofilm, which protects bacterial organisms from the body's defence mechanisms and antibiotics. The bacteria can infect the bloodstream and cause body tissues to become dysfunctional and suppress the body's immune system. A suppressed immune system exacerbates the growth of invading bacteria. [ 6 ]  Infection is predominant cause of removal of alloplastic implants. A disadvantage of the removal of an infected implant is that bone defects that the implant was responsible for, continue to exist. Another complication is that some synthetic organic materials such as fisiograft, that are used to make alloplastic implants can be hydrolytically decomposed which "leads to a local acidulation of the tissue and causes an inflammatory reaction during absorption". [ 5 ]  There can be complications with the long term function of alloplastic implants, if implants are poorly engineered and inadequately fixated. Improper fixation and numerous biomechanical and mechanical factors can contribute to the fracture of alloplastic implants or prostheses, loosening of alloplastic implants and reduced or complete loss of osseointegration. Biomechanical overload from the use of bone as leverage, creating leverage force, can place enormous stress on the implant as well as the bone–implant interface. [ 5 ]


Anaplastology  ( Gk.  ana -again, a new, upon  plastos -something made, formed, molded  logy -the study of ) is a branch of  medicine  dealing with the  prosthetic  rehabilitation of an absent, disfigured or malformed anatomically critical location of the  face  or  body . The term  anaplastology  was coined by  Walter G. Spohn  and is used worldwide.


An anaplastologist (also known as a  maxillofacial prosthetist and technologist  in the  United Kingdom ) is an individual who has the knowledge and skill set to provide the service of customizing a facial ( craniofacial prosthesis ), ocular or  somatic prosthesis . In locations around the world that facial, ocular and somatic prostheses are not readily available, a  dentist  who specializes in  maxillofacial  prosthetics (prosthodontics), or a dental technician or an  ocularist , may also be titled an anaplastologist. In  urban  or more developed locations, an individual referred to as an anaplastologist is one who solely works with facial, ocular or somatic prostheses. In such a setting, the anaplastologist sometimes collaborates with prosthodontists and ocularists.


The studies of an anaplastologist consist of the arts and sciences.  Visual arts  are studied, namely  photography ,  illustration ,  sculpture , and  painting .  Biology ,  behavioral sciences ,  materials science , and  physics  are the studied sciences with emphases in  superficial anatomy  and  physiology  of  humans ,  polymer science ,  optics ,  dermatology ,  oral and maxillofacial surgery ,  otolaryngology , and  oncology  to name a few.


Certification in the field of anaplastology is provided by the Board for Certification in Clinical Anaplastology (BCCA). Professionals certified by the BCCA are designated as Certified Clinical Anaplastologists and denote their credential with the CCA title.


In the  Battle of the Somme , an estimated 4,000,000 shots were fired, causing 20,000  facial injuries . [ 1 ]  Individuals whose injuries were unable to be treated with  plastic surgery  or  reconstructive surgery  techniques available to them at the time were given the option of wearing customized pieces to restore the natural appearance of their face. These pieces were crafted by sculptors. A notable sculptor who created prosthetic pieces for victims of war was  Anna Coleman Ladd , a member of the  Red Cross  who made casts of her patients' faces and then, by hand, would create pieces out of  galvanized  copper,  tin foil , and  human hair  for them to wear. [ 2 ] [ 3 ]  Ladd's pieces were secured with bands around the head, which were often concealed by false  eyeglasses .


In 1980  Walter G. Spohn  and a group of like-minded colleagues found the American Anaplastology Association (AAA) at  Stanford University , in  Palo Alto , California. [ 4 ]


In the 1986 musical,  Andrew Lloyd Weber's The Phantom of the Opera , the character  Erik  wears a facial mask to hide his facial deformities.


In the 2004 film,  The Libertine ,  John Wilmot, 2nd Earl of Rochester , as portrayed by American actor  Johnny Depp  is shown to wear a facial mask to cover the sores on his face caused by  syphilis . [ 5 ]


In the 2010 television show  Boardwalk Empire , the character  Richard Harrow  wears a tin mask with glasses to hide the disfigurement of his face. He endured during his service as a soldier in World War I.


In the 2017  Wonder Woman  movie, the character Dr. Maru, also known as Dr. Poison, is a chemist working with the Germans in WWI. In the film, Dr. Maru wears a primitive mask colored and shaped like her face, to cover the bottom left side of her face. [ 6 ]


An  angiosome  is a three-dimensional unit of  skin  and  underlying tissues  vascularized by a source  artery , termed an  arteriosome  and drained by a vein termed a  venosome . It is a concept that is used by  plastic surgeons , and other medical disciplines like CMF,  ENT , etc., for the design and harvesting of  free flap  transplants (e.g. fibula free-flap transplant [ 1 ] ), and by  vascular surgeons  and  interventional radiologists  for the  endovascular treatment  of critical  limb ischemia .  It is an alternative model to the traditional "best vessel" model. [ 2 ]


An example is the angiosome of the  fibular artery  (also called the  peroneal artery ), that primarily vascularizes the skin of the distal two-thirds of the  lateral-posterior  aspect of the leg. Furthermore, also the underlying  fibula bone  and parts of the local muscles, like the  flexor hallucis longus muscle .


Small arteries, called  arterial perforators , branch off from the larger arteries below the deep body  fascia . These arterial perforators penetrate the deep body fascia in their course towards the skin and further ramify in the  subcutaneous tissue . A three-dimensional unit of tissue, only encompassing skin and the subcutaneous tissue – but not the tissue from below the body fascia (like muscle and bone) – primarily supplied by a dominant arterial perforator, is called a  perforasome . Although multiple other arterial perforators may also supply this unit of tissue with arterial blood, it is the dominant arterial perforator that is essential for the survival of the perforasome.


Arterial perforators can be further defined by their path, in three categories: direct-cutaneous perforator, septo-cutaneous perforator and musculo-cutaneous perforator, depending on what anatomical structure the perforator progresses through, after branching from the deep source artery.


Therefore, generally speaking, one “big” angiosome can contain multiple “smaller” perforasomes.


This article related to  medical imaging  is a  stub . You can help Wikipedia by  expanding it .


An  auricular splint  ( AS ) or  ear splint  is a custom-made medical device that is used to maintain auricular projection and dimensions following second stage auricular reconstruction. The AS is made from  ethylene-vinyl acetate  (EVA), which is typically used to make  custom-made mouthguards  and was developed by a team from  Great Ormond Street Hospital  in the  United Kingdom .


The  auricle  is typically reconstructed using  autogenous   cartilage , which is the most reliable material for producing the best results with the least complications. [ 1 ]  Cartilage from the  knee  and contralateral auricular cartilage from the  concha  have also been reported but  costal cartilage  is typically used as it is the only donor site that provides sufficient tissue to fabricate the complete auricular framework. The four main elements to consider when assessing the final reconstructed auricle are: [ citation needed ]


In order to prevent compression during sleep and to prevent the grafted skin from contracting, the use of a  Foley catheter , [ 3 ]   Reston Foam , [ 4 ]   silicone foam , [ 5 ]   polysiloxane [ 6 ] [ 7 ]  and
 dental impression compound [ 8 ]  have been described. The auricular splint was developed with the aim of overcoming the drawbacks associated with these methods.


The auricular splint (AS) is easy to fit and remove, self-retaining, lightweight and easy to camouflage due to its transparency. The AS is made from  ethylene-vinyl acetate  (EVA), which is inert and non-toxic, non-absorbent, sufficiently elastic to allow it to fitted and removed but sufficiently rigid to avoid breakage. [ citation needed ]


The concept was first presented at the 2nd Congress of the International Society for Auricular Reconstruction in  Beijing ,  China  in September 2017 [ 9 ]  and published in the  Annals of Plastic Surgery  the following year. [ 2 ]


The first stage involves taking an impression of the reconstructed auricle with Soft Putty Elastomer, which is cast in  dental stone  to make a model of the reconstructed auricle. The splint is made by  thermoforming  a 4mm sheet of transparent  ethylene-vinyl acetate  (EVA) over the stone model. The edges of the splint are trimmed and polished using the outline on the model as a guide. [ 2 ] [ 9 ]


The splint has been found to maintain auricular projection and other key dimensions up to the six-month post-operative follow-up. [ 10 ] [ 11 ]


Azficel-T , sold under the brand name  Laviv , is a  cell therapy  product for the improvement of the appearance of moderate to severe  nasolabial fold  wrinkles in adults. [ 1 ] [ 2 ] [ 3 ]  It consists of  fibroblasts  harvested from the patient's own skin. [ 2 ]


It was approved for medical use in the United States in June 2011. [ 2 ]


This  pharmacology -related article is a  stub . You can help Wikipedia by  expanding it .


Botulinum toxin , or  botulinum neurotoxin  (commonly called  botox ), is a  neurotoxic   protein  produced by the  bacterium   Clostridium botulinum  and related species. [ 24 ]  It prevents the release of the  neurotransmitter   acetylcholine  from  axon  endings at the  neuromuscular junction , thus causing  flaccid paralysis . [ 25 ]  The toxin causes the disease  botulism . [ 26 ]  The toxin is also used commercially for medical and cosmetic purposes. [ 27 ] [ 28 ]  Botulinum toxin is an acetylcholine release inhibitor and a neuromuscular blocking agent. [ 1 ] [ 23 ]


The seven main types of botulinum toxin are named types A to G (A, B, C1, C2, D, E, F and G). [ 27 ] [ 29 ]  New types are occasionally found. [ 30 ] [ 31 ]  Types A and B are capable of causing disease in humans, and are also used commercially and medically. [ 32 ] [ 33 ] [ 34 ]  Types C–G are less common; types E and F can cause disease in humans, while the other types cause disease in other animals. [ 35 ]


Botulinum toxins are among the most potent toxins known to science. [ 36 ] [ 37 ]  Intoxication can occur naturally as a result of either wound or intestinal infection or by ingesting formed toxin in food. The estimated human  median lethal dose  of type A toxin is 1.3–2.1   ng /kg  intravenously  or  intramuscularly , 10–13   ng/kg when inhaled, or 1000   ng/kg when taken by mouth. [ 38 ]


Botulinum toxin is used to treat a number of therapeutic indications, many of which are not part of the approved drug label. [ 28 ]


Botulinum toxin is used to treat a number of disorders characterized by overactive muscle movement, including  cerebral palsy , [ 32 ] [ 33 ]  post-stroke  spasticity , [ 39 ]  post-spinal cord injury spasticity, [ 40 ]   spasms  of the head and neck, [ 41 ]   eyelid , [ 26 ]   vagina , [ 42 ]  limbs, jaw, and  vocal cords . [ 43 ]  Similarly, botulinum toxin is used to relax the clenching of muscles, including those of the  esophagus , [ 44 ]   jaw , [ 45 ]   lower urinary tract  and  bladder , [ 46 ]  or clenching of the anus which can exacerbate  anal fissure . [ 47 ]  Botulinum toxin appears to be effective for  refractory   overactive bladder . [ 48 ]


Strabismus , otherwise known as improper eye alignment, is caused by imbalances in the actions of muscles that rotate the eyes. This condition can sometimes be relieved by weakening a muscle that pulls too strongly, or pulls against one that has been weakened by disease or trauma. Muscles weakened by toxin injection recover from paralysis after several months, so injection might seem to need to be repeated, but muscles adapt to the lengths at which they are chronically held, [ 49 ]  so that if a paralyzed muscle is stretched by its antagonist, it grows longer, while the antagonist shortens, yielding a permanent effect. [ 50 ]


In January 2014, botulinum toxin was approved by UK's  Medicines and Healthcare products Regulatory Agency  for treatment of restricted ankle motion due to lower-limb spasticity associated with stroke in adults. [ 51 ] [ 52 ]


In July 2016, the US  Food and Drug Administration  (FDA) approved abobotulinumtoxinA (Dysport) for injection for the treatment of lower-limb spasticity in pediatric patients two years of age and older. [ 53 ] [ 54 ]  AbobotulinumtoxinA is the first and only FDA-approved botulinum toxin for the treatment of pediatric lower limb spasticity. [ 55 ]  In the US, the  FDA approves  the text of the labels of prescription medicines and for which medical conditions the drug manufacturer may sell the drug. However, prescribers may freely prescribe them for any condition they wish, also known as  off-label use . [ 56 ]  Botulinum toxins have been used off-label for several pediatric conditions, including  infantile esotropia . [ 57 ]


AbobotulinumtoxinA has been approved for the treatment of axillary  hyperhidrosis , which cannot be managed by topical agents. [ 43 ] [ 58 ]


In 2010, the FDA approved  intramuscular  botulinum toxin injections for  prophylactic   treatment  of  chronic   migraine   headache . [ 59 ]  However, the use of botulinum toxin injections for episodic migraine has not been approved by the FDA. [ 60 ]


In cosmetic applications, botulinum toxin is considered relatively safe and effective [ 61 ]  for reduction of facial  wrinkles , especially in the uppermost third of the face. [ 62 ]  Commercial forms are marketed under the brand names Botox Cosmetic/Vistabel from  Allergan , Dysport/Azzalure from  Galderma  and  Ipsen , Xeomin/Bocouture from Merz, Jeuveau/Nuceiva from Evolus, manufactured by  Daewoong  in South Korea. [ 63 ]  The effects of botulinum toxin injections for  glabellar  lines ('11's lines' between the eyes) typically last two to four months and in some cases, product-dependent, with some patients experiencing a longer duration of effect of up to six months or longer. [ 62 ]  Injection of botulinum toxin into the muscles under facial wrinkles causes relaxation of those muscles, resulting in the smoothing of the overlying skin. [ 62 ]  Smoothing of wrinkles is usually visible three to five days after injection, with maximum effect typically a week following injection. [ 62 ]  Muscles can be treated repeatedly to maintain the smoothed appearance. [ 62 ]


DaxibotulinumtoxinA (Daxxify) was approved for medical use in the United States in September 2022. [ 23 ] [ 64 ]  It is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (wrinkles between the eyebrows). [ 23 ] [ 64 ] [ 65 ]  DaxibotulinumtoxinA is an acetylcholine release inhibitor and neuromuscular blocking agent. [ 23 ]  The FDA approved daxibotulinumtoxinA based on evidence from two clinical trials (Studies GL-1 and GL-2), of 609 adults with moderate to severe glabellar lines. [ 64 ]  The trials were conducted at 30 sites in the United States and Canada. [ 64 ]  Both trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines. [ 64 ]  Participants received a single intramuscular injection of daxibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. [ 64 ]  The most common side effects of daxibotulinumtoxinA are headache, drooping eyelids, and weakness of facial muscles. [ 64 ]


LetibotulinumtoxinA (Letybo) was approved for medical use in the United States in February 2024. [ 1 ] [ 66 ]  It is indicated to temporarily improve the appearance of moderate-to-severe glabellar lines. [ 1 ] [ 67 ]  The FDA approved letibotulinumtoxinA based on evidence from three clinical trials (BLESS I [NCT02677298], BLESS II [NCT02677805], and BLESS III [NCT03985982]) of 1,271 participants with moderate to severe wrinkles between the eyebrows for efficacy and safety assessment. [ 66 ]  These trials were conducted at 31 sites in the United States and the European Union. [ 66 ]  All three trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines (wrinkles between the eyebrows). [ 66 ]  Participants received a single intramuscular injection of letibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. [ 66 ]  The most common side effects of letibotulinumtoxinA are headache, drooping of eyelid and brow, and twitching of eyelid. [ 66 ]


Botulinum toxin is also used to treat disorders of hyperactive nerves including excessive sweating, [ 58 ]   neuropathic pain , [ 68 ]  and some  allergy  symptoms. [ 43 ]  In addition to these uses, botulinum toxin is being evaluated for use in treating  chronic pain . [ 69 ]  Studies show that botulinum toxin may be injected into arthritic shoulder joints to reduce chronic pain and improve range of motion. [ 70 ]  The use of botulinum toxin A in children with  cerebral palsy  is safe in the upper and lower limb muscles. [ 32 ] [ 33 ]


While botulinum toxin is generally considered safe in a clinical setting, serious side effects from its use can occur. Most commonly, botulinum toxin can be injected into the wrong muscle group or with time spread from the injection site, causing temporary paralysis of unintended muscles. [ 71 ]  In at least three cases temporary  diplopia  was reported due to subcutenious injections for cosmetic purposes. [ 72 ]


Side effects from cosmetic use generally result from unintended paralysis of facial muscles. These include partial facial paralysis, muscle weakness, and  trouble swallowing . Side effects are not limited to direct paralysis, however, and can also include headaches, flu-like symptoms, and allergic reactions. [ 73 ]  Just as cosmetic treatments only last a number of months, paralysis side effects can have the same durations. [ 74 ]  At least in some cases, these effects are reported to dissipate in the weeks after treatment. [ 75 ]  Bruising at the site of injection is not a side effect of the toxin, but rather of the mode of administration, and is reported as preventable if the clinician applies pressure to the injection site; when it occurs, it is reported in specific cases to last 7–11 days. [ 76 ]  When injecting the masseter muscle of the jaw, loss of muscle function can result in a loss or reduction of power to chew solid foods. [ 73 ]  With continued high doses, the muscles can atrophy or lose strength; research has shown that those muscles rebuild after a break from Botox. [ 77 ]


Side effects from therapeutic use can be much more varied depending on the location of injection and the dose of toxin injected. In general, side effects from therapeutic use can be more serious than those that arise during cosmetic use. These can arise from paralysis of critical muscle groups and can include  arrhythmia ,  heart attack , and in some cases, seizures, respiratory arrest, and death. [ 73 ]  Additionally, side effects common in cosmetic use are also common in therapeutic use, including trouble swallowing, muscle weakness, allergic reactions, and flu-like syndromes. [ 73 ]


In response to the occurrence of these side effects, in 2008, the FDA notified the public of the potential dangers of the botulinum toxin as a therapeutic. Namely, the toxin can spread to areas distant from the site of injection and paralyze unintended muscle groups, especially when used for treating muscle spasticity in children treated for cerebral palsy. [ 78 ]  In 2009, the FDA announced that boxed warnings would be added to available botulinum toxin products, warning of their ability to spread from the injection site. [ 79 ] [ 80 ] [ 81 ] [ 82 ]  However, the clinical use of botulinum toxin A in cerebral palsy children has been proven to be safe with minimal side effects. [ 32 ] [ 33 ]  Additionally, the FDA announced name changes to several botulinum toxin products, to emphasize that the products are not interchangeable and require different doses for proper use. Botox and Botox Cosmetic were given the generic name of onabotulinumtoxinA, Myobloc as rimabotulinumtoxinB, and Dysport retained its generic name of abobotulinumtoxinA. [ 83 ] [ 79 ]  In conjunction with this, the FDA issued a communication to health care professionals reiterating the new drug names and the approved uses for each. [ 84 ]  A similar warning was issued by  Health Canada  in 2009, warning that botulinum toxin products can spread to other parts of the body. [ 85 ]


Botulinum toxin produced by  Clostridium botulinum  (an anaerobic, gram-positive bacterium) is the cause of botulism. [ 26 ]  Humans most commonly ingest the toxin from eating improperly canned foods in which  C. botulinum  has grown. However, the toxin can also be introduced through an infected wound. In infants, the bacteria can sometimes grow in the intestines and produce botulinum toxin within the intestine and can cause a condition known as  floppy baby syndrome . [ 86 ]  In all cases, the toxin can then spread, blocking nerves and muscle function. In severe cases, the toxin can block nerves controlling the respiratory system or heart, resulting in death. [ 24 ]


Botulism can be difficult to diagnose, as it may appear similar to diseases such as  Guillain–Barré syndrome ,  myasthenia gravis , and  stroke . Other tests, such as brain scan and spinal fluid examination, may help to rule out other causes. If the symptoms of botulism are diagnosed early, various treatments can be administered. In an effort to remove contaminated food that remains in the gut, enemas or induced vomiting may be used. [ 87 ]  For wound infections, infected material may be removed surgically. [ 87 ]  Botulinum antitoxin is available and may be used to prevent the worsening of symptoms, though it will not reverse existing nerve damage. In severe cases, mechanical respiration may be used to support people with respiratory failure. [ 87 ]  The nerve damage heals over time, generally over weeks to months. [ 88 ]  With proper treatment, the case fatality rate for botulinum poisoning can be greatly reduced. [ 87 ]


Two preparations of botulinum antitoxins are available for treatment of botulism. Trivalent (serotypes A, B, E) botulinum  antitoxin  is derived from equine sources using whole  antibodies . The second antitoxin is  heptavalent botulinum antitoxin  (serotypes A, B, C, D, E, F, G), which is derived from equine antibodies that have been altered to make them less immunogenic. This antitoxin is effective against all main strains of botulism. [ 89 ] [ 31 ]


Botulinum toxin exerts its effect by cleaving key proteins required for nerve activation. First, the toxin binds specifically to presynaptic surface of  neurons  that use the neurotransmitter  acetylcholine . Once bound to the nerve terminal, the neuron  takes up  the toxin into a  vesicle  by receptor-mediated  endocytosis . [ 91 ]  As the vesicle moves farther into the cell, it acidifies, activating a portion of the toxin that triggers it to push across the vesicle membrane and into the cell  cytoplasm . [ 24 ]  Botulinum neurotoxins recognize distinct classes of receptors simultaneously ( gangliosides ,  synaptotagmin  and  SV2 ). [ 92 ]  Once inside the cytoplasm, the toxin cleaves  SNARE proteins  (proteins that mediate vesicle fusion, with their target membrane bound compartments) meaning that the acetylcholine vesicles cannot bind to the intracellular cell membrane, [ 91 ]  preventing the cell from releasing vesicles of neurotransmitter. This stops nerve signaling, leading to  flaccid paralysis . [ 24 ] [ 92 ]


The toxin itself is released from the bacterium as a single chain, then becomes activated when cleaved by its own proteases. [ 43 ]  The active form consists of a two-chain  protein  composed of a 100- kDa  heavy chain  polypeptide  joined via  disulfide bond  to a 50-kDa light chain polypeptide. [ 93 ]  The heavy chain contains domains with several functions; it has the domain responsible for binding specifically to  presynaptic  nerve terminals, as well as the domain responsible for mediating translocation of the light chain into the cell cytoplasm as the vacuole acidifies. [ 24 ] [ 93 ]  The light chain is a M27-family zinc  metalloprotease  and is the active part of the toxin. It is translocated into the host cell cytoplasm where it cleaves the host protein  SNAP-25 , a member of the SNARE protein family, which is responsible for  fusion . The cleaved SNAP-25 cannot mediate fusion of vesicles with the host cell membrane, thus preventing the release of the  neurotransmitter  acetylcholine from axon endings. [ 24 ]  This blockage is slowly reversed as the toxin loses activity and the SNARE proteins are slowly regenerated by the affected cell. [ 24 ]


The seven toxin serotypes (A–G) are traditionally separated by their antigenicity. They have different tertiary structures and sequence differences. [ 93 ] [ 94 ]  While the different toxin types all target members of the SNARE family, different toxin types target different SNARE family members. [ 90 ]  The A, B, and E serotypes cause human botulism, with the activities of types A and B enduring longest  in vivo  (from several weeks to months). [ 93 ]  Existing toxin types can recombine to create "hybrid" (mosaic, chimeric) types. Examples include BoNT/CD, BoNT/DC, and BoNT/FA, with the first letter indicating the light chain type and the latter indicating the heavy chain type. [ 95 ]  BoNT/FA received considerable attention under the name "BoNT/H", as it was mistakenly thought it could not be neutralized by any existing antitoxin. [ 31 ]


Botulinum toxins are closely related to  tetanus toxin . The two are collectively known as  Clostridium  neurotoxins  and the light chain is classified by  MEROPS  as family M27. [ 96 ]   Clostridium  neurotoxins belong in the wider family of  AB toxins , which also includes   Anthrax toxin  and  Diphtheria toxin . Nonclassical types include BoNT/X ( P0DPK1 ), which is toxic in mice and possibly in humans; [ 30 ]  a BoNT/J ( A0A242DI27 ) found in cow  Enterococcus ; [ 97 ]  and a BoNT/Wo ( A0A069CUU9 ) found in the rice-colonizing  Weissella oryzae . [ 95 ]


One of the earliest recorded outbreaks of foodborne botulism occurred in 1793 in the village of  Wildbad  in what is now  Baden-Württemberg , Germany. Thirteen people became sick and six died after eating pork stomach filled with  blood sausage , a local delicacy. Additional cases of fatal food poisoning in  Württemberg  led the authorities to issue a public warning against consuming smoked blood sausages in 1802 and to collect case reports of "sausage poisoning". [ 98 ]  Between 1817 and 1822, the German physician  Justinus Kerner  published the first complete description of the symptoms of botulism, based on extensive clinical observations and animal experiments. He concluded that the toxin develops in bad sausages under anaerobic conditions, is a biological substance, acts on the nervous system, and is lethal even in small amounts. [ 98 ]  Kerner hypothesized that this "sausage toxin" could be used to treat a variety of diseases caused by an overactive nervous system, making him the first to suggest that it could be used therapeutically. [ 99 ]  In 1870, the German physician Müller coined the term  botulism  to describe the disease caused by sausage poisoning, from the Latin word  botulus , meaning 'sausage'. [ 99 ]


In 1895  Émile van Ermengem , a Belgian microbiologist, discovered what is now called  Clostridium botulinum  and confirmed that a toxin produced by the bacteria causes botulism. [ 100 ]  On 14 December 1895, there was a large outbreak of botulism in the Belgian village of  Ellezelles  that occurred at a funeral where people ate pickled and smoked ham; three of them died. By examining the contaminated ham and performing autopsies on the people who died after eating it, van Ermengem isolated an anaerobic microorganism that he called  Bacillus botulinus . [ 98 ]  He also performed experiments on animals with ham extracts, isolated bacterial cultures, and toxins extracts from the bacteria. From these he concluded that the bacteria themselves do not cause foodborne botulism, but rather produce a toxin that causes the disease after it is ingested. [ 101 ]  As a result of Kerner's and van Ermengem's research, it was thought that only contaminated meat or fish could cause botulism. This idea was refuted in 1904 when a botulism outbreak occurred in  Darmstadt , Germany, because of canned white beans. In 1910, the German microbiologist J. Leuchs published a paper showing that the outbreaks in Ellezelles and Darmstadt were caused by different strains of  Bacillus botulinus  and that the toxins were serologically distinct. [ 98 ]  In 1917,  Bacillus botulinus  was renamed  Clostridium botulinum , as it was decided that term  Bacillus  should only refer to a group of aerobic microorganisms, while  Clostridium  would be only used to describe a group of anaerobic microorganisms. [ 100 ]  In 1919,  Georgina Burke  used toxin-antitoxin reactions to identify two strains of  Clostridium botulinum , which she designated A and B. [ 100 ]


Over the next three decades, 1895–1925, as food canning was approaching a billion-dollar-a-year industry, botulism was becoming a public health hazard.  Karl Friedrich Meyer , a Swiss-American veterinary scientist, created a center at the Hooper Foundation in San Francisco, where he developed techniques for growing the organism and extracting the toxin, and conversely, for preventing organism growth and toxin production, and inactivating the toxin by heating. The California canning industry was thereby preserved. [ 102 ]


With the outbreak of World War II, weaponization of botulinum toxin was investigated at  Fort Detrick  in Maryland. Carl Lamanna and James Duff [ 103 ]  developed the concentration and crystallization techniques that Edward J. Schantz used to create the first clinical product. When the Army's  Chemical Corps  was disbanded, Schantz moved to the Food Research Institute in Wisconsin, where he manufactured toxin for experimental use and provided it to the academic community.


The mechanism of botulinum toxin action – blocking the release of the neurotransmitter acetylcholine from nerve endings – was elucidated in the mid-20th century, [ 104 ]  and remains an important research topic. Nearly all toxin treatments are based on this effect in various body tissues.


Ophthalmologists specializing in eye muscle disorders ( strabismus ) had developed the method of EMG-guided injection (using the  electromyogram , the electrical signal from an activated muscle, to guide injection) of local anesthetics as a diagnostic technique for evaluating an individual muscle's contribution to an eye movement. [ 105 ]  Because  strabismus surgery  frequently needed repeating, a search was undertaken for non-surgical, injection treatments using various anesthetics, alcohols, enzymes, enzyme blockers, and snake neurotoxins. Finally, inspired by  Daniel B. Drachman 's work with chicks at Johns Hopkins, [ 106 ]   Alan B. Scott  and colleagues injected botulinum toxin into monkey extraocular muscles. [ 107 ]  The result was remarkable; a few picograms induced paralysis that was confined to the target muscle, long in duration, and without side effects.


After working out techniques for freeze-drying, buffering with  albumin , and assuring sterility, potency, and safety, Scott applied to the FDA for investigational drug use, and began manufacturing botulinum type A neurotoxin in his San Francisco lab. He injected the first strabismus patients in 1977, reported its clinical utility in 1980, [ 108 ]  and had soon trained hundreds of ophthalmologists in EMG-guided injection of the drug he named Oculinum ("eye aligner").


In 1986, Oculinum Inc, Scott's micromanufacturer and distributor of botulinum toxin, was unable to obtain product liability insurance, and could no longer supply the drug. As supplies became exhausted, people who had come to rely on periodic injections became desperate. For four months, as liability issues were resolved, American blepharospasm patients traveled to Canadian eye centers for their injections. [ 109 ]


Based on data from thousands of people collected by 240 investigators, Oculinum Inc (which was soon acquired by Allergan) received FDA approval in 1989 to market Oculinum for clinical use in the United States to treat adult strabismus and  blepharospasm . Allergan then began using the trademark Botox. [ 110 ]  This original approval was granted under the  1983 US Orphan Drug Act . [ 111 ]


The effect of botulinum toxin type-A on reducing and eliminating forehead wrinkles was first described and published by Richard Clark, MD, a plastic surgeon from Sacramento, California. In 1987 Clark was challenged with eliminating the disfigurement caused by only the right side of the forehead muscles functioning after the left side of the forehead was paralyzed during a facelift procedure. This patient had desired to look better from her facelift, but was experiencing bizarre unilateral right forehead eyebrow elevation while the left eyebrow drooped, and she constantly demonstrated deep expressive right forehead wrinkles while the left side was perfectly smooth due to the paralysis. Clark was aware that Botulinum toxin was safely being used to treat babies with strabismus and he requested and was granted FDA approval to experiment with Botulinum toxin to paralyze the moving and wrinkling normal functioning right forehead muscles to make both sides of the forehead appear the same. This study and case report of the cosmetic use of Botulinum toxin to treat a cosmetic complication of a cosmetic surgery was the first report on the specific treatment of wrinkles and was published in the journal  Plastic and Reconstructive Surgery  in 1989. [ 112 ]  Editors of the journal of the American Society of Plastic Surgeons have clearly stated "the first described use of the toxin in aesthetic circumstances was by Clark and Berris in 1989." [ 113 ]


Also in 1987, Jean and Alastair Carruthers, both doctors in  Vancouver, British Columbia , observed that blepharospasm patients who received injections around the eyes and upper face also enjoyed diminished facial glabellar lines ("frown lines" between the eyebrows). Alastair Carruthers reported that others at the time also noticed these effects and discussed the cosmetic potential of botulinum toxin. [ 114 ]  Unlike other investigators, the Carruthers did more than just talk about the possibility of using botulinum toxin cosmetically. They conducted a clinical study on otherwise normal individuals whose only concern was their eyebrow furrow. They performed their study between 1987 and 1989 and presented their results at the 1990 annual meeting of the American Society for Dermatologic Surgery. Their findings were subsequently published in 1992. [ 115 ]


William J. Binder  reported in 2000 that people who had cosmetic injections around the face reported relief from chronic headache. [ 116 ]  This was initially thought to be an indirect effect of reduced muscle tension, but the toxin is now known to inhibit release of peripheral nociceptive neurotransmitters, suppressing the central pain processing systems responsible for  migraine  headache. [ 117 ] [ 118 ]


As of 2018 [update] , botulinum toxin injections are the most common cosmetic operation, with 7.4 million procedures in the United States, according to the  American Society of Plastic Surgeons . [ 119 ]


The global market for botulinum toxin products, driven by their cosmetic applications, was forecast to reach $2.9 billion by 2018. The facial aesthetics market, of which they are a component, was forecast to reach $4.7 billion ($2 billion in the US) in the same timeframe. [ 120 ]


In 2020, 4,401,536 botulinum toxin Type A procedures were administered. [ 121 ]  In 2019 the botulinum toxin market made US$3.19 billion. [ 122 ]


Botox cost is generally determined by the number of units administered (avg. $10–30 per unit) or by the area ($200–1000) and depends on expertise of a physician, clinic location, number of units, and treatment complexity. [ 123 ]


In the US, botox for medical purposes is usually covered by insurance if deemed medically necessary by a doctor and covers a plethora of medical problems including overactive bladder (OAB), urinary incontinence due to neurologic conditions, headaches and migraines, TMJ, spasticity in adults, cervical dystonia in adults, severe axillary hyperhidrosis (or other areas of the body), blepharospasm, upper or lower limb spasticity. [ 124 ] [ 125 ]


Botox for excessive sweating is FDA approved. [ 71 ]


Standard areas for aesthetics botox injections include facial and other areas that can form fine lines and wrinkles due to every day muscle contractions and/or facial expressions such as smiling, frowning, squinting, and raising eyebrows. These areas include the glabellar region between the eyebrows, horizontal lines on the forehead, crow's feet around the eyes, and even circular bands that form around the neck secondary to platysmal hyperactivity. [ 126 ]


Botulinum toxin has been recognized as a potential agent for use in  bioterrorism . [ 127 ]  It can be absorbed through the eyes, mucous membranes, respiratory tract, and non-intact skin. [ 128 ]
The effects of botulinum toxin are different from those of nerve agents involved insofar in that botulism symptoms develop relatively slowly (over several days), while nerve agent effects are generally much more rapid. Evidence suggests that nerve exposure (simulated by injection of  atropine  and  pralidoxime ) will increase mortality by enhancing botulinum toxin's mechanism of toxicity. [ 129 ]
With regard to detection, protocols using  NBC  detection equipment (such as M-8 paper or the ICAM) will not indicate a "positive" when samples containing botulinum toxin are tested. [ 130 ]  To confirm a diagnosis of botulinum toxin poisoning, therapeutically or to provide evidence in death investigations, botulinum toxin may be quantitated by immunoassay of human biological fluids; serum levels of 12–24 mouse LD 50  units per milliliter have been detected in poisoned people. [ 131 ]


During the early 1980s, German and French newspapers reported that the police had raided a  Baader-Meinhof  gang safe house in Paris and had found a makeshift laboratory that contained flasks full of  Clostridium botulinum , which makes botulinum toxin. Their reports were later found to be incorrect; no such lab was ever found. [ 132 ]


Commercial forms are marketed under the brand names Botox (onabotulinumtoxinA), [ 19 ] [ 83 ] [ 133 ]  Dysport/Azzalure (abobotulinumtoxinA), [ 83 ] [ 134 ]  Letybo (letibotulinumtoxinA), [ 1 ] [ 2 ] [ 135 ]  Myobloc (rimabotulinumtoxinB), [ 21 ] [ 83 ]  Xeomin/Bocouture (incobotulinumtoxinA), [ 136 ]  and Jeuveau (prabotulinumtoxinA). [ 137 ] [ 63 ]


Botulinum toxin A is sold under the brand names Jeuveau, Botox, and Xeomin. Botulinum toxin B is sold under the brand name Myobloc. [ 21 ]


In the United States, botulinum toxin products are manufactured by a variety of companies, for both therapeutic and cosmetic use. A US supplier reported in its company materials in 2011 that it could "supply the world's requirements for 25  indications  approved by Government agencies around the world" with less than one gram of raw botulinum toxin. [ 138 ]  Myobloc or Neurobloc, a botulinum toxin type B product, is produced by Solstice Neurosciences, a subsidiary of US WorldMeds. AbobotulinumtoxinA), a therapeutic formulation of the type A toxin manufactured by  Galderma  in the United Kingdom, is licensed for the treatment of focal dystonias and certain cosmetic uses in the US and other countries. [ 84 ]  LetibotulinumtoxinA (Letybo) was approved for medical use in the United States in February 2024. [ 1 ]


Besides the three primary US manufacturers, numerous other botulinum toxin producers are known. Xeomin, manufactured in Germany by  Merz , is also available for both therapeutic and cosmetic use in the US. [ 139 ]  Lanzhou Institute of Biological Products in China manufactures a botulinum toxin type-A product; as of 2014, it was the only botulinum toxin type-A approved in China. [ 139 ]  Botulinum toxin type-A is also sold as Lantox and Prosigne on the global market. [ 140 ]  Neuronox, a botulinum toxin type-A product, was introduced by Medy-Tox of South Korea in 2009. [ 141 ]


Botulism toxins are produced by bacteria of the genus  Clostridium,  namely  C. botulinum ,  C. butyricum ,  C. baratii  and  C. argentinense , [ 142 ]  which are widely distributed, including in soil and dust. Also, the bacteria can be found inside homes on floors, carpet, and countertops even after cleaning. [ 143 ]  Complicating the problem is that the taxonomy for  C. botulinum  remains chaotic. The toxin has likely been  horizontally transferred  across lineages, contributing to the multi-species pattern seen today. [ 144 ] [ 145 ]


Food-borne botulism results, indirectly, from ingestion of food contaminated with  Clostridium  spores, where exposure to an  anaerobic environment  allows the spores to germinate, after which the bacteria can multiply and produce toxin. [ 143 ]  Critically, ingestion of toxin rather than spores or vegetative bacteria causes  botulism . [ 143 ]  Botulism is nevertheless known to be transmitted through canned foods not cooked correctly before canning or after can opening, so is preventable. [ 143 ]  Infant botulism arising from consumption of honey or any other food that can carry these spores can be prevented by eliminating these foods from diets of children less than 12 months old. [ 146 ]


Proper refrigeration at temperatures below 4.4 °C (39.9 °F) slows the growth of  C. botulinum . [ 147 ]  The organism is also susceptible to high salt, high oxygen, and low pH levels. [ 35 ] [ failed verification ]  The toxin itself is rapidly destroyed by heat, such as in thorough cooking. [ 148 ]  The spores that produce the toxin are heat-tolerant and will survive boiling water for an extended period of time. [ 149 ]


The botulinum toxin is  denatured  and thus deactivated at temperatures greater than 85 °C (185 °F) for five minutes. [ 35 ]  As a zinc  metalloprotease  (see below), the toxin's activity is also susceptible, post-exposure, to  inhibition  by  protease inhibitors , e.g., zinc-coordinating  hydroxamates . [ 93 ] [ 150 ]


University-based ophthalmologists in the US and Canada further refined the use of botulinum toxin as a therapeutic agent. By 1985, a scientific protocol of injection sites and dosage had been empirically determined for treatment of  blepharospasm  and strabismus. [ 151 ]  Side effects in treatment of this condition were deemed to be rare, mild and treatable. [ 152 ]  The beneficial effects of the injection lasted only four to six months. Thus, blepharospasm patients required re-injection two or three times a year. [ 153 ]


In 1986, Scott's micromanufacturer and distributor of Botox was no longer able to supply the drug because of an inability to obtain product liability insurance. People became desperate, as supplies of Botox were gradually consumed, forcing him to abandon people who would have been due for their next injection. For a period of four months, American blepharospasm patients had to arrange to have their injections performed by participating doctors at Canadian eye centers until the liability issues could be resolved. [ 109 ]


In December 1989, Botox was approved by the US FDA for the treatment of strabismus, blepharospasm, and  hemifacial spasm  in people over 12 years old. [ 110 ]


In the case of treatment of  infantile esotropia  in people younger than 12 years of age, several studies have yielded differing results. [ 57 ] [ 154 ]


The effect of botulinum toxin type-A on reducing and eliminating forehead wrinkles was first described and published by Richard Clark, MD, a plastic surgeon from Sacramento, California. In 1987 Clark was challenged with eliminating the disfigurement caused by only the right side of the forehead muscles functioning after the left side of the forehead was paralyzed during a facelift procedure. This patient had desired to look better from her facelift, but was experiencing bizarre unilateral right forehead eyebrow elevation while the left eyebrow drooped and she emoted with deep expressive right forehead wrinkles while the left side was perfectly smooth due to the paralysis. Clark was aware that botulinum toxin was safely being used to treat babies with strabismus and he requested and was granted FDA approval to experiment with botulinum toxin to paralyze the moving and wrinkling normal functioning right forehead muscles to make both sides of the forehead appear the same. This study and case report on the cosmetic use of botulinum toxin to treat a cosmetic complication of a cosmetic surgery was the first report on the specific treatment of wrinkles and was published in the journal  Plastic and Reconstructive Surgery  in 1989. [ 112 ]  Editors of the journal of the American Society of Plastic Surgeons have clearly stated "the first described use of the toxin in aesthetic circumstances was by Clark and Berris in 1989." [ 113 ]


J. D. and J. A. Carruthers also studied and reported in 1992 the use of botulinum toxin type-A as a cosmetic treatment.[78] They conducted a study of participants whose only concern was their glabellar forehead wrinkle or furrow. Study participants were otherwise normal. Sixteen of seventeen participants available for follow-up demonstrated a cosmetic improvement. This study was reported at a meeting in 1991. The study for the treatment of  glabellar  frown lines was published in 1992. [ 115 ]  This result was subsequently confirmed by other groups (Brin, and the Columbia University group under Monte Keen [ 155 ] ). The FDA announced regulatory approval of botulinum toxin type A (Botox Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines) in 2002 after extensive clinical trials. [ 156 ]  Well before this, the cosmetic use of botulinum toxin type A became widespread. [ 157 ]  The results of Botox Cosmetic can last up to four months and may vary with each patient. [ 158 ]  The US  Food and Drug Administration  (FDA) approved an alternative product-safety testing method in response to increasing public concern that  LD50  testing was required for each batch sold in the market. [ 159 ] [ 160 ]


Botulinum toxin type-A has also been used in the treatment of  gummy  smiles; [ 161 ]  the material is injected into the hyperactive muscles of upper lip, which causes a reduction in the upward movement of lip thus resulting in a smile with a less exposure of  gingiva . [ 162 ]  Botox is usually injected in the three lip elevator muscles that converge on the lateral side of the ala of the nose; the  levator labii superioris  (LLS), the  levator labii superioris alaeque nasi muscle  (LLSAN), and the  zygomaticus minor  (ZMi). [ 163 ] [ 164 ]


Botulinum toxin type-A is now a common treatment for muscles affected by the  upper motor neuron  syndrome (UMNS), such as  cerebral palsy , [ 32 ]  for muscles with an impaired ability to effectively  lengthen . Muscles affected by UMNS frequently are limited by  weakness , loss of  reciprocal inhibition , decreased movement control, and hypertonicity (including  spasticity ). In January 2014, Botulinum toxin was approved by UK's  Medicines and Healthcare products Regulatory Agency  (MHRA) for the treatment of ankle disability due to lower limb spasticity associated with stroke in adults. [ 51 ]  Joint motion may be restricted by severe muscle imbalance related to the syndrome, when some muscles are markedly hypertonic, and lack effective active lengthening. Injecting an overactive muscle to decrease its level of contraction can allow improved reciprocal motion, so improved ability to move and exercise. [ 32 ]


Sialorrhea  is a condition where oral secretions are unable to be eliminated, causing pooling of saliva in the mouth. This condition can be caused by various neurological syndromes such as  Bell's palsy , intellectual disability, and cerebral palsy. Injection of botulinum toxin type-A into salivary glands is useful in reducing the secretions. [ 165 ]


Botulinum toxin type-A is used to treat  cervical dystonia , but it can become ineffective after a time. Botulinum toxin type B received FDA approval for treatment of cervical  dystonia  in December 2000. Brand names for botulinum toxin type-B include Myobloc in the United States and Neurobloc in the European Union. [ 139 ]


Onabotulinumtoxin A (trade name Botox) received FDA approval for treatment of chronic  migraines  on 15 October 2010. The toxin is injected into the head and neck to treat these chronic headaches. Approval followed evidence presented to the agency from two studies funded by Allergan showing a very slight improvement in incidence of chronic migraines for those with migraines undergoing the Botox treatment. [ 166 ] [ 167 ]


Since then, several randomized control trials have shown botulinum toxin type A to improve headache symptoms and quality of life when used prophylactically for participants with chronic  migraine [ 168 ]  who exhibit headache characteristics consistent with: pressure perceived from outside source, shorter total duration of chronic migraines (<30 years), "detoxification" of participants with coexisting chronic daily headache due to medication overuse, and no current history of other preventive headache medications. [ 169 ]


A few small trials have found benefits in people with  depression . [ 170 ] [ 171 ] [ 172 ]  A 2021 meta-analysis supports the usefulness of botox in unipolar depression, but finds significant heterogenity among the findings. [ 173 ]  The main hypothesis for its action is based on the  facial feedback hypothesis . [ 174 ]  Another hypothesis involves a connection between the facial muscle and specific brain regions in animals, but additional evidence is required to support or disprove this theory. [ 172 ]


The drug for the treatment of  premature ejaculation  has been under development since August 2013, and is in  Phase II  trials. [ 171 ] [ 175 ]


A  brachioplasty , commonly called an  arm lift , is a  surgical procedure  to reshape and provide improved contour to the upper arms and connecting area of chest wall. [ 1 ]  Although "brachioplasty" is commonly used to describe a specific procedure for the upper arms, the term can also be used to describe any surgical arm contouring. Brachioplasty is often used to address issues such as excessive loose skin or excessive fat in the arms when it does not respond well to diet and exercise. [ 2 ]


The least-invasive manner to contour the upper arms is to simply remove extra fat via  liposuction . However, traditional deep liposuction often leaves sagging and wrinkled skin. An alternative to this is Circumferential para-Axillary Superficial Tumescent (CAST) liposuction, which maximizes the skin retraction. [ 3 ]


Under the right conditions such as adequate skin elasticity and minimal excess skin, the surgical incision for the brachioplasty can be placed under the arm. This allows for easy concealment of the scar. Minimal incision brachioplasty includes lipoplasty of the upper arm, wide-axillary and upper-arm skin excision, and dermal suspension of the upper-arm skin to the axillary fascia. [ 4 ]


The typical brachioplasty involves removing excessive loose skin via  surgical excision , leaving a significant scar along the bottom of the upper arms.


If there is also a significant amount of loose skin that goes from the upper arms and continues along the chest wall, an extended brachioplasty may be called for. In an extended brachioplasty, the incision and excision of skin continues along the upper arm onto the area under the arm along the chest wall.


This method is used for patients with an enormous amount of soft tissue excess. Fish-incision brachioplasty uses mathematical measurements and anatomic marking that allows the preoperative marking of the incision in the shape of a fish. [ 5 ]


This technique is used to decrease the post- operative seroma formation and nerve injury. In this method liposuction is done for the arm with excessive liposuction under the area of excision to make it paper thin. Only the skin over the marked area is excised followed by invagination of the tissue and closure with dermal to dermal sutures and skin edge closure.


In this procedure anchoring of the arm flap to the  axillary fascia  is secured along with strong superficial fascial system repair of incisions. This method reduces the risk of widening or migration of scars and unnatural contours. [ 6 ]


This technique uses a mold to mark the incision in an italic double S-shape for better incision control, symmetrical and smaller scars. This method has often been used in association with other brachioplasty procedures. [ 7 ]


Some of the possible complications associated with brachioplasty include: [ 8 ]


Buccal fat pad extraction  or  buccal fat removal  is a  plastic surgery  procedure that removes a piece of   buccal fat-pad  tissue from each side of the face. This reduces the appearance of cheek puffiness, creating a sharper jawline. The amount of fat removed varies based on the desired facial shape. [ 1 ]  It is a strictly cosmetic surgery. [ 2 ]


The  buccal fat pad  was first described by  Lorenz Heister  in 1732 as a glandular tissue. In 1802,  Xavier Bichat  correctly defined the structure as fat tissue and popularized awareness of it. [ 3 ] [ 4 ]


In 2021,  Chrissy Teigen  revealed that she had undergone buccal fat removal. The following year,  The New York Times  reported that the procedure was gaining popularity due to discussion on  Twitter  and  TikTok , and quoted a plastic surgeon who called it "one of the classic celebrity secret plastic surgeries". [ 2 ]  Speculation about celebrity buccal fat removal became a popular subject online, with people such as  Bella Hadid , [ 5 ]   Lea Michele  and  Khloe Kardashian [ 6 ]  guessed to have undergone it.


The  American Society of Plastic Surgeons  did not collect statistics on buccal fat removal until 2022. That year, they recorded 4,543 such procedures performed by their surgeons, making it the least popular facial technique that they recorded statistics for. [ 7 ]


Buccal fat removal is a cosmetic procedure with no medical benefit, and thus rarely covered by insurance. It is typically performed by plastic surgeons.


According to  RealSelf , the average cost in 2023 was $4,097, but could go as low as $1,000. [ 8 ]  Interviewed by  The New York Times  in 2022, one plastic surgeon stated he charged $40,000 for the procedure, while others said they typically charged between $7,000 and $16,000. The  Times  also described a  medical tourist  who got the procedure for $600 in  Tijuana  2020. [ 2 ]


Buccal fat removal is often performed as a solo procedure but can be done alongside a facelift, chin implant,  neck lift  or any other surgery attempting to add definition to the face. It is also often done in combination with chin liposuction and fat grafting.


The reduction of buccal fat pad is usually performed under local anesthesia with the patient completely awake. The typical approach for removing the buccal fat pad is through an incision in the mouth, towards the back of the oral cavity, near the second upper  molar . The  buccinator muscle  is then encountered and without making an incision, the fibers are separated until the buccal fat is seen. Once the buccal fat is visualized, a thin casing over the fat is opened and the fat is gently teased out while gentle pressure is applied externally. The fat is then cauterized at the base and removed. The remainder of the buccal fat pad then is replaced to its anatomic site and the oral mucosa is sutured close, and the two incisions are  sutured . The procedure typically takes about 30 minutes.


Patients typically have swelling for a few days, but often this swelling is not visible externally. Typically, self absorbing sutures that dissolve on their own are used. The final results can take up to 3 months to manifest.


Injury to the buccal branch of the  facial nerve  is a risk.  The buccal branch nerves that might be affected control facial functions, therefore, such damage might result in partial facial paralysis, regional facial numbness, loss of  taste , et cetera. Likewise, damage to the  parotid duct  also might occur in men and women whose  parotid ducts  run deep to the buccal fat pad, which can lead to a salivary fistula or buildup of saliva. [ 9 ]


Buccal fat removal is permanent; the fat pads do not grow back. However, new techniques for restoring buccal fat such as injecting fat intra-orally back into the buccal space or applying a dermal fat graft are gaining popularity. Other options include mimicry with  injectable fillers . [ 1 ]  There is a lack of research on its long-term health effects. [ 10 ]


In an aesthetic sense, buccal fat removal may cause an excessively gaunt appearance when the cheeks naturally lose more volume with age. [ 11 ]


The surgery and discussion of it became a trend in the early 2020s, gaining the colloquial nickname "Handsome Squidward surgery", referencing an exaggeratedly chiseled face from the  SpongeBob SquarePants  episode  "The Two Faces of Squidward" . [ 12 ] [ 13 ] [ 14 ]


Capsular contracture  is a response of the  immune system  to foreign materials in the human body. Medically, it occurs mostly in context of the  complications  from  breast implants  and  artificial joint  prosthetics.


The occurrence of capsular contraction follows the formation of capsules of tightly woven  collagen  fibers, created by the  immune response  to the presence of foreign objects surgically installed to the human body, e.g. breast implants,  artificial pacemakers ,  orthopedic prostheses ; biological protection by isolation and toleration. Capsular contracture occurs when the collagen-fiber capsule shrinks, tightens and compresses the breast implant, much like the collapse of a bubble gum bubble. [ 1 ]  It is a medical complication that can be painful and discomforting, and might distort the aesthetics of the breast implant and the breast. Although the cause of capsular contracture is unknown, factors common to its incidence include bacterial contamination, rupture of the breast-implant shell, leakage of the silicone-gel filling, and  hematoma .


Moreover, because capsular contracture is a consequence of the immune system defending the patient's bodily integrity and health, it might recur, even after the requisite corrective surgery for the initial incidence. The degree of an incidence of capsular contracture is graded using the four-grade Baker scale:


The surgical implantation methods that have reduced capsular contracture include submuscular breast implant placement, using either textured or polyurethane-coated implants, [ 2 ] [ 3 ] [ 4 ]  limited handling of the implants, minimal contact with the chest wall skin before their insertions, and irrigating the surgical sites with triple-antibiotic solutions. [ 5 ] [ 6 ]  The use of macrotextured implants and polyurethene-coated implants may increase the risk of  BIA-ALCL , a rare form of lymphoma associated to the presence of breast implants. [ 7 ] [ 8 ]


The correction of capsular contracture might require the surgical removal (release) of the capsule, or the removal, and possible replacement, of the breast implant, itself. Closed capsulotomy (disrupting the capsule via external manipulation), a once-common maneuver for treating hard capsules, was discontinued because it might rupture the breast implant. Non-surgical methods of treating capsules include massage, external  ultrasound , [ 9 ]  treatment with  leukotriene  pathway inhibitors (e.g.  Accolate ,  Singulair ), [ 10 ] [ 11 ]  and pulsed electromagnetic field therapy. [ 12 ]


The  Mentor Worldwide LLC  corporation, one of the three, U.S. FDA-approved breast-implant device manufacturers, conducted a study of the  medical complications  suffered by breast implantation surgery patients. In March 2000, at a Food and Drug Administration presentation, the Mentor report indicated that 43 per cent of patients with saline breast implants reported medical complications occurring within three years of the surgery; moreover, 10 per cent of that percentage group complained of capsular contracture. [ citation needed ]


Cheiloplasty  or surgical lip restoration (from   Greek :  χείλος   kheilos  – "lip") is the technical term for surgery of the  lip  usually performed by a  plastic surgeon  or  oral and maxillofacial surgeon . Among other procedures it includes lip reduction, the process of surgically reducing the size of the lip or lips to reduce the appearance of abnormally large or protruding lips, as well as the process of forming an artificial tip or part of the lips by using a piece of healthy  tissue  from some neighboring part. The procedure can also larger.


Cheiloplasty  can be performed to treat  tight lip syndrome  in  Shar Pei  dogs by repositioning the lower lip and allowing it to heal in a normal position. [ 1 ]


Chin augmentation  using  surgical implants  alter the underlying structure of the  face , intended to balance the facial features. The specific medical terms  mentoplasty  and  genioplasty  are used to refer to the reduction and addition of material to a patient's  chin . This can take the form of chin height reduction or chin rounding by  osteotomy , or chin augmentation using implants. Altering the facial balance is commonly performed by modifying the chin using an implant inserted through the mouth. The intent is to provide a suitable projection of the chin as well as the correct height of the chin which is in balance with the other facial features. [ 1 ]


This operation is often, but not always, performed at the time of  rhinoplasty  to help balance the facial proportions.  Chin augmentation may be achieved by manipulation of the jaw bone (mandible) and augmentation utilizing this technique usually provides a more dramatic correction than with the use of prosthetic implants.


Chin implants are used in the cosmetic industry to alter one's profile [ 2 ]  to resolve confidence and self-esteem issues by the physical augmentation of an individual's jawline and neck. [ 3 ]  Patients' own bone is donated from ribs and from part of the pelvis (the ilium). Use of donated bone implants in chin augmentation, even the patient's own, appears to be associated with a higher rate of  infection , even after the implant has been in place for decades.


Chin augmentation is still popular because it is a relatively easy operation for the patient while producing noticeable changes in the  silhouette  of the face. This type of surgery is usually performed by an oral and maxillofacial surgeon, otolaryngologist, or plastic surgeon.


T-osteotomy method (or mini V-line) [ 4 ]  is used to narrow and lengthen the chin using an osteotomy technique formulated by Korean surgeons. The surgery is performed under general anesthesia (orotracheal intubation) using an intraoral approach. [ 5 ]  Using a double-bladed reciprocating saw, [ 6 ]  a horizontal osteotomy is performed, leaving a small portion of bone in the middle. Then two vertical osteotomies are performed in an upside-down trapezoidal shape which is excised. The bones remaining from the horizontal osteotomy are then attached and adjusted to lengthen the chin, and advanced forward for an additional frontal chin projection if required. [ 5 ]  Pre-bent titanium plates and screws are used to fixate the bone to its new position. [ 6 ]  The chin can be lengthened 2 to 3 mm on average. [ 7 ]


The mentalis muscles controls the elevation functions of the lower lip and chin, so extra caution should be taken to carefully attach the mentalis muscle back after the surgery. [ 8 ] [ 9 ]


The usual complications are relatively minor and include swelling,  hematoma  (blood pooling), weakness or numbness of the lower lip, which usually does not last long. Other, less common risks include infection, bony changes, displacement of the implant, and nerve damage. [ 10 ]  Surgeon experience can help reduce risks of complications. [ 11 ]


Chewing should be kept at a minimum immediately after this procedure, and patients are recommended to eat only soft food and drink for a time after the surgery.