What are common cosmetic surgical and nonsurgical procedures?

Common Cosmetic Surgical and Nonsurgical Procedures

Nonsurgical Procedures

Botulinum toxin injections and hyaluronic acid fillers are the two most commonly performed nonsurgical cosmetic procedures in the United States, with botulinum toxin being the single most popular cosmetic procedure overall. 1, 2

Injectable Neuromodulators (Botulinum Toxin)

• Botulinum toxin type A is FDA-approved for temporary improvement of moderate to severe glabellar lines (frown lines between the eyebrows), with a standard dose of 20 Units distributed across five injection sites. 3
• The most common treatment areas include the forehead, glabella (between eyebrows), and lateral canthal lines (crow's feet). 1
• Clinical trials demonstrate that 68-70% of patients achieve ≥2-grade improvement in glabellar line severity at 30 days post-injection, compared to only 1% with placebo. 3
• Adverse effects are transient and self-limited. 1

Dermal Fillers

• Hyaluronic acid is the most commonly used dermal filler because it is hypoallergenic and has predictable characteristics. 1
• Other filler types include calcium hydroxylapatite, poly L-lactic acid, and polymethylmethacrylate, each selected based on elasticity and viscosity requirements for specific anatomic applications. 1
• The most serious complication is vascular occlusion leading to tissue necrosis or blindness, requiring immediate recognition and management to prevent permanent sequelae. 1

Skin Resurfacing Procedures

• Chemical peels, laser treatments, and microdermabrasion are among the most frequently performed nonsurgical procedures. 2, 4
• For periorbital hyperpigmentation specifically, chemical peeling with TCA 3.75% and lactic acid 15% combination is the most effective treatment, showing excellent improvement in 38% of cases and superior results compared to platelet-rich plasma (PRP). 5
• Microneedling offers effective skin rejuvenation with minimal downtime. 4

Fat Reduction (Nonsurgical)

• Cryolipolysis (fat freezing) is the primary nonsurgical fat reduction modality, using cold temperatures to achieve lipolysis without surgery. 6
• Radiofrequency lipolysis devices use heat to destroy adipose tissue. 6
• Ultrasonographic modalities include both nonthermal low-intensity methods (mechanical fat cell destruction) and high-intensity focused ultrasound (thermal methods). 6

Surgical Procedures

Breast Surgery

Breast-conserving surgery (BCS) with oncoplastic techniques is the preferred approach for the majority of early breast cancer patients, maintaining cosmetic outcomes while achieving oncologic safety. 7

Breast Reconstruction

• Reconstruction options include implant-based procedures, autologous tissue transplantation, or combined approaches, and can be performed immediately or in a delayed fashion. 8
• For patients requiring post-mastectomy radiation, autologous tissue reconstruction is strongly preferred over tissue expanders/implants due to significantly lower risk of capsular contracture, malposition, poor cosmesis, and implant exposure. 7, 8
• When implant reconstruction is planned with radiation, a staged approach with immediate tissue expander placement followed by permanent implant placement after radiation completion is preferred. 7
• Immediate reconstruction is contraindicated only for inflammatory breast cancer due to high recurrence risk. 7, 8

Skin-Sparing and Nipple-Sparing Mastectomy

• Nipple-areolar complex (NAC)-sparing mastectomy should be limited to carefully selected patients with early-stage, biologically favorable cancers (Nottingham grade 1-2, node-negative, HER2-negative, no lymphovascular invasion) located >2 cm from the nipple. 7, 8
• Assessment of nipple margins is mandatory when performing NAC-sparing procedures. 7
• Absolute contraindications include Paget disease, bloody nipple discharge, or imaging findings suggesting malignant nipple involvement. 7
• Skin-sparing mastectomy reduces scar size and provides more natural breast shape, particularly when autologous tissue is used for reconstruction. 7

Liposuction

• Liposuction is performed using tumescent technique for local anesthesia, which has replaced the need for regional nerve blocks or general anesthesia in most cases. 6
• Variations include laser-assisted, power-assisted, and ultrasound-assisted liposuction, each using different energy applications to facilitate fat removal. 6
• Abdominoplasty can be combined with liposuction for management of excess skin. 6

Facial Cosmetic Surgery

• Brow lifts, midface lifts, and upper/lower blepharoplasty are established surgical procedures for facial rejuvenation. 2
• Fat sculpturing techniques address volume loss and contour irregularities. 2

Technical Principles for Optimal Cosmetic Outcomes

Surgical Technique Fundamentals

• Curvilinear skin incisions following Langer's lines (natural skin tension lines) achieve the best cosmetic results, except at the 3 o'clock and 9 o'clock breast positions and lower breast where radial incisions may be superior. 7
• The skin should be closed with subcuticular technique, and preservation of subcutaneous tissue with separate closure improves cosmetic outcomes. 7, 9
• Meticulous hemostasis is critically important to prevent hematoma formation, which complicates postoperative evaluation and healing. 8, 9
• Excision of skin segments should be avoided as this alters nipple position or inframammary crease placement. 7, 9

Common Pitfalls to Avoid

• Do not reapproximate breast tissue in a manner that appears adequate when the patient is supine but causes distortion when upright, as this creates excessive tension. 7, 9
• Periareolar incisions for peripheral breast lesions are inappropriate and should be avoided. 7
• Ensure adequate incision size to allow proper visualization without excessive tension on closure. 9