p. 217), adnexal, rare skin and other soft tissue cancers.Plastic surgery is a broad surgical speciality which encompasses the management of a wide range of elective and acute pathologies. Its spectrum includes skin and soft tissue oncology, microvascular reconstruction, hand and upper limb, oncoplastic breast, aesthetics, head and neck, burns, lower limb trauma, and paediatric/cleft/craniofacial surgery. Plastic surgeons are heavily involved in cancer and trauma reconstruction of all parts of the body that require surgery following tissue loss, or for specialist functional and aesthetic considerations. Plastic surgery aims to restore optimal ‘form and function’ for patients.
Trivia
Originally derived from the Greek ‘plastikos’ (which means to mould or reshape), plastic surgery is a surgical specialty which encompasses both reconstructive and aesthetic surgery.
These patients usually undergo day case surgery under local anaesthetic (for smaller lesions). These are excellent cases to practise basic lump examinations and to assess important characteristics such as the depth, mobility, and attachments of the lesion to the surrounding structures. Understanding these relationships early will help you develop a solid foundation for future examinations (including lymph nodes and malignancies).
Injuries range from soft tissue lacerations, to bony fractures and complex injuries involving both hands. Follow the on-call surgeon, assess these acute injuries, learn how to interpret radiographs, and present your findings; these activities provide powerful learning experiences.
These can typically be seen at dedicated skin oncology clinics and operating lists (smaller lesions will likely be on day case local anaesthetic lists; larger lesions requiring major reconstruction will tend to be performed under GA). Learn to comment on skin lesion appearances (including the size, shape, symmetry, attachment and surface of the lesion) and to examine the local and regional lymph node basins.
Seen in specialist cleft centres due to the specialist MDT input required (e.g. surgeons, psychologists, geneticists, speech therapists, and specialist nurses). Attend outpatient clinics, sessions with the speech therapists, and other specialists to gain a broader understanding of the patient journey from birth, through surgery, to speech therapy and later development.
Patients usually present to the ED but are only managed definitively in specialist burns centres or units. Make yourself available to join the burns team on-call. The resuscitation and multifaceted management of major burns is highly specialized, exciting, and can be very satisfying.
Lower limb trauma such as open tibial fractures are one of the most common injuries referred by orthopaedic surgeons. These injuries are typically high-energy polytraumas and can be extremely gory! Get involved with every aspect of care in these patients, from the initial assessment and resuscitation to the surgical debridement and reconstruction.
Plastic surgery is an ideal rotation to master the techniques of delicate tissue handling, meticulous suturing, and to gain an appreciation for aesthetic refinements (e.g. when repairing facial wounds). You can learn to use a hand-held Doppler (also used by vascular surgeons) for finding the tiny blood vessels (perforators) in the skin and when assessing certain flaps in the postoperative period.
Uses a thin, hollow needle to aspirate samples of tissue or fluid from an organ of the body or a lump (e.g. lymph node). It can identify the type of cells within a mass, or provide information on the treatment progress of a previously known lump. It is commonly used to investigate lumps found in the breast or thyroid, but it can also be used in other palpable lymph nodes, and is a useful way of detecting cancer (e.g. melanoma metastases to the groin).
A diagnostic procedure that identifies and removes the sentinel lymph node (the first node to be involved in lymphatic spread from a particular area of the body). This is an excellent modality to identify if a cancer has spread to the lymph nodes. There are two important technical aspects that aid the procedure: (1) preoperative injection of radioactive tracer into the lymphatics of the primary lesion, which highlights the location of the node in the associated lymph node basin. This can then be detected intraoperatively on table by a gamma probe; (2) the surgeon may inject blue dye in the same area; this stains the lymphatics and involved lymph node(s) draining this site.
Used in the planning phase for free flap reconstruction of the lower limb (to assess availability and patency of vessels) or breast (to identify appropriate perforators in DIEP (deep inferior epigastric artery perforator flap) autologous reconstruction). It enables the visualization of the vascular supply and also the position and size of arterial perforators and veins which can influence the design and choice of free flaps.
Skin cancer is a broad subspecialty which encompasses BCC, SCC, malignant melanoma (see p. 217), adnexal, rare skin and other soft tissue cancers.
Sun exposure (UV radiation), pale skin (lower Fitzpatrick types), radiation or chemical exposure (tar/soot), age, immunosuppression, PMHx, FHx, and dysplastic naevi (for malignant melanoma).
British Association of Dermatologists (BAD) guidelines recommend specific excision margins for skin carcinomas. These currently guide treatment approaches in the UK, with continued research taking place.
Small BCCs <2 cm = 3–5 mm margin (a 3 mm margin will clear tumour in 85% of cases; a 4–5 mm margin will 
the peripheral clearance rate to 95%). Larger lesions will require larger excisions. Also, note that lesions are classified into low risk and high risk. Morphoeic subtype lesions require 13–15 mm margins to achieve 95% peripheral clearance.
Treated by wide local excision with 4 mm margins in low-risk tumours (<2 cm, well defined) and ≥6 mm in higher-risk cases which gives a 95% confidence of complete excision. Tumours classified as higher risk (e.g. >2 cm wide, >4 mm thick, ear/lip/nose, moderately/poorly/undifferentiated, extending into the subcutaneous tissue) are removed with a wider excision margin. Deep margin clearance is also important in skin cancer excisions.
Excisional biopsy confirms subtype and Breslow thickness among numerous microscopic characteristics. This subsequently guides excision margins of the residual scar (e.g. <1 mm thickness on excision biopsy requires 1 cm wide local excision, 1.01–2 mm thickness requires 1–2 cm excision). Patients who have had non-melanoma skin cancer have a tenfold higher risk of a second non-melanomatous skin cancer. Melanoma patients have a threefold higher risk than the average risk of getting a non-melanomatous skin cancer. These patients require regular follow-up for monitoring—for local recurrence, satellite lesions, and distant metastases.
Involves progressive circumferential (peripheral and deep) layered excision of tumour; each layer is analysed under the microscope in frozen sections in real time until clearance is achieved, to avoid extensive tissue resection. Recommended technique for certain anatomical or cosmetically sensitive areas (e.g. nose, eyelids) and tumour types (e.g. morphoeic BCC) to optimize treatment and reconstruction.
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• Change in the surface like scaling, oozing, bleeding, nodule, etc.
An area of skin and underlying subcutaneous tissue damaged as a result of sufficient and persistent pressure that impairs the blood supply. They can develop at any site; however, certain pressure area points such as the occiput, sacrum, ischium, and heels are at higher risk. Locally they can be worsened by moisture, infection, and shear forces, and systemically by poor wound healing (e.g. in diabetics and PVD). All patients are at risk of developing pressure sores although particularly susceptible groups include the elderly, malnourished, acutely ill, quadriplegic, and bed-bound patients. It must be noted that pressure sores are preventable, and NICE has published guidelines for the prevention and management of these sores. 10% of patients in acute care facilities develop pressure sores. Pressure sores are graded 1–4, depending on how deep the tissue damage extends (in grade 4, tissue necrosis extends down to muscle or bone). Management always begins with optimizing the local and systemic factors that contributed to the pressure sore in the first place (i.e. pressure relief, wound toilet and appropriate dressings, adequate nutrition, etc.) Surgery may be required in complex pressure sores for debridement and reconstruction.
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This is a method of assessing patients for the risk of developing pressure sores, based on their comorbidities and other factors: BMI, skin changes, age, sex, adverse healing, continence, neurological deficit, mobility, surgical intervention, nutrition, and drugs (steroids).
The face and upper lip develop between weeks 5–9 of pregnancy. Most clefts are identified either at the time of the routine 20-week scan, or soon after birth. The cleft can affect the lip, palate (roof mouth), or both. The cleft can involve a part or the whole area (i.e. partial or complete) and may be one-sided (unilateral) or affect both sides (bilateral). The management of cleft patients begins in the neonatal period and continues until their teenage years and adulthood. A cleft lip and palate is the most common facial birth defect in the UK (1 in 700). The most common finding is a cleft palate, found in ~ 50% of all cases; ~25% of affected children have a cleft lip and ~25% have both a cleft lip and palate.
A cleft palate is repaired because it can affect hearing, feeding, and, later, speech. A cleft lip (particularly if it extends from the lip to involve the alveola) may affect the growth of teeth. Repairing a cleft lip is important to restore the normal function of the mouth as well as to improve the cosmetic appearance, which is extremely important. Surgery is the usual treatment for cleft lip and palate. Other interventions consist of speech and language therapy and orthodontics. Most tend to have a normal appearance with minimal scarring and good speech postoperatively.
A rare condition (1 in 2000 births) involving the premature fusion of one or more of the fibrous sutures of the infant’s skull, causing the baby to be born with or develop an abnormally shaped head. 75% of cases affect boys. The skull compensates by growing in the direction parallel to the fused suture. If, however, the compensatory growth is insufficient to allow for normal brain growth, ICP 
persistent headaches, learning difficulties, and visual impairment (all in later childhood). Treatment is surgical, involving remodelling of the cranium. 80–95% of cases are isolated (non-syndromic) but may be associated with >150 syndromes.
As for all surgical patients, remember your ATLS® approach: ABCDE.
Make sure you take a detailed history and perform a meticulous examination every time. Remember that what may appear to be innocuous injuries on the surface, can be extensive and in actual fact be extremely disabling for the patient. There are some crucial aspects to the hand history: age, hand dominance, occupation, smoking status, and specific hobbies (e.g. musical instruments) are the first five details that should be elucidated. Ask about the exact circumstances that led to the injury including the timing (particularly important for amputations and open injuries) and the mechanism of injury (e.g. power tools, broken glass, and slamming doors).
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Irrigate the wound thoroughly with saline or warm running tap water to remove debris. Local anaesthesia may need to be infiltrated to avoid pain, but try to assess nerve function prior to this. Give a tetanus booster if the primary vaccination course is incomplete or boosters are not up to date. Consider human tetanus immunoglobulin in high-risk wounds (e.g. in soil/manure contamination).
Glass injuries will never fail to surprise you by the severity of internal damage to tendons, nerves, and vessels; power tools and DIY injuries tend to be bloody and involve extensive bone and soft tissue damage. Explore the patient's social circumstances, as these may prompt you to think about home help and community therapy upon hospital discharge. Assessment is based on look, feel, move, plus special tests. In summary, assess for skin, soft tissue, bone, and joint injuries systematically. Soft tissue in the hand includes tendons (flexors and extensors), nerves (motor and sensory), and blood vessels (arteries and veins). Dirty or contaminated wounds (e.g. animal bites, human bites, and work-related, dirty machinery-induced injuries) need to go to theatre as soon as possible (ideally within 24 hours for a washout), but clean cuts (including tendon and nerve injuries) can safely be done on the next available operating list as long as the wound has been irrigated and there is no joint exposure. Some patients may require antibiotics.
Closed fractures that require an operation may best be fixed a few days after the original injury, particularly if there is significant swelling which would first benefit from elevation (e.g. in a Bradford sling) to reduce oedema.
If a traumatic episode results in complete amputation whereby the body part is totally severed (e.g. a finger that has been sliced off and is brought in separately by the patient/family), this can sometimes be replanted (re-attached), especially when proper care is taken of the severed part and stump. Smoking unfavourable outcomes. In a partial amputation, some soft tissue connection remains. A partially severed extremity may or may not be able to be reattached in which case a ‘terminalization’ (down to the next proximal joint) is advised.
Plastic surgeons are frequently involved in the management of open fractures, working closely with the orthopaedic surgeons. Polytrauma patients need thorough assessment and resuscitation. It is important to consider the mechanics of the injury (i.e. low- vs high-energy impact). Plastic surgery involvement is mainly for soft tissue reconstruction (skin, muscle, nerve, and vessels) but bone injury must be documented (fracture site, size, shape, comminution, contamination, loss). The Gustillo–Anderson classification for open fractures is used to describe these injuries. Reconstruction in theatres involves repair of soft tissues plus providing adequate bone cover (if exposed). National lower limb trauma guidelines have been established, and can be found online (
www.bapras.org.uk) and are a British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons collective endeavour. A thorough neurovascular examination should be performed of the limb involved. There should be a high suspicion of compartment syndrome if there is severe pain or swelling peri-injury and perioperatively.
Can be caused by thermal (hot and cold), chemical (acid or alkali), or electrical injuries. Most burn accidents occur at home and in the workplace. About 75% of all burn injuries in children are preventable. Flame burns are the leading causes of burn injury in adults, while scalding is the leading cause of burn injury in children. Infants and the elderly are at the greatest risk for burn injury. Burns are classified by the mode of injury (e.g. scald/flame/chemical/electrical), their depth (e.g. superficial partial thickness/deep partial thickness/full thickness), and also the extent (e.g. dependent on total body surface area (TBSA) involved). Major burns are those covering >15% of the TBSA in adults and 10% in children. If major burns are taken to theatre, due to skin damage (what would have been their main barrier for thermoregulation), theatre temperatures are usually turned up to very warm levels.
The depth of the burn will depend on the temperature of the heat and how long it is applied for:
• Superficial erythema: involves the dermis only, skin is dry and intact, bright red, usually no/small blisters, very painful. This does not contribute towards TBSA calculation in a burn (e.g. sunburn).
• Superficial/partial thickness: the skin is pink/red and blistered, blanches on pressure application, and is very painful. This should heal spontaneously within 10–14 days.
• Deep dermal/deep partial thickness: the skin is pinky red or white, feels thickened, no blisters, does not blanch on pressure application, and has reduced sensation. This should heal in 3 weeks if left to heal alone and will likely leave a scar. Such burns may require debridement and grafting to heal more quickly.
• Full thickness: the skin is white, brown, or black, leathery, dry and painless. May need debridement ± skin grafting. There are indications for hydrosurgery, enzymatic debridement, or maggot therapy.
IV fluid resuscitation is required in burns of 15% in an adult, and 10% in a child or the elderly, and inhalation injuries, so these patients require admission. People who have lesser burns but in special areas such as the face or perineum usually also require admission, and suspected NAI must be seen by the paediatric on-call team. Refer obviously large full-thickness burns, or hand burns, and those requiring surgery.
The original formula noted a volume of 3.7–4.3 mL but has since been modified. It is currently one of the most popular formulas used (4 mL/%TBSA/kg). This calculates the total millilitres of crystalloid (e.g. Hartmann’s or Ringer’s lactate) required for the first 24 hours after the time of the burn. Give half of this volume in the first 8 hours, the remainder over the next 16 hours. Children additionally require maintenance fluid (dextrose saline) calculated based on their weight. The aim is to achieve adequate urine output and avoid fluid overload. Fluid resuscitation is a dynamic process and with regular assessments, fluid volumes can be titrated as necessary. Other formulas have been described; e.g. Mount Vernon, Brooke, Shriner’s (paediatric), and Galveston’s (paediatric).
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• Consider if >3% TBSA, partial thickness burns (2% TBSA in children).
• All deep dermal and full-thickness burns.
• All burns associated with electrical shock, chemical agents, NAI, relevant anatomy (face, hands, perineum, feet), circumferential to limbs/trunk/neck, and inhalation injury.
Plastic surgery should be considered a collection of specialized surgical techniques that once mastered (some with steep learning curves), can be utilized to solve difficult reconstructive challenges in most areas of the body.
Plastic surgeons are often required to deal with complex wounds following trauma, infection, or cancer. A vital skill that you can learn is how to assess a wound, debride it effectively, and decide on the type of procedure that is required to reconstruct it. When assessing a wound in theatre, it is imperative to identify and differentiate viable vs non-viable tissue. In the context of necrotic and infected wounds or heavy contamination, this can be more challenging.
Tips and tricks
There are a few assessment tools to keep in mind which will help you identify non-viable from viable tissue (dead from the living):
• Colour: of the tissue compared with surrounding similar tissue. Dermis which is black or is a fixed, non-blanching red is probably non-viable. When assessing fat, a bright, shiny yellow is healthy, whereas pale, cream-coloured or red fat is probably not.
• Temperature: changes in the skin can be very useful in determining if tissue is alive and hence well perfused or not.
• Bleeding: if in doubt, you can check for bleeding using a needle or by scoring with a knife.
• Tug test: when assessing a complex wound with fracture fragments and contamination, any tissue that is easy to pull away with a pair of forceps with minimal little resistance is unlikely to survive and should be removed.
The next task is to debride the wound. Effective debridement involves removing all non-viable tissue and contaminants and irrigating the wound with copious volumes of saline. Wounds should be debrided to remove all dead and contaminated tissue, exposing healthy, bleeding edges. Any devitalized tissue left in situ may become necrotic and liquefy collections, infections, and delays in wound healing. Reconstruction of a wound is the next step along this pathway. Achieving tissue healing in the quickest time, when possible, is the best way to prevent infections and complications. A plastic surgeon will always aim to reconstruct a wound with three factors in mind: form, function, and safety. Re-establishing form and function can get the patient back on the path of recovery and rehabilitation.
An example is the reconstruction of a burn scar contracture above a joint. By releasing the scar and reconstructing with a skin graft (with or without a dermal substitute) or flap, function is restored to what could otherwise become a stiff and immobile joint. Arguably the most important consideration is safety. The plastic surgeon must choose the most appropriate reconstruction to achieve the best form and functional result; however, it must be appropriate and safe for the individual patient. For example, it would be considered inappropriate to perform a highly technical reconstruction on a frail patient who may suffer if a prolonged GA is required, especially when there is an easier, shorter, and safer option available.
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This model was originally devised to help plan appropriate management. It includes a number of reconstructive options, which are progressively more complex:
1. Healing by secondary intention (allow to heal by granulation).
2. Healing by primary intention (suture).
3. Skin grafting (split thickness and full thickness).
When faced with a reconstructive challenge, choose the simplest option first and consider if it will give the best outcome in terms of form and function and if it is safe for the patient before moving up. This concept has been superseded by the reconstructive elevator—signifying the importance of selecting the most appropriate level of reconstruction as opposed to defaulting to the least complex; sometimes one may have to jump several options, or start immediately with a free flap as best management. We also now have other options to consider: topical negative pressure dressings (e.g. vacuum assisted closure) and dermal substitute matrices, in addition to tissue expansion.
A graft is a unit of tissue that is harvested from a donor area and transferred to another area of the body. The crucial factor is that the graft does not carry with it its blood supply; instead, in order to survive, it must get its blood supply from its new tissue bed. It is a reliable and repeatable procedure that reconstructs tissues with like-tissues using relatively simple techniques. Skin grafts are the commonest grafts performed. Skin grafts are used when a wound is too large to close directly, such as following a large skin cancer excision or an extensive defect following a large burn or necrotizing fasciitis.
Skin can be harvested as a shaving of the epidermis and part of the dermis (termed split-thickness skin graft) vs excised as full thickness of the skin (termed full-thickness skin graft). When a large amount of graft is required at several sites, split-thickness skin grafts are preferentially harvested. Meshing is a process of cutting the split-thickness skin graft in a criss-cross pattern making numerous small holes in the skin (using a mesher). This is performed to allow the graft to drape more easily in an uneven wound and to allow any fluid or blood to escape from underneath the graft (which may otherwise have lifted off the graft). Furthermore, when massive wound areas are encountered, such as in the case of large burns, then a skin graft can be meshed and expanded up to nine times its original size!
Skin grafts initially stick to the wound bed by fibrin adhesion. They are nourished directly by the plasma in the wound (plasma imbibition) for 48 hours. It is followed by a process of inosculation, which involves cut ends of arteries in the skin graft lining up and ‘kissing’ with ends of arteries in the wound bed. The graft is dependent on these processes for its survival over the first 4–5 days, after which revascularization of the graft occurs and it can then survive by itself.
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The skin receives its blood supply through a series of deep and superficial plexuses (networks): subepidermal, dermal, subdermal, subcutaneous, and prefascial.
Cartilage grafts are sometimes needed to reconstruct a defect of the nose or ear. These defects may be congenital, traumatic, or following cancer excisions. Cartilage is needed to provide shape and can be harvested from the ears, nasal septum, and ribs (costal cartilage). Bone grafts are used to fill gaps in the bone since skeletal continuity is vital for support and movement. Defects in the bone can result from trauma, infection (osteomyelitis), and congenital defects. Cancellous bone is typically harvested from the pelvic bone (e.g. iliac crest). Other forms of tissue grafting include, muscle, nerve, vein, and fat, which have specific indications.
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• Advantages: large grafts can be harvested, meshed to expand coverage, rapid healing, donor sites heal spontaneously with minimal scarring.
• Disadvantages: easily sheared and traumatized, less natural colour and texture, meshing pattern remains visible, significant contracture.
• Advantages: better match for normal skin colour and texture, less contracture, less contour deformity, remains soft and pliable, better over joints.
• Disadvantages: limited size of graft as donor site should be amenable to direct closure, higher risk of graft failure, scar at site.
A flap is a unit of tissue which is transferred from one part of the body to another, but at all times retains its blood supply. This enables surgeons to transfer much larger, more bulky tissues to fill deep defects and also transfer them to areas that may not be suitable for grafting, such as directly onto bone and over tendons. Remember, however, that attention must be paid to the resultant donor site, minimizing deformity and disability. Flaps can be classified according to their contents, circulation, contour, and contiguity.
Flaps can get their blood supply through a named artery that runs within that flap (axial flaps) or through a random network of small blood vessels that supply blood through the base of the flap (random pattern flaps). Random pattern flaps are relatively easy to raise, however they have a limited length:width ratio (up to 2:1 on the body, and 4:1 on the face possible due to its excellent blood supply). Axial pattern flaps receive their blood supply directly from a named artery and accompanying vein. They allow for a much greater length of flap to be raised and are generally more reliable. Axial flaps are subdivided into fasciocutaneous and musculocutaneous depending on the course that the blood vessels take before reaching and supplying the skin. Perforator flaps are now popular and have their own evolving nomenclature; they are generally named with a focus on the perforating vessel that the flap contains (e.g. ALT (anterolateral thigh flap), based on a perforator from the descending branch of lateral circumflex femoral artery).
A flap may be composed of any layer of soft tissue including skin, fat, fascia, muscle, or bone. The most common flaps that you will encounter in plastic surgery are fasciocutaneous flaps (containing skin and fascia) and muscle flaps (gracilis, latissimus dorsi, etc.).
Flaps can be described as local, regional, or distant depending on their origin. Local flaps are composed of tissue adjacent to the defect; regional flaps are composed of tissue from the same region (e.g. upper limb, head and neck or trunk); and distant flaps are composed of tissue from another part of the body and can be transferred whilst pedicled (still attached) or free (completely detached) flap, the latter requiring microsurgical anastomoses.
The contour of a flap describes the movement that a flap makes in order to reach its destination. These can be described as advancement, rotation, transposition, and interpolation. This refers mainly to local flaps (e.g. performed on the face: bilobed, V-Y advancement, cheek rotation). If a perforator vessel is identified (e.g. on Doppler or imaging), where a local flap can be designed, then a local perforator flap can be used for reconstruction of the defect (e.g. a lumbar artery perforator flap to reconstruct a defect on the back).
In trauma, microsurgery is often required for the anastomosis of tiny arteries and veins in amputated limbs, digits, and appendages. In breast cancer reconstruction, free flaps are usually harvested from the abdomen, e.g. DIEP flaps (and in certain cases from the medial thigh or buttocks) and transferred to reconstruct the breast. The arteries and veins of the abdominal tissue are anastomosed to recipient vessels in the chest or axilla. Nerves in the brachial plexus or peripherally in the arms or hands often need reconstruction. It is important to align the nerve axons accurately under a microscope to achieve the best re-innervation and functional outcomes from the nerve repair.
Aesthetic principles pervade all aspects of plastic surgery, including trauma, cancer reconstruction, burns, and, of course, aesthetic surgery.
The plastic surgeon will use the principles of aesthetic/cosmetic surgery, such as skin tension lines, natural creases, and ideal proportions in order to achieve the best aesthetic outcome in any scenario, wherever possible. Aesthetic surgery is a branch of plastic surgery which is concerned with providing an enhancement of shape and form of the body. History and examination must still be thorough, e.g. when taking a history for a breast reduction patient, you should ask about risk factors for malignancy and when examining you must also examine the breast and axillae for lumps; when taking a history for a blepharoplasty (eyelid rejuvenation) you must ask about vision/glasses/contact lenses/dry eyes, etc.
Aesthetic surgery is performed on all parts of the body including the face, breasts, trunk, and limbs.
Trivia
Breast enlargement remains the most popular procedure, with 11,135 augmentations performed in 2013, up 13% year-on-year, according to figures collected by the British Association of Aesthetic Plastic Surgeons. There are numerous types of implants. For example, in very basic terms these can be described by their shape (rounded vs. anatomical), or surface (textured vs. smooth). Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is topical. It is a rare and highly treatable type of lymphoma that can develop around breast implants, mainly certain textures. The ABS (Association of Breast Surgery), BAAPS, BAPRAS and MHRA have recently issued a joint UK update; it is important that you remain aware of this discussion for the future.
Autologous fat grafting for breast enlargement is also commonly performed, in both aesthetic and reconstructive cases.