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Two hypotheses are unique to the study: higher (general) media exposure will predict the likelihood of considering having surgery; and highly religious subjects will be less likely to consider cosmetic surgery than less religious subjects. A total of 204 individuals (90 men, 114 women) ranging in age from 18 to 74 years (mean [± SD] age 34.73±16.14 years) participated in the present study. Most of the participants were of European Caucasian descent (67.2%), but other ethnic groups were also represented including Asian (12.3%) and Afro-Caribbean (2%). They rated their religiosity on a 7-point scale (1 = not at all; 7 = very) with a mean of 3.02±1.72. The majority of participants were either Christian (38.2%) or atheist (38.7%), although some were Buddhist (2.9%) or were of some other religious affiliation (12.3%). In terms of marital status, 31.4% were single, 26% were dating, 32.4% were married and 10.3% were of some other relationship status. Finally, most participants reported never undergoing cosmetic surgery (94.1%).Measures Likelihood of having cosmetic surgery scale (5): Questions assessed the participants’ acceptance of cosmetic surgery (five items) and their likelihood of undergoing cosmetic surgery (10 items) rated on a five-point agree-disagree scale. The two subscales were shown to have high alphas (acceptance: α=0.90, and likelihood: α=0.94). Self-esteem: The Rosenberg self-esteem scale (24) was used to measure participants’ self-worth. The scale consists of 10 items, each of which are rated on a four-point scale (1 = stongly disagree, 4 = strongly agree). The scale had good internal consistency in the current study (α=0.91). Life satisfaction scale (5): This five-item scale measures life satisfaction on a five-point scale (1 = strongly disagree, 5 = strongly agree). Participants were asked to indicate the extent to which they agreed or disagreed with the various statements (eg, ‘In most ways, my life is close to my ideal’). Cronbach’s alpha for this scale was This part of the questionnaire required participants to rate their overall physical attractiveness, facial attractiveness, body weight or size and body shape or figure. Participants were provided with a bell-curve graph showing the typical distribution of attractiveness scores (M=100±15). Thus, 70 was labelled unattractive, 85 low average, 100 average. This had successfully been used in previous studies (7). These four items had high internal consistency (α=0.95). Second, participants were asked about their time spent watching television, reading magazines, listening to podcasts and browsing the Internet, which were rated on a seven-point scale: 1 = ≥4 h; 2 = 2 h to 4 h, 3 = 1 h to <2 h; 4 =≤1 h; 5 = two to three times per week; 6 = once per week; 7 = less often. The following mean scores were recorded: television, M=3.97±1.02; magazines, M=3.02±1.10; pod-casts, M=1.48±1.06; and Internet, M=5.21±1.38. Due to the small number of individuals who reported having heard radio shows on cosmetic surgery, this item was not included in the analysis. available for use? F. What is the best way to restore form and function? G. Replace like with like: the best reconstruction will utilize tissues similar to the missing tissues (i.e., glabrous skin for reconstruction of the weight-bearing sole or fingertips). H. “Don’t throw anything away” 1. Spare parts surgery 2. Composite grafts 3. Biological dressings I. Designing incisions. Incision design is critical, as the location of scars impacts both their visibility as well as their ability to heal. 1. Ideal incision placement a. Langer’s lines: Langer, a 19th-century anatomy professor in Vienna, first studied and described the relationship between resting skin tension and wounds. However, his studies were carried out on cadavers and were never intended to serve as a guide for surgical technique. b. Borges described relaxed skin tension lines in 1962: these lines follow the furrows formed when skin is relaxed and are revealed by pinching the skin. (Figure 1) c. Best incision designs usually involve a combination of factors i. Allowing for appropriate access 16 ii. Taking advantage of pre-existent scars or wrinkles iii. Placement with respect to aesthetic subunits Figure 1. Relaxed skin tension lines (RSTL) versus other skin lines From Borges A. Plast Reconstr Surg 1984;73(1):144-50. 2. Aesthetic units and subunits (Figure 2) a. Have been described for multiple anatomic regions, including breast, face, and lower extremity b. Defined by naturally-occurring concave and convex surfaces c. Scars that cross aesthetic subunits are more noticeable than those that are hidden in the boundaries between subunits 17 Figure 2. Conforming to its underlying skeleton, the surface of the nose is crossed by gentle valleys and low ridges that divide it into topographic subunits. They are the dorsum, tip, sidewalls, alar lobules, and soft triangles. From Burget G, et al. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76(2):239-47. E. Methods of excision 1. Elliptical a. Most common method b. Usually designed with length: width ratio of 3:1 2. Wedge a. Used for lesions located at or near a free tissue margin 3. Circular a. May be utilized when shorter scar is desired 4. Serial a. For large lesions which cannot be excised in one stage (i.e. congenital nevi) b. Frequently used in conjunction with tissue expansion II. THE RECONSTRUCTIVE LADDER A. Conceptual framework for understanding reconstructive options (Figure 3) 1. Starts with most simple option: i.e., healing by secondary intention 2. Progresses to more complex options in a step-wise fashion 18 Figure 3. An early version of the reconstructive ladder From Janis J, et al. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011 Jan;127 Suppl:205S-212S. B. The “reconstructive elevator” (Figure 4) 1. Proposed by Gottlieb and Krieger in 1994 2. Best reconstructive option is not always the least complex 19 Figure 4. The reconstructive elevator, as proposed by Gottlieb and Krieger. This formulation emphasizes the importance of selecting the most appropriate level of reconstruction as opposed to defaulting to the least complex. From Gottlieb L, et al. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93:1503-1504. III. PRINCIPLES OF SUTURING A. Layered closure. Any wound deeper than skin should be closed in layers. 1. Eliminate dead space 2. Prevent dehiscence while wound healing is occurring 3. Precisely approximate skin edges without tension B. Wound edge eversion 1. Takes advantage of scar contraction 2. Allows for optimal wound healing C. Choosing suture 1. Permanent versus absorbable 2. Monofilament versus multifilament 3. Suture size 4. Needle type a. Cutting b. Taper 5. Surgical glue 6. Staples D. Timing of suture removal 1. Sutures should be removed from face within 5-7 days 2. Sutures in other anatomic areas should be removed within 7-14 days 3. Exceptions include wounds that cross joints, wounds that are under significant tension, wounds in irradiated or otherwise damaged surgical fields IV. SUTURING TECHNIQUE A. Simple interrupted sutures: most commonly used suture technique (Figure 5) 1. Needle enters epidermis at 90-degree angle 2. Needle turned to exit immediately below deep dermis 3. Care must be taken to enter and exit at same levels on opposite side Figure 5. Simple Interrupted Suture Technique 20 A. Running simple sutures 1. Rely on well-approximated wound edges 2. Not as precise as interrupted sutures, but faster B. Subcuticular sutures 1. Needle passed horizontally through the superficial dermis, parallel to skin surface 2. Can be running or interrupted 3. Allows close approximation of skin edges without need for external skin sutures C. Horizontal mattress sutures (Figure 6) 1. Everting sutures that spread tension across a wound edge 2. Needle passed across the wound and then back the other way 3. Useful in fragile tissue 4. Also useful in suturing glabrous skin of hands/ feet 5. Can be performed as a running suture Figure 6. Horizontal Mattress Suture Technique A. Vertical mattress sutures (Figure 7) 1. Used for increased wound eversion 2. Far-far near-near suture placement Figure 7. Vertical Mattress Suture Technique 21 REFERENCES 1. Thorne CH. “Chapter 1: Techniques and Principles in Plastic Surgery.” Grabb and Smith’s Plastic Surgery, 6th ed. Ed. Charles H. Thorne. LWW, 2006. 2. Neligan P. “Chapter 1: Plastic
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