Cosmetic, or aesthetic, surgery represents a universal

Transcription

1 The American Journal of Cosmetic Surgery Vol. 16, No.2, GUEST EDITORIALS Richard L. Dolsky, MD Guest Editor Cosmetic Surgery in the United States: Its Past and Present Cosmetic, or aesthetic, surgery represents a universal human desire to maintain or restore normal appearance or to enhance it toward an aesthetic ideal. The goal may be to return an abnormal or unsightly feature to normal or to produce a younger, more beautiful appearance. Although this desire is a fundamental human characteristic, surgeons have been able to address it predictably and safely only within the last century. The American Academy of Cosmetic Surgery and the American Society of Liposuction Surgery are the largest multidisciplinary societies in the United States that represent physicians concerned with the improvement of human appearance. These bodies welcome physicians of all medical and surgical specialties who have the desire to learn, and they are open to the ideas of all those who wish to teach. This paper offers a broad historical survey of developments in the field of cosmetic surgery. Its thesis is that the dramatic medical and technical progress of cosmetic surgery in the 20th century has been made possible by contributions from many medical specialties. The history of cosmetic surgery has often been characterized by doctrinal disputes (eg, the legitimacy of aesthetic surgery as opposed to reconstructive surgery) and by interspecialty conflicts. Yet as the century comes to a close, practitioners in varying specialties have made substantial progress in moving beyond these limiting distinctions. Reconstructive surgery can be traced to the Indian and Italian surgeons who reconstructed noses mutilated by war and criminal punishment. Nevertheless, until the closing decades of the 19th century, plastic surgery as a distinct discipline did not exist. Only a few isolated surgeons had begun to explore the possibility of altering nasal shape and size for the goal of improving the patient's appearance, not for function or reconstruction.i In 1845, Diffenbach of Germany published a text that described surgical procedures for nasal reduction through external incisions.' For almost a half century, there appeared to be little more published on the subject of cosmetic surgery. Then, during the ll-year period from 1887 to 1898, the seminal publications and presentations on rhinoplasty appeared in the United States and Germany. In 1887, John Orlando Roe, an otolaryngologist who studied in New York and Europe, published in the New York Medical Record an article titled "The Deformity Termed 'Pug Nose' and Its Correction by a Simple Operation."2 This was the first published report on an endonasal rhinoplasty. Four years later, Roe reported on 5 patients who had an endonasal hump removal. This 1891 article was titled " The Correction of Angular Deformities of the Nose by a Subcutaneous Operation."2 In 1892, Robert F. Weir, a professor of surgery in New York City, published an article titled "On Restoring Sunken Noses Without Scarring the Face."? Weir claimed to have performed a reduction rhinoplasty in 1885, 2 years before Roe published his first accounts. This article describes hump removal, nasal shortening, tip modification, and narrowing of the base through alar base wedge excisions ("the Weir incision"). In 1898, Jacques Joseph, considered by many to be the father of modem rhinoplasty surgery, presented his endonasal techniques to the Medical Society of Berlin.' During the question period, an American doctor in the audience asked Joseph if he were aware that Roe had previously described a similar procedure. I. ~ Even if Joseph was not the first to perform co smetic

2 110 The American Journal of Cosmetic Surgery Vol. 16, No.2, 1999 rhinoplasty, he was the first surgeon to dedicate a career to the cosmetic enhancement of the most prominent facial feature. A creative man who began his career in orthopedic surgery, he defined the essential steps of the procedure: reducing the hump, narrowing the bony vault, shortening the nose, and modifying the tip. He also invented the necessary instruments, many of which are still found on surgical instrument trays a century later.' Late 19th-century American cosmetic surgery was not limited to rhinoplasty, however. In 1881, Robert Talbott Ely, a staff member of the Manhattan Eye, Ear, and Throat Hospital in New York, performed an otoplasty for protruding ears on a 12-year-old boy.' World War I marked the appearance of plastic surgery as a medical specialty.l-' Trench warfare and modem weaponry produced many horrible facial injuries. The treatment of these deforming injuries was advanced by improved anesthesia techniques, utilization of antiseptic surgery techniques, and the availability of the electric light bulb to illuminate the surgical field and body cavities. The terrible destructive effects of war brought surgeons of different backgrounds together for rehabilitation of the facially disfigured. Rhinologists, oral surgeons, general surgeons, dental surgeons, ophthalmologists, and neurosurgeons collaborated in these efforts. Many surgeons who were to become the fathers of plastic surgery arose to recognition. These surgeons included Sir Harold Gillies, who was born in New Zealand and trained as an otolaryngologist; Vilray Blair, an orthopedic surgeon from Saint Louis; Robert Ivy, a general surgeon from Philadelphia; Lee Cohen, an American otolaryngologist; and Varaztad Kazanjian, an Armenian immigrant who studied dentistry at Harvard Dental School and worked on the staff of Massachusetts General Hospital. l.2 The efforts of these men laid the foundation for the specialty of plastic and reconstructive surgery. Among these surgeons, Cohen, an otolaryngologist who had studied in Europe, was performing rhinoplasty surgery prior to his reconstructive efforts in World War I. Following World War I, 3 surgeons who were later to practice in the United States had the common experience of training with Jacques Joseph in Berlin. Jacques Maliniac, born in Poland and trained in France, served in the Russian army, where his wartime experience drew him to the new area of plastic surgery. Gustave Aufricht was born in Hungary and trained in Budapest and Berlin. Joseph Safian, a general practitioner from New York, learned about Jacques Joseph's work at the time of his discharge from the United States Army. These 3 men studied with Joseph in Berlin in about They all eventually practiced their surgical craft in New York and were influential in the establishment of both plastic and cosmetic surgery as recognized areas of medicine. 1.2 One of the men who had most to do with the dissemination of information on plastic and cosmetic surgery was neither an otolaryngologist nor a surgeon. Prior to World War I Simon Fomon had conceived of the idea of teaching 'a refresher course for physicians preparing for state medical board examinations. His review covered all areas of medicine and surgery. In 1920, his collected materials resulted in the publication of the 5-volume Medicine and Allied Sciences.' Fomon's interest soon focused on facial plastic surgery and rhinoplasty. He made at least 2 trips to Europe between the late 1920s and early 1930s. He spoke and read German and visited Berlin, Paris, and Vienna, so one may assume that he met, observed, and studied with Joseph. In 1939, he published Surgery of Injury and Plastic Repair, an attempt to document all known plastic and cosmetic surgery techniques.' Fomon began to teach courses on rhinoplasty and otoplasty in The first course was held in Boston and attracted 2 otolaryngologists. About 1942, Fomon moved to New York and began to conduct the lecture series that evolved into the "Fomon Course."? Soon after the formation of this course, its graduates founded a society named the American Academy of Facial Plastic Surgery. A year later, the American Otorhinologic Society for the Advancement of Plastic and Reconstructive Surgery (later shortened to American Otorhinological Society for Plastic Surgery) was founded.? This was the largest otolaryngological plastic surgery society for the next 2 decades. During the 1950s, the number of otolaryngologists seeking to learn nasal surgery increased. Two men Maurice Cottle and Irving B. Goldman-stand out as the primary teachers of nasal surgery in the 1950s and 1960s. In Chicago, Cottle emphasized functional nasal surgery. His first instructional course took place in The American Rhinologic Society was founded by his supporters in In New York, Goldman developed an interest in rhinoplasty through his friendship with the plastic surgeon, Joseph Safian. Goldman studied in Europe and was a student of the Fomon Course. During the 1940s, he developed a flourishing practice that included many well-known show business personalities." In 1950, Goldman began a formal teaching course on rhinoplasty that he personally taught until In contrast to Cottle's emphasis on functional surgery, Goldman's emphasis was on cosmetic rhinoplasty. The tradition of the Goldman course continues today with the annual Mount Sinai Hospital rhinoplasty course. Just as Fomon and Cottle had inspired societies, Goldman and his students founded the American Facial Plastic Surgery Society in This group continued until It must be emphasized that the progress described in the preceding paragraphs occurred only because a number of individuals put the advancement of medical technique and the diffusion of medical knowledge ahead of rivalries with competing medical specialties. They faced formidable opposition, however. In 1921, at the same time that Maliniac, Aufricht, and Safian were studying with Joseph in Berlin, the American Association of Oral and Plastic Surgeons was founded in Chicago.' Membership was limited to surgeons with

3 The American Journal of Cosmetic Surgery Vol. 16, No.2, both medical and dental degrees. The requirement for a dental degree was dropped in 1923, as was the word "oral" in The American Association of Plastic Surgeons that we know of today was established, 1 but surgeons who openly performed cosmetic surgery were not included within the select membership of the Association. Among the surgeons not offered membership in the American Association of Oral and Plastic Surgeons were Maliniac and Aufricht. Ma1iniac went on to lay the foundation for a society that "would be an open forum for all engaged in the ethical practice of plastic and reconstructive surgery."l(pl4a) It would be a source of information for members of other specialties interested in plastic surgery problems. It is reported that Maliniac sought the support of representatives of related fields such as anesthesiology, dermatology, radiology, and otolaryngology.' Maliniac's original society, organized in 1931, had an allied membership category. Aufricht criticized Maliniac's group as "consisting mostly of borderline specialists such as eye surgeons, otolaryngologists, oral surgeons, and dermatologists." l(pl5a) This organization, the American Society of Plastic and Reconstructive Surgeons (ASPRS), grew during the 1930sand held both regional and annual meetings for the exchange of ideas. Presentations on cosmetic, or aesthetic, surgery were rare, and they were usually presented by Aufricht on the topic of rhinoplasty.1 From 1937 to 1944, all of the presidents of the American Society of Plastic and Reconstructive Surgery had been previously certified by the American Board of Otolaryngology. The most recent written history of the American Society of Plastic and Reconstructive Surgery clearly defines the scope and the attitude of plastic surgeons during the 1930s: "Legitimate plastic surgery was considered reconstructive surgery and largely limited to helping patients with congenital defects." Although Maliniac, Aufricht, and others 'bobbed noses' and performed some breast operations, such procedures were not considered mainstream."l(p18a) Some aesthetic procedures were carried out by "legitimate plastic surgeons," but such work occurred quietly, without fanfare. Most plastic surgeons yearned to be recognized as "serious surgeons" and avoided what were considered frivolous procedures. ' Richard C. Webster, a board-certified plastic surgeon and first president ofthe American Academy of Cosmetic Surgery, reported that when he began his practice in 1947, the message was crystal clear: "Reconstruction is in, cosmetic is out. "3(p8) Indeed, for a time, as plastic surgery became established as a surgical specialty in the United States, the exchange of ideas between disciplines decreased rather than increased. Operating room doors were closed, hospital privileges were blocked, and meetings were closed to nonmembers.' With the establishment of a board and a society, many of the founders soon abandoned their original discipline and forgot that their skills and knowledge had a basis in their original training and experience. As a result, many of the advancements and refinements in cosmetic surgery techniques arose through the creation of informal study groups. A small group of surgeons would travel to observe a colleague operate, then gather to analyze, criticize, and discuss the surgical procedures. This group included Benito B. Rish, Maury Parkes, Jesse Fuchs, Ira Tresley, Oscar Becket, Richard Farrier, Jack Anderson, John Dickinson, and William Wright. Knowledge increased and information spread. Nevertheless, conflicts between plastic surgeons and regional plastic surgeons increased and found their way into the popular media and press.l-' As a result of the public denigration of regional plastic surgeons, plastic and reconstructive surgery was clearly established as an integral component of otolaryngology education, practice, and board certification.' Indeed, until the early 1960s, organized plastic surgery in the United States was openly hostile to the public practice of cosmetic surgery and, as a result, to education in this field. That decade, however, saw an important turning point with the Dalinde seminar on cosmetic surgery in Mexico City, organized by Mario Gonzalez-Ulloa. The activities of their colleagues in Mexico made plastic surgeons in the United States recognize the growing importance of cosmetic surgery and the need for education and communication.v' In hopes of providing one voice for cosmetic surgery, negotiations began between Fomon's American Otolaryngologic Society of Plastic Surgery, Goldman's Society of Facial Plastic Surgery, and Cottle's American Rhinologic Society. In 1963, Richard Webster, later known as "the father of American cosmetic surgery," attended an informal meeting of members of the 3 nasal societies. Webster describes his reaction as follows: "For the first time in my life, I met man after man who honestly, without any shame at all, evinced a paramount interest in what I considered my field, cosmetic surgery."3(pl2) On October 18, 1964, the American Otolaryngologic Society of Plastic Surgery and the Society of Facial Plastic Surgery united to form the American Academy of Facial Plastic and Reconstructive Surgery.' The Academy was open to physicians of all disciplines and its major activity was postgraduate education. Cottle did not allow the American Rhinological Society to join the new academy." It is conjectured that he would not be part of an organization that emphasized cosmetics over function. By the end of the 1960s, the foundations for a true specialty of cosmetic surgery had been laid. The first American cosmetic surgery educational program was held by the American Academy of Facial Plastic Surgery at Cook County Hospital in Chicago in In 1969, under the direction of Richard Webster, the Facial Plastic Academy held its first course on aging faces at Tulane University in New Orleans. Webster assessed the importance of this event by saying, "This

4 112 The American Journal of Cosmetic Surgery Vol. 16, No.2, 1999 was the first course given in which the regional or systemic specialist was exposed to subjects that might be thought of as not in his field at all, unless his field had become, in truth, cosmetic surgery.":' This meeting represented a multidisciplinary exchange of ideas between different specialists on the common topic of cosmetic surgery. In 1967, 2 plastic surgeons, Simon Fredricks of Houston and John Lewis of Atlanta, met and discovered that they both felt separate from the mainstream of plastic surgery. They and their colleagues could not get the podium at plastic surgery meetings, and there was no sharing of ideas or communication of techniques in the area of cosmetic surgery. According to Fredricks, "It was almost impossible to be able to give a paper on aesthetic surgery." \(p63a) The pair organized the American Society of Aesthetic Plastic Surgery in 1967, with Webster as the historian. The first meeting was planned for February The majority of ASPRS members considered the founders of the Aesthetic Society to be a "not so loyal opposition." I (p64a) Webster had told the organizers of the American Society of Aesthetic Plastic Surgery that a similar organization had been proposed by members of the American Academy of Facial Plastic and Reconstructive Surgery and that it would be open to men from all disciplines, including plastic surgeons interested in cosmetic surgery. Webster was convinced to urge his non-plastic surgeon colleagues to postpone their society. He was told that no plastic surgeon would join the other group, but that the American Society of Aesthetic Plastic Surgery would invite reputable cosmetic surgeons from other disciplines to join so that it could represent all of the field of cosmetic surgery. After the first meeting of the American Society of Aesthetic Plastic Surgery, Webster was told that the invitation to non-plastic surgeons would need to be delayed due to the hostility toward the new society from plastic surgeons themselves.' In May 1969, the American Association of Cosmetic Surgeons was incorporated by the original study group that had traveled from city to city to learn each other's rhinoplasty and facial plastic techniques. Its founders decided not to activate the association and to wait for the promised invitations from the aesthetic plastic surgeons. Five years later, the invitations never materialized, and active meetings ofthe American Association of Cosmetic Surgeons began in Membership of this group included ophthalmologists, plastic surgeons, dermatologists, otolaryngologists, general surgeons, and physicians from other fields.' On March 19, 1979, Richard Aronsohn, a Los Angeles otolaryngologist, and Robert Franklin, a Los Angeles plastic surgeon, incorporated the American Board of Cosmetic Surgery in Delaware. These men had devoted their practices and careers to cosmetic surgery and recognized the interdisciplinary nature of the specialty. They wished to create a board so that the public would have a standard of qualifications. On May 18, 1981, Aronsohn invited people from all parts of the United States to meet for the first organizational meeting of the American Board of Cosmetic Surgery. At that time, the board meeting was primarily an educational meeting. In 1982, the first certifying examination in the new specialty of cosmetic surgery was offered under the direction of Harrison Robbins of San Diego (R. B. Aronsohn, oral communication, 1997). At that time, Aronsohn recognized that a board should only have the responsibility for certification. The role of education should fall under the organizational or educational arm of a specialty. Therefore, the American Society of Cosmetic Surgery was organized in 1982 as the educational society in the field of cosmetic surgery (R. B. Aronsohn, oral communication, 1997). In the spring of 1984, under the editorship of Aronsohn, the Society published the American Journal of Cosmetic Surgery. Cosmetic surgeons were not the only physicians who recognized the importance of a board devoted to this unique field of medicine. Three plastic surgeons, all members ofboth ASPRS and the American Society of Aesthetic Plastic Surgery, incorporated 2 separate boards-the American Board of Aesthetic Plastic Surgery and the American Board of Cosmetic Plastic Surgery (R. B. Aronsohn, unpublished data). Neither of these 2 boards appeared to have offered examinations or issued certificates. For the most part, this narrative has so far emphasized rhinoplasty and the small group of men who did this surgery. Similar developments were occurring in other fields of medicine. In 1932, for example, the first meeting of ASPRS included a report by an ophthalmologist, John Wheeler, on eyelid repairs. The specialty of ocular plastic surgery grew out ofthe interest and efforts ofwendell Hughes, Sidney Fox, John Wheeler, and Byron Smith. Carl Johnson, in 1947, was already doing tarsal fixation maneuvers and ptosis surgery as well as establishing the upper-lid crease at a point of election; this procedure was later to be applied by plastic surgeons to the eyelids of Asian patients and in cosmetic blepharoplasty to the eyes of Caucasians. In 1969, eye surgeons with an interest in ocular plastic surgery founded the American Society of Ophthalmic Plastic and Reconstructive Surgery.' During the formative years of cosmetic surgery, dermatological cosmetic surgeons made contributions to procedures for the enhancement ofhuman appearance. In 1952, McKee reported on 50 years of experience with phenol chemical peels (the chemical peel can actually be traced to ancient Egyptian history)." In the 1960s, several surgeons reported on variations of trichloroacetic acid peel procedures. In 1982, Stegman presented histological comparisons of different peeling agents.' In the same decade, Van Scott described the use of alpha hydroxy acids for exfoliation, and Kligman described the topical use of tretinoin for the treatment of sun-damaged and aging skin." Dermabrasion had been first described in 1905 by Kromeyer." However, the major advancement in dermabrasion was

5 The American Journal of Cosmetic Surgery Vol. 16, No.2, made by Curtin in 1953 with the description of the rotary wire brush and the use of ethyl chloride to anesthetize and firm the skin. This was followed by the development of the diamond fraise." Ocude, a Japanese dermatologist, had described hair restoration utilizing small hair-bearing grafts, although it was some time before his work became known in the West.? In 1959, Orentreich presented the theory of "donor dominance" that laid the ground work for hair transplantation.v' In the 1970s, Blanchard, and Blanchard and Unger began the early work on scalp-reduction techniques.v? An early European pioneer in facial rejuvenation procedures such as blepharoplasty and face-lifting was Susan Noel, a French dermatologist." In 1961, Goldman was the first physician to apply lasers to medicine and surgery." The 1970s saw advances in American treatment of sclerotherapy with the reintroduction of hypertonic saline." In 1988, David described the technique for laser blepharoplasty." In 1970, the American Society of Dermatological Surgery was founded with the first president, Norman Orentreich." Five years later, in 1975, the Journal of Dennatologic Surgery (now Dennatologic Surgery) was founded with Perry Robins as its first editor.v? Liposuction, which has become the most commonly performed cosmetic surgery procedure in the United States, was first observed in 1977 by Lawrence Field during his visits to the European pioneers." In 1987, Klein introduced the concept of the tumescent technique." In 1992, Carruthers and Carruthers described the use of Botox for the treatment of facial aging and wrinkles." Liposuction revolutionized body contouring surgery; the procedure evolved into a truly cosmetic surgical procedure, and within a short period of time it became the single most popular cosmetic surgery procedure in the United States. Liposuction helped to break down specialty barriers by becoming a magnet for surgeons interested in the science of surgical enhancement of human appearance. Gynecologists, general surgeons, and dermatologists all made significant contributions to the advancement of this procedure. Ives-Gerard Illouz of France was invited to present his work at the educational meeting of the American Society of Cosmetic Surgery. The implications of his January 1982 report on lipolysis was immediately apparent to those in his audience and stimulated extensive exchanges of information. For example, Fred Berkowitz from Newport Beach, Calif, traveled to Paris to observe Illouz, Fournier, and Otteni.!" Upon his return to the United States, Berkowitz conveyed his experiences and observations to his associate, Michael Elam, in California. Richard Dolsky, of Philadelphia, visited and observed Bahman Teimourian, a Maryland plastic surgeon who had begun suctioning fat several years earlier. Berkowitz, Elam, and Dolsky conferred on an almost daily basis on surgical procedures, instruments, and results. In October 1982, a workshop was held at the Graduate Hospital in Philadelphia, and Dolsky's surgical demonstrations marked the first or- ganized teaching of liposuction to American surgeons. In December 1982, Julius Newman incorporated the American Society of Liposuction Surgery. The first of many workshops, instructional courses, and World Congresses was held at Hollywood Community Hospital in Los Angeles in June In 1984 and 1985, surgeons practicing cosmetic surgery in the United States recognized that many of them had dual memberships in the American Association of Cosmetic Surgeons and the American Society of Cosmetic Surgery. In addition, they recognized that the 2 organizations were competing for members and for attendance at their educational meetings. The American Society of Liposuction Surgery was closely aligned with the American Society of Cosmetic Surgery, which published the American Journal of Cosmetic Surgery," The leaders of these 2 organizations, George Brennan, president of the Association, and Benito Rish, president of the Society, appreciated the value of the maxim "strength in numbers." The 2 societies amalgamated in 1985 to form the American Academy of Cosmetic Surgery, the first annual scientific meeting of which was held in Los Angeles in Richard Webster was elected the founding president of this organization. The techniques of cosmetic surgery have developed to a striking degree in response to increasingly sophisticated consumer demand. For example, hair transplantation is the most common cosmetic procedure sought by American men. Patients and doctors will not accept the artificial work of the old hair plugs. State-of-theart hair restoration combines the techniques of scalp expansion and reduction, mini- and micrografts, and individual hair grafts. Many surgeons are employing lasers to produce accurate graft recipient sites bloodlessly. In January 1995, under the direction of the president of the American Academy of Cosmetic Surgery, Howard Tobin, the American Society for Hair Restoration Surgery was formed. This is a multidisciplinary organization devoted to advancements in this subspecialty area of cosmetic surgery. One of the most exciting areas of cosmetic surgery is the utilization of lasers for many tasks. CO 2 lasers are used as cutting instruments in transconjunctival blepharoplasty, endoscopic forehead-lifts, and endoscopic transaxillary augmentation mammoplasties. II In addition, KTP and contact YAG lasers have advocates for their use in face-lifts, abdominoplasties, and reduction mammoplasties. Pigmented and vascular skin lesions, as well as tattoos, are obliterated and lightened without scarring by the Q-Switch Ruby laser, Copper Vapor laser, Flashlamp Pulsed Dye laser, and the Q Switched Frequency Doubled Nd:YAG laser. Perhaps the greatest excitement in cosmetic laser surgery involves facial skin resurfacing. New techniques such as the Coherent UltraPulse CO 2 laser and the Sharplan Silk Touch CO 2 laser provide new tools in the battle against facial wrinkles and aging." The ongoing evolution of laser cosmetic surgery continues with the use

6 114 The American Journal of Cosmetic Surgery Vol. 16, No.2, IlJlJlI of the Erbium:Yag laser for the treatment of wrinkles. Today, surgeons are combining treatment with both the Erbium:Yag and the CO 2 lasers to enhance the results available to patients. Overall, liposuction continues to be the most popular cosmetic surgery procedure. The use of tumescent infiltration is accepted by most surgeons as a major advance in the effort to decrease blood loss and to improve cosmetic results. Instruments continue to get smaller and smaller." Many surgeons advocate superficial lipoplasty to improve results. Ultrasonic liposuction has been brought to the United States. The Task Force of the American Academy of Cosmetic Surgery and the American Society of Liposuction Surgery has studied this procedure and has presented its initial findings to the Academy and to the Society. These organizations are at the forefront in evaluating and teaching the newest technologies in liposuction. Options in chemical peel have increased with the introduction of new peeling agents and new combinations of agents." Glycolic acid, lessner's solution, trichloroacetic acid, and phenol are the major peeling acids. Control of pigmentation is increased with the use of new topical agents such as Kojic acid. Perhaps the area of American cosmetic surgery generating the most interest is endoscopically assisted minimal-incision surgery." Cosmetic surgeons in the United States were slower to recognize the possibilities for endoscopic surgery than their orthopedic colleagues, who led in repairing knees, shoulders, and elbows through minimal incisions. General surgeons and gynecologists also learned to move through the abdominal cavity and pelvis under television endoscopic control. Now cosmetic surgeons are using endoscopic techniques for forehead- and face-lifting. Breast implants are endoscopically placed from the axilla or umbilicus. Implants are checked for leaks or ruptures through a minimal incision endoscopic evaluation. Endoscopic abdominoplasties tighten the anterior abdominal wall fascia and redistribute the skin without large mcisions. The techniques of rhinoplasty surgery, a field more than 100 years old, continue to evolve and improve. The concept of open-structure rhinoplasty gives the surgeon many options not available in the classic endonasal route. Surgery is more conservative; normal anatomical relations are maintained, and structures may be stabilized and strengthened by cartilage grafts and suture techniques. Finally, new ideas and concepts flow into cosmetic surgery from oral and maxillofacial surgeons. There is a close relationship between cranial facial surgery and aesthetic surgery; the orthognathic techniques and subperiosteal approach to facial rejuvenation have been improved by oral surgeons. This brief overview suggests a clear, if sometimes erratic, trend. The notion that there can be a clear line drawn between "reconstructive" and "cosmetic" surgeries has been largely abandoned. Cosmetic surgery is flourishing in the United States as more and more patients are seeking surgical enhancement of their appearance. They also demand a higher level of results. and this in tum has led to more sophisticated procedures. Today's practitioners of cosmetic surgery include plastic surgeons, otolaryngologists, dermatologists, ophthalmologists, oral and maxillofacial surgeons, and general surgeons. All of these disciplines contribute to the vital growth of the specialty. Increasingly, individual cosmetic surgeons may be expected to have familiarity, if not certification. in more than one discipline. (For example, the training of this author has led to triple board certification in otolaryngology, plastic surgery, and cosmetic surgery; in the future, such multidisciplinary approaches may become more common.) Whatever the future may hold with respect to formal training-membership in professional organizations or board certification-it is clear that the profession of cosmetic surgery owes a huge debt to physicians like Webster. In addition to their specific medical and clinical contributions, they emphasized that surgical skill, inventiveness, and compassion for patients derives from intellectual curiosity and personal character, rather than from any particular medical specialty. References 1. Hait P, Schnur PL. History of the American Society of Plastic and Reconstructive Surgeons, Inc Plast Reeonstr Surg. 1994;94:5A-78A. 2. Simons RL. Coming of Age; A Twenty-fifth Anniversary History ofthe Academy offacial Plastic and Reconstructive Surgery. New York, NY: Theme Medical Publishers; Webster RC. Cosmetic surgery: its past, present. and future. Am J Cosm Surg. 1984;1: Webster RC. Cosmetic surgery: its past, present. and future; part II. Am J Cosm Surg. 1984;1: Hanke CW, Francis LA. Growth in skin surgery. Clin Dermatol. 1992;10: Coleman WP III. Advances in dermatologic surgery. Dermatol Surg. 1997;23: Coleman WP III, Alt TH. Dermatologic cosmetic surgery. J Dermatol Surg Oneol. 1990;16: Officers and board members of the American Society for Dermatologic Surgery-past and present. J Dermatol Surg Oneol. 1990; 16: Hanke CW, Krull EA. Timeline: milestones in dermatologic surgery, Dermatol Surg ;21 : Newman 1. Lipo-suction surgery: past-presentfuture. Am J Cosm Surg. 1984;1: Garden 1M, Geronemus RG. Dermatologic laser surgery. J Dermatol Surg Oneol. 1990;16: Geronemus RG. Laser surgery Dermato{ Surg. 1995;21: Klein la. Tumescent technique chronicles: local anesthesia, liposuction, and beyond. Dermatol Surg ;21 : Brody HI. Current advances and trends in chemical peeling. Dermatol Surg. 1995;21: