Plastic Surgery
Reconstructive and Aesthetic Plastic Surgery is a complex and unique discipline as it interfaces with numerous other specialties, spanning all anatomical regions. It originates with different orientations from traditional surgery, which is fundamentally "resective" or "amputative," as its primary purpose is to repair damage caused by trauma, degenerative diseases, malformations, post-oncological reconstructive procedures, or aging, rather than removing or amputating tissues.
Plastic surgery aims to restore form and function where they have been lost, addressing situations where various etiological factors have compromised what is considered “normal.” In such cases, it is appropriately termed “reconstructive,” although it can never ignore aesthetic considerations in its practice. Conversely, the goals of purely “aesthetic” surgery are different, aiming to enhance a “normal” anthropomorphic situation, while reconstructive surgery aims to restore lost or never-experienced somatic normality.
Definitions
Reconstructive Plastic Surgery deals with organs and body areas that have lost their function and shape due to trauma, burns, infections, destructive surgeries or which present congenital or degenerative malformations. It is therefore carried out on body structures that are no longer “normal”.
Aesthetic Plastic Surgery deals with problems related to aging and dysmorphism without functional compromise. It is therefore carried out on “normal” body structures with the aim of improving their appearance, and is a personal choice of the patient not supported by medical indications.
There is a clear “grey area” between reconstructive and aesthetic surgery, and this is because:
Reconstructive surgery always has aesthetic aspects, since it is aimed at restoring form as well as function
Specific cases on specific patients can be reconstructive or aesthetic depending on the individual situation: (for example, a reduction mammoplasty, usually an aesthetic operation, is to be considered reconstructive where the breast is large enough to hinder normal daily activities or cause disturbances of posture).
The principles and surgical technical solutions are fundamentally based on identical principles, whether it is Reconstructive or Aesthetic Surgery.
Names of the discipline
Especially in recent years, the “aesthetic” component of Plastic Surgery has gained increasing prominence, both because it is necessarily associated with reconstructive procedures and as purely aesthetic surgery. This shift has been notable from a scientific and educational perspective. The following developments have occurred:
The term “Reconstructive and Aesthetic Plastic Surgery” was adopted at the European level in the late ’90s through a resolution by the ADVISORY COMMITTEE of the UEMS. The majority of Scientific Societies in nations belonging to the Union have changed the designation from “Plastic Surgery” to “Plastic and Aesthetic Surgery” (e.g., France SFCPRE, Italy SICPRE, United Kingdom BAPRAS, Spain SECPRE, Germany DGPRÄG, European Society ESPRAS, USA ASPS, International Society IPRAS, etc.). This formal name change has also been reflected in the Specialization Schools, as seen in Italy with the designation “Specialization in Reconstructive and Aesthetic Plastic Surgery.” There has been a proliferation of meetings and refresher courses that emphasize the “aesthetic” aspect of procedures traditionally considered “reconstructive.”
Classifications of procedures
While it is evident, as mentioned above, that the practical difficulty lies in categorizing the extensive range of interventions in Plastic Surgery solely into “reconstructive” and “aesthetic” categories, a classification remains fundamental. This is done to prevent unethical behavior and to ensure the recognition of situations where the functional component is predominant. The following list has been compiled after a careful examination of local situations in multiple Italian hospital divisions of Plastic Surgery and the guidelines of European and American Plastic Surgery Scientific Societies.
Generic list of procedures performed institutionally or in private practice in Plastic Surgery:
- Oncologic Surgery of the Head, Neck, Trunk, and Limbs
- Reparative Surgery of Complex Soft Tissue Trauma
- Surgery for Post-Traumatic, Post-Radiation, Post-Infectious, and Multidistrict Post-Oncologic Sequelae
- Surgery for Cutaneous Ulcers, Diabetic Ulcers, and Decubitus Ulcers
- Reconstructive Breast Surgery
- Burn Surgery, Sequelae of Burns, and Deforming/Contracting Scars
- Surgery for Congenital and Acquired Malformations of the Head-Neck District; Trunk, Breast, and Limbs
- Elective and Emergency Surgery of the Hand and Limbs
- Surgery for Vascular Malformations
- Surgery for Facial Nerve Paralysis
- Maxillofacial Surgery
- Craniofacial Surgery
- Surgery for Spasticity
List of specific procedures to be considered aesthetic (with a prevalent or exclusive cosmetic significance) performed only in private practice in Plastic Surgery (without National Health Service (SSN) contribution):
- Mastopexy
- Breast Augmentation
- Breast Reduction
- Abdominoplasty
- Blepharoplasty
- Rhinoplasty
- Otoplasty
- Cheiloplasty (lip treatment)
- Dermabrasion for Acne Sequelae
- Aesthetic Scars (non-deforming or contracting)
- Lipofilling and Injectable Treatments (Fillers)
- Profiloplasty with Chin and Cheek Implants
- Cervicofacial Lifting
- Liposuction and Liposculpture
- Botulinum Toxin
Following the issuance of the agreement on November 22, 2001, between the Government, Regions, and the Autonomous Provinces of Trento and Bolzano regarding the essential levels of healthcare assistance pursuant to Article 1 of Legislative Decree No. 502 of December 30, 1992, and subsequent amendments, published in the Official Gazette’s Supplement on January 21, 2002, General Series – No. 19, which, concerning Aesthetic Surgery, identifies procedures eligible for coverage by the National Health Service (Sistema Sanitario Nazionale) only when aimed at treating conditions “resulting from accidents, illnesses, or malformations,” we are attaching a detailed list of Aesthetic Surgery procedures. This list specifies the pathological conditions for which these procedures can be provided in accordance with the Decree.
These procedures, listed in the document “Classification of Diseases, Traumas, Surgical Interventions, and Diagnostic and Therapeutic Procedures,” Italian Version of ICD-9-CM (International Classification of Diseases – 9th revision – Clinical Modification) 1997, prepared by the Ministry of Health, Department of Planning, should only be considered if appropriate for the treatment of conditions “resulting from accidents, illnesses, or malformations.”
It is emphasized that all circumstances purely for aesthetic purposes are excluded from coverage.
• Rhytidectomy or Facelift Not covered by the National Health Service (SSN).
• Blepharoplasty Covered when the excess eyelid skin causes a functional problem (visual field limitation not less than 60%).
• Rhinoplasty Covered when the deformity of the nasal pyramid is a result of trauma, congenital malformations (e.g., cleft lip and palate), or severe respiratory problems. Rhinoplasty for purely aesthetic reasons is not covered.
• Otoplasty (Correction of protruding ears) Covered only for children under 14 years old since the deformity known as “bat ear” is often a source of significant distress during this delicate age.
• Breast Augmentation Covered for congenital absence of the breast (amastia), breast asymmetry, or other breast malformations (tubular breast, Poland Syndrome). Generally not covered in other cases. The SSN covers post-mastectomy breast reconstruction performed by a Plastic Surgeon, including the use of breast implants, and, where possible, during mastectomy. Breast augmentation is also covered for adjusting the contralateral breast in breast reconstruction.
• Mastopexy Generally not covered except in cases of severe breast ptosis due to the aftermath of bariatric surgery and in breast reconstruction for adjusting the contralateral breast.
• Breast Reduction Covered for mammary hypertrophy where a reduction of more than 500 grams per side is planned (American Medical Association) or when there are vertebral static problems related to breast weight in patients with normal body weight. Also covered in cases of symmetrization of the contralateral breast in post-mastectomy breast reconstruction. Not covered in patients with a Body Mass Index exceeding 35.
• Abdominoplasty Covered when there is abdominal wall herniation, severe intertrigo, or skin ulcerations, or in cases where there is a large skin-adipose apron that represents a significant functional limitation due to weight loss. Discouraged in smokers and patients with a Body Mass Index exceeding 35.
• Liposuction Not covered for aesthetic reasons. Covered only in the treatment of lipomas, lymphedema, or severe lipodystrophies. It may be used occasionally as a complement to other surgical procedures. Covered for fat removal for use in lipofilling for defects resulting from trauma, diseases, malformations, or surgeries.
• Tattoo Removal Generally not covered except for tattoos resulting from trauma or causing frequent allergic reactions.
• Scalp Reconstruction Covered in cases where alopecia is a consequence of trauma, burns, or removal of neoplastic lesions. Hair transplantation for aesthetic reasons is not covered.
All other services with purely aesthetic significance are not covered.
This information is sourced from the website of the “Società Italiana di Chirurgia Plastica Ricostruttiva ed Estetica” (Italian Society of Reconstructive and Aesthetic Plastic Surgery).
Plastic surgery and insurance
Insurance companies must cover pathologies that are recognized as treatable by the NHS. Among these we remember the cutaneous tumor pathology (nevi of uncertain behavior, melanomas, basal cell carcinomas, spinaliomas, etc.), benign but functionally relevant cutaneous and subcutaneous pathologies (lipomas, warts, etc.); the disfiguring and functionally relevant scars, the outcomes of traumas that have caused disabling skin pathologies, breast reconstruction after mastectomy and prophylactic mastectomies, gynecomastia. Most insurance companies cover respiratory disorders of the nasal pyramid but only if caused by a proven trauma and exclude the aesthetic part from reimbursement. Few insurance companies cover congenital malformations. These are almost always family insurance policies which provide for the extension of insurance coverage upon the birth of the child.
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