Plastic and Reconstructive Surgery and the Evolution of Cosmetic Surgery Education

The most reliable way to predict the future is to create it. —Abraham Lincoln As we celebrate the 75th anniversary of Plastic and Reconstructive Surgery, it is timely to look back and examine the evolution of plastic surgery and how it has been reflected in the articles that have been published in Plastic and Reconstructive Surgery. Following our overarching look back (and forward),1 each of our section editors has elected to contribute their thoughts in monthly editorials for a specific area of plastic surgery.2 We continue this year-long celebration of the 75th anniversary of Plastic and Reconstructive Surgery by focusing on how the Journal has influenced the development and practice of cosmetic surgery across the globe. At its inception, plastic surgery had its origin as a branch of general surgery and focused on those early procedures, which remain the hallmark of reconstructive surgery. Plastic and Reconstructive Surgery began publication in 1946, and its inaugural issues focused largely on war time injuries, cleft lip and palate, and wound management. The first article published on cosmetic surgery appeared in Volume 2 of Plastic and Reconstructive Surgery, published in 1947, and was written by Joseph Safian, entitled “A Critical Review of Recent Literature on Rhinoplasty.”3 Additional advances in rhinoplasty4 (Fig. 1) and many important articles on techniques to correct ear deformities were published in the Journal, but the next landmark cosmetic article was published in Volume 8, 1951, by Salvadore Castanares focusing on intraorbital anatomy and describing modern techniques to improve eyelid appearance in blepharoplasty5 (Fig. 2).Fig. 1.: Advances in bone grafts for rhinoplasty. Original caption: “Two types of graft may be carved from the iliac crest.” (Reprinted with permission from Gerrie J, Cloutier GE, Woolhouse FM. Carved cancellous bone grafts in rhinoplasty. Plast Reconstr Surg. 1950;6:196–206. DOI: 10.1097/00006534-195009000-00002)Fig. 2.: Landmark advances in blepharoplasty. Original caption: “Diagrammatic sagittal section through the right orbit showing the separation of the intraorbital fat deep under the eyeball by a fascial extension from the inferior rectus sheath to the suspensory ligament of Lockwood, as well as the fascial extensions from the sheath of the inferior oblique to the periorbita.” (Reprinted with permission from Castanares S. Blepharoplasty for herniated intraorbital fat. Plast Reconstr Surg. 1951;8:46–58.)Cosmetic surgery procedures gradually developed through the 1950s, and as these techniques became more consistent, public demand increased. Nonetheless, few articles on cosmetic procedures appeared in Plastic and Reconstructive Surgery. and those that did were authored primarily by well-regarded university-based plastic surgeons during this era. A notable exception to this trend was the first face-lift article published in Plastic and Reconstructive Surgery, which was authored by James Buford Johnson in 1955, a private practitioner in Beverly Hills, California.6 This rarely quoted article described not only techniques for face lifting but also the submental approach to remove cervical fat, which later was popularized by Millard et al. in their landmark article in 19687 (Fig. 3).Fig. 3.: Illustration depicting advances in face lifting from Millard et al. from 1968. Original caption: “A. Postauricular pull lifts point X from its original position at the ear lobe to the top of the postauricular incision. This tension insures a clean mandibular line and a good cervico-mandibular angle. B. Anterior lift in the temporal area returns tone to the cheek. C. Closure places scars in hidden positions, with tension confined to the postauricular and temporal suspension points. No tension on, or distortion of, the tragus or ear lobe.” (Reprinted with permission from Millard DR, Piggott, R, Hedo, A: Submandibular lipectomy in conjunction with a face lift. Plast Reconstr Surg. 1968;41:513–522. DOI: 10.1097/00006534-196806000-00001.)Many of the articles published in Plastic and Reconstructive Surgery in the 1960s and 1970s were originally presented at the annual American Society of Plastic and Reconstructive Surgeons meeting before their acceptance in the Journal and represented an academic approach and predisposition toward the cosmetic articles accepted for publication. As an example, one of the earliest articles on cervical contouring (through direct external excision of cervical skin) was authored by Jerome Adamson and Charles Horton8 in 1964. Adamson and Horton were highly regarded reconstructive surgeons from Norfolk, Virginia. Modern approaches to face lifting (termed rhytidectomy) were authored by Gonzales Ulloa9 in 1962 (in that article he also described techniques for coronal brow lifting) and Milton Edgerton10 (from Johns Hopkins) in 1964, both recognized experts affiliated with university-based plastic surgery. Modern approaches to the cervical rejuvenation were popularized by D. Ralph Millard7,11 (from the University of Miami) describing the submental incision to defat the neck, which led to more advanced submental techniques by means of platysmaplasty by Bruce Connell12 and Jose Guerrero-Santos et al.13 Other examples include techniques for correction of the prominent ear pioneered by Tanzer14 (Fig. 4) (from Dartmouth) and Converse and Wood-Smith (from New York University).15Fig. 4.: Advances in otoplasty. Original caption: “The cornucopia concept of correcting prominent ears, as modified after Converse…”. (Reprinted with permission from Tanzer RC. The correction of prominent ears. Plast Reconstr Surg. 1962;30:236–246. DOI: 10.1097/00006534-196208000-00002.)The schism between academic and private practice cosmetic surgery in the United States was compounded by the perceived indifference or reluctance in many university centers to teach aesthetic surgery. This subsequently led to some important developments in our specialty beyond the umbrella of academic centers. Tom Baker and Howard Gordon, in 1967, pioneered the Baker Gordon Symposium on Cosmetic Surgery, which was the first live cosmetic surgery symposium in the United States.16 The rationale for this educational forum was to provide a vehicle for surgeons of that era to learn cosmetic surgery techniques from experts in cosmetic surgery, many of whom were not university-based physicians. Alternative vehicles for aesthetic surgery education were established, including the formation of the American Society for Aesthetic Plastic Surgery in 1968 (which founded the Aesthetic Surgery Journal in 1996), the publication of the journal Aesthetic Surgery in 1976 (focused entirely on aesthetic surgery articles), and Clinics in Plastic Surgery, which focused many early issues on cosmetic surgery subjects. The leadership in organized plastic surgery recognized the importance and validity of cosmetic surgery and led the way for Plastic and Reconstructive Surgery to remain at the forefront of aesthetic surgery education. In 1970, Tom Baker and Joseph Murray (the only plastic surgeon to win the Nobel Prize) wrote an editorial17 on the importance of cosmetic surgery and the need for it to remain as a key component of plastic surgery education. In 1972, Dr. Robert Goldwyn authored an editorial entitled “Cosmetic Surgery and the University Hospital” that noted the importance of aesthetic surgery as a legitimate subspecialty of plastic surgery and the schism that had developed between the university and the private practitioner.18 When Dr. Goldwyn became Editor-in-Chief of Plastic and Reconstructive Surgery in 1979, the number of articles published on cosmetic surgery increased and a global diversity of publication of articles occurred. Over the 25 years of his leadership with the Journal, cosmetic articles became an important focus of Plastic and Reconstructive Surgery, as organized plastic surgery specifically recognized the importance of cosmetic surgery as an integral aspect of our specialty. In 1998, Dr. Goldwyn (with the support from Society leadership) and the Journal established the first subsection within Plastic and Reconstructive Surgery that focused on cosmetic surgery, led by then–Editorial Board members, Drs. Rohrich and Stuzin. In 2005, when Rod Rohrich became the Editor-in-Chief and Jim Stuzin became the Co-Editor of Plastic and Reconstructive Surgery, the Journal began its transformation into a section-specific and vastly expanded global, online, and video-oriented plastic surgery journal, reflecting the depth and breadth of modern plastic surgery and the desire for readers to focus on specific articles of interest before examining the rest of each issue. This transformation included the expansion and rapid development of the online Plastic and Reconstructive Surgery version into the true journal of record on PRSJournal.com. The digital presentation of the Journal brought the content to life, specifically for younger surgeons, who began showing interest in shorter articles and more digital media, including videos for mastering techniques in cosmetic surgery and cosmetic medicine. Besides publishing peer-reviewed cosmetic articles in each issue of the Journal, Plastic and Reconstructive Surgery began publishing entire supplements dedicated to cosmetic topics. The first supplement published was an issue devoted entirely to the newly developed cosmetic applications for botulinum toxin, published in both English and Spanish.19 Other supplements followed, providing in-depth coverage on a broad spectrum of topics ranging from injectable fillers to breast implants. The Journal also focused on publishing key clinical trials in cosmetic medicine and highlighting the newest nonsurgical developments in cosmetic medicine, which had never been done before in Plastic and Reconstructive Surgery. When Dr. Rohrich introduced evidence-based medicine standards and evidence-based medicine grading for all clinical articles in 2009, the emphasis changed from expert-based to evidence-based cosmetic surgery publications in Plastic and Reconstructive Surgery. Furthermore, the emphasis was placed on publishing a wide variety of anatomical articles relevant to safety and outcomes for both surgical and nonsurgical aesthetic procedures. One of the most important contributions to the educational efforts of Plastic and Reconstructive Surgery has been the addition of streaming video, which was added to our platform in 2007 and was initially launched to allow our readers to watch, in real time, techniques in cosmetic surgery. Over the ensuing 13 years, PRSJournal.com has come to host almost 2000 videos on a wide range of topics, including a variety of instructional videos from nearly every CME article over the past decade. However, by far the most-watched videos come from the Baker Gordon collection,20 a standalone gallery of surgical and lecture videos from this annual cosmetic symposium. Overall cosmetic surgery articles now account for over 40 percent of all articles viewed on our digital platform, attesting to both the relevance and importance of cosmetic surgery to the readers of Plastic and Reconstructive Surgery and the field as a whole. Looking forward, the future is bright as Plastic and Reconstructive Surgery seeks to maintain and expand its role in cosmetic surgery, cosmetic medicine, and cosmetic innovation and education (Fig. 5). The rapid evolution in aesthetic surgery and cosmetic medicine demands a journal with the scientific integrity of Plastic and Reconstructive Surgery to provide our readers with evidence-based information that separates facts from fiction, truth from hype. Looking back, we feel secure that visionaries such as Robert Goldwyn, Joseph Murray, and Tom Baker would be proud that the current state of the Journal has not only embraced aesthetic surgery but has made it a major focus of our educational and multimedia efforts, ensuring its future for teaching the next generation of plastic surgeons. Publishing the highest quality articles from the world’s authorities in cosmetic surgery and cosmetic medicine remains at the core of our goals in maintaining Plastic and Reconstructive Surgery as the foremost global resource for information in plastic surgery. Continue to grow and evolve. —Mahatma GandhiFig. 5.: Over the past 75 years, Plastic and Reconstructive Surgery has influenced the development and practice of cosmetic surgery across the globe. Looking forward, the future is bright as the Journal seeks to maintain and expand its role in cosmetic surgery, cosmetic medicine, and cosmetic innovation and education.ACKNOWLEDGMENTS The authors wish to acknowledge David Hidalgo, M.D., for serving as the Cosmetic Section editor of Plastic and Reconstructive Surgery from 2013 to 2021, and Charles Thorne, M.D., for serving as Cosmetic Section Editor of Plastic and Reconstructive Surgery from 2006 to 2013. Their leadership paved the way for the modern, multimedia, multidisciplined, evidence-based cosmetic plastic surgery content we see today. The authors also acknowledge Plastic and Reconstructive Surgery Senior Managing Editor, Aaron Weinstein, for organizing this year-long series of editorials in celebration of the 75th anniversary of Plastic and Reconstructive Surgery and for assistance on this editorial.