The Top Ten Ways to Avoid Needing Cosmetic Medical Care

It seems strange to have to say this, but aging is a natural human pro cess. We are finite beings. What is even stranger is that despite the inevitability of growing older, our culture has managed to persuade us that it is a sign of personal weakness if we allow the signs of aging to encroach upon us without a fight. If one wishes to become the CEO of a Fortune 500 company or the spouse of a publicityprone real estate mogul, then the pressure to look “better than good” undoubtedly reflects the reality of a job requirement. For the other almost 300 million people in the United States, however, the message has become quite insistent. One is not normal if not narcissistic.

You must look great and feel great about it. If you don’t, it is your own fault if your life doesn’t work out the way you hoped. But you can’t look great without help from cosmetic medicine. In order to emphasis this imperative about actively altering your appearance, you are reminded of the “sad truth . . . that no matter how we wish it weren’t so, each day brings tiny, frustrating changes, constantly chipping away at youth and beauty.” This happy message is from a doctor in the beginning of his book about “preemptive” cosmetic procedures. So the ball is in your court. “Why sit idly by, spending the best years of one’s life waiting to look bad enough to warrant a facelift?” And if that isn’t brutal enough for you, remember that it’s your fault. You are told to “stop making things worse.” You can feel lucky that there are options because in the past all you could do was sit “helplessly watching the changes add up . . . and grind [your] teeth and wait for things to get worse.”

At any age, Americans are addicted to the quick fi x. We like ready access, rapid turnover, and immediate results. We are not very good at patience, deference, and delayed or, worse yet, uncertain satisfactions. On top of this, we can’t convince our teenagers to adopt these latter characteristics in order to ease their transition into the adult world. This chapter cannot cure you of a desire to look younger, and if you are over fifty, it will have less to offer you than if you are under thirty. Even so, we all know perfectly well that we can do more to improve our health, and by doing so we will definitely improve our looks. Nothing on the list below will be news to you, but that doesn’t make it any less true. Best of all, most of these tips cost you nothing to implement.

THE TOP TEN WAYS TO AVOID NEEDING A COSMETIC SURGEON

1. Get New Genes

Of course, you can’t do this; we know that skin type is inherited, but that does not mean that you are doomed to look like your mother or father. Upper-class women in the 1800s went to great lengths to protect their skin from the elements, but every generation since then has spent more time outdoors and has received exponentially increasing levels of ultraviolet radiation. We now have much more knowledge and better products to help us avoid skin damage. You can control the quality of your inherited skin.

2. Avoid Ultraviolet Exposure

It bears repeating. There is no single thing that you can do to keep your skin looking young that is more effective than protecting it from the sun, tanning booths, and other forms of ultraviolet exposure. There is even a scary term for this: photoaging. Worse, we physicians are now seeing patients in their twenties and thirties with basal cell carcinomas and squamous cell carcinomas—those sun-related skin cancers that we used to see only in people in their sixties and seventies—and more teenagers with potentially lethal malignant moles (melanomas).

3. Stop Smoking

Smokers always advertise their habit on their skin. Even young people who smoke have a characteristic gray skin color that is a direct result of the reduction of blood supply that ordinarily gives a young person’s skin a healthy glow. Eventually, all smokers look old before their time, and their skin, chronically starved for oxygen, develops a dull, prematurely wrinkled appearance.

4. Get More Exercise

Extreme exercise habits can actually lead to a gaunt appearance, but this applies to very few people. Most people need more physical activity, and moderate exercise has innumerable health benefi ts, including improving one’s appearance and sense of well-being.

5. Practice Good Nutritional habits

Eat a balanced diet and stay away from high-fat foods, sugar, and refined, high-carbohydrate foods that have been stripped of their natural nutrients. Consider taking a multivitamin if you do not eat a good variety of fruits and vegetables.

6. Limit Alcohol Consumption

Excess alcohol intake contributes to many problems, including weight gain. 7. Control Your Weight

We all know how much harder it is to lose weight as we get older, so it is better not to put it on. As we age our skin gradually loses its ability to “spring back” after weight loss. On the other hand, excessive thinness makes anyone look unwell or malnourished, and this effect becomes more pronounced with age.

8. Get Enough Sleep

Studies have shown that large numbers of Americans are sleep deprived. Adequate sleep is essential for good physical and psychological health.

9. Reduce Stress

Stress, whether it be job related, relationship based, or physical, can cause round-the-clock facial muscle hyperactivity that leads to increased facial wrinkling, not to mention loss of sleep, loss of appetite, high blood pressure, and other bodily effects that eventually cause premature evidence of aging and increase the risk of more serious health problems. If you feel that you are under severe stress but cannot identify and/or reduce the causes, you may need to seek outside help.

10. Stay Mentally Stimulated

This is the key to vitality. Vitality is an incredibly attractive human characteristic. People who are not physically beautiful in the classical sense can be desirable to be around simply because they project warmth, charisma, and other hard-to-define qualities that attract others to them. Stay engaged with the world of ideas. Find something that you care about, other than your appearance, on which you can focus your creative energies. Soon you will find that people care less about the way you look than they do about who you are. The purpose of this book is not to tell you whether cosmetic medicine is a good thing or a bad thing, or whether it is appropriate for you or your family or your friends. The message is that cosmetic interventions have risks and don’t make everyone who undergoes them happy that they did. If you are a princess and live in a castle with your prince who used to be frog, then by all means believe everything you see on TV. If not, research your options. See a reputable doctor. Seek a second opinion if you need to. Be a truly informed patient. If you do these things, your dreams may not all come true, but at least you will be less likely to fall down the rabbit hole.

Despite the growing appetite for cosmetic medical care, there persists a thread of uneasiness in public, media, and medical commentary about it. Some express philosophical concerns: What does it mean for humankind when bodies can be altered beyond recognition, detached to a large degree from their genetic imperatives? Has the value of appearance superseded that of character? Others contemplate the potentially corrosive social effects of the pervasive message encouraging cosmetic physical alteration. Will the cosmetic medical craze pass, or are our future generations doomed to seek out increasing amounts of surgery in order to achieve generic, surgically facilitated familial or cultural norms of appearance? Is cosmetic medical care simply there for the choosing if one has the desire for it, or is there in fact a cultural pressure, heavily reinforced by marketing, that is starting to penalize those who do not make signifi cant efforts to alter their appearance? Considered in the latter light, “Be all that you can be” feels like a heavy-handed and subversive message. In an effort to explore the religious implications of cosmetic interventions, plastic surgery professional journals have published the opinions of Jewish and Protestant scholars. As theologian Jonathan Sinclair Carey has pointed out, there is little definitive guidance from ancient religious texts on the propriety of cosmetic surgery, and within and between religions there are conflicting interpretations of what is written. The physical body itself is variously assigned intrinsic value by different religious groups. Carey refers to a survey of theological literature by Wïlhelm Reich that suggests that Protestantism, in principle, puts a fairly low emphasis on physical appearance or the body itself, whereas Catholicism and Judaism give physical attributes a far higher position in a hierarchy of values.

There is also a significant absence in religious tradition and scripture of the concept of an individual’s “right” to cosmetic physical alterations, in contrast to today’s heavy cultural emphasis on themes such as individual empowerment, self-actualization, and personal transformation. Not every religious writer is willing to consider cosmetic surgery acceptable. Proponents of orthodoxy in more than one religion have put forth the view that the body is to be violated only for the treatment of disease or for other therapeutic purposes. The concept of therapy, of course, is variously interpreted.

Others express political discomfort, reflecting the difficulty some have assigning value to cosmetic concerns. When National Public Radio reported the rising rate of cosmetic surgery in post-Saddam Iraq, some listeners were disturbed by the implication that this might be a symbol of what our soldiers are fighting and dying for. Larger concerns notwithstanding, every physician–patient encounter takes place within the context of what society has designated a special relationship. Society recognizes certain professions whose members are entrusted with a duty to protect the public welfare. Rules of professional conduct are based on ancient principles of ideal human relations, especially proper consideration for others, that have influenced societies and religions for centuries. Physicians, like members of other professions, are expected to maintain fundamental ethical standards of behavior.

The tenets of acceptable physician behavior are well established, the old unwritten code of gentlemanly conduct having long ago been replaced with a more formalized set of principles. These principles include a duty to promote good and act in the best interest of the patient and the health of society, known as beneficence, and the duty to do no harm to patients, also called nonmaleficence. A third principle is the duty to respect patients’ autonomy, allowing them free choice without coercion. Inherent in respect for patient autonomy is the physician’s duty to tell the truth, provide full disclosure, preserve confidentiality, maintain appropriate relationships, and obtain truly informed consent.

In addition to adherence to principles of behavior, society expects physicians to accept certain responsibilities, such as to maintain professional competence, seek ongoing improvements in quality of care, uphold scientific standards, disclose conflicts of interest, and discipline those in their ranks who fail to act according to professional principles.

The obligations that society imposes on physicians apply to their relationships with all patients, but cosmetic medical patients do form a special class. These patients are not sick when they seek treatment and in fact are requesting to be temporarily injured so that they can reach a primarily psychological rather than a physical goal. The cosmetic patient is the instigator and an active participant in the decision-making pro cess to a far greater degree than is the typical patient who seeks treatment for an illness. However, this positioning of the patient as the initiator of the medical encounter does not absolve the physician of the moral responsibility to care for the patient according to the fundamental ethos of good medicine.

The growing practice of cosmetic medicine has brought to the greater profession of medicine a unique set of ethical conflicts that have so far been inadequately addressed by physicians or the public. Despite efforts by various professional medical organizations to encourage physicians who offer cosmetic services to behave in an ethical manner, individual physicians do not necessarily adhere to the standards of the larger medical community. The ethical concerns raised after examination of cosmetic medical care in the United States today include but are hardly limited to those regarding the dynamics of the physician–patient relationship, the influence of commercial interests on medical decision making, the intrusive and distorting effect of media on individual patient care and public perceptions, and the social impact of this “Hollywoodization” of medical care.

PHYSICIAN–PATIENT RELATIONSHIP

In the not too distant past, physicians exercised absolute authority over health-care decisions, dictated how patients should live, and opined about what should or should not bother them. As a result physicians’ advice at times trivialized real problems, degenerated into moral preaching, or effectively blamed the patient for whatever problems existed. Women may have received more than their share of questionable diagnoses and bad advice over the course of history: Fainting was pronounced to be caused by hysteria rather than a suffocating corset; facial wrinkling was a woman’s fault for smiling too much; a woman with back pain caused by huge breasts is told she will get better if she loses weight; cosmetic surgery is viewed as a preoccupation of the vain and should not be condoned.

Physicians have long been educated to behave in such a paternalistic manner. Even Hippocrates recommended that physicians tell their patients nothing about their treatment. Today’s patients are less accepting of this attitude, and the bias in contemporary medical ethics as well as in our culture at large is to respect patient autonomy in medical decision making. This is not to say that doctors should “roll over” and do whatever a patient demands—standards of good medical judgment do not permit this. A cosmetic medical provider’s authority takes, or should take, precedence mainly in relation to more narrowly defined questions: Is there a procedure or procedures that can reasonably be done to address the patient’s concern without undue risk? Is the patient psychologically healthy enough to have reasonable expectations, tolerate the stress of the procedure, and understand the potential risks and likely outcomes?

Although the dynamic between a cosmetic patient and her physician is different from that between a sick or injured individual and her doctor, the obligations of each party are not diminished by the distinctive goals of cosmetic medicine. Just as the physician has ethical responsibilities, the patient is obligated to be educated, forthcoming, and willing to commit to the requirements of a mutually agreed upon course of treatment. She should also feel compelled to ensure that she is making her decisions without coercion, that she has reflected on her own motivations and goals, and that she willingly assumes responsibility for her choices.

For decades many physicians did not believe that a doctor could practice in the middle ground between the care of patients suffering from disease, deformity, or injury and the performance of procedures strictly for commercial gain. Today the dilemma of a thoughtful doctor doing this work is still how to balance the lucrative performance of discretionary procedures with good medical decision making that minimizes risks and that is consistent with professional ethical standards. The tricky part for a patient seeking a cosmetic intervention is to find a physician who has maintained that balance.

Unfortunately, some physicians do not concern themselves with ethical boundaries. Some practice outside their scope of expertise. Others mislead patients about risks and outcomes. Still others fail to ensure patient safety, perhaps by turning a blind eye to potential dangers. Ethical responsibilities can apply even when a physician has no direct contact with a patient. For example, at the social events where participants get injections or laser treatments, the necessary medical supplies and equipment can be procured legally only by a physician. Yet if that physician fails to ensure their use in an appropriate manner, he or she has abandoned an ethical, and in some cases legal, obligation to the treatment recipients. This type of unprofessional behavior is not limited to fringe practitioners. Even though individual physicians and professional organizations have decried these rather more risky medical versions of the old-fashioned Avon party, fully credentialed physicians have been known to supply or participate in them. At the very least, ethical standards require that a physician never perform or endorse the performance of a medical procedure on a patient who gave consent while under the influence of intoxicants or peer pressure.

FOLLOW THE MONEY: HONESTY, SCIENCE, AND FINANCIAL CONFLICTS OF INTEREST

Honesty in cosmetic medicine is elusive. Scientific knowledge about what really works is scarce, and marketing rhetoric tends to blur the distinction between what is proven and what is hype. Without question there are honest physicians in America providing cosmetic medical care, but no one knows how many, because their voices are not being heard. Instead, the public is subjected to the shrill hawking of so many vendors of cosmetic medical services that it has become a contest to see who has the biggest tail feathers and can attract the most customers.

It is widely known that the medical products industry is heavily involved in the practice of medicine well beyond contracts to sell drugs and technology. Companies regularly court doctors with gifts, meals, and other perks. Professional meetings are heavily subsidized by interested manufacturers. Academic institutions increasingly rely on the financial resources provided by the companies with whom their faculty members have contracts and grants, and prestigious hospitals and training programs routinely encourage faculty to market their partic ular inventions or discoveries, to which the institution may hold a patent or receive licensing fees, even before independent scientific proof of efficacy of the product has been established. Industry also funds training positions in many specialties. This subsidization of faculty and residents effectively controls the directions in which medical research can proceed.

Because few physicians in practice do primary research, most of them rely heavily on the opinions of others when adopting new treatments. Thus bias by one influential physician can affect an entire medical field when that physician publishes in academic or trade journals; makes presentations at professional meetings and seminars, especially those designed to meet mandatory continuing education requirements; or is involved in developing clinical practice guidelines that will be used by others. Published opinions correlate strongly with the writers’ financial ties to manufacturers, and this trend is quite evident in cosmetic medicine. The editors of reputable professional journals try to eliminate author bias, but they are not always successful. In contrast, “educational” articles in trade magazines are usually quite obviously written for the purpose of promoting a partic ular product or procedure.

New kinds of financial relationships between academic medical institutions and companies marketing retail beauty products and services raise new ethical questions. When an academic institution with a financial interest in a retail business gets involved with that business’s research and allows its name to enhance that business’s marketing, a red flag is raised, according to the Dr. Arthur Caplan. Dr. Caplan, a medical ethicist, has stated that it is a conflict of interest for an academic institution to “study what you own.”

Financial conflicts exist in nonacademic medicine as well. Providers sometimes have exclusive contractual arrangements with manufacturers to use their machines or promote their drugs. Physicians tend to promote to patients the technology and treatments they have available, sometimes to the exclusion of better options. There are understandable reasons for this. Physicians who commit to expensive pieces of equipment find them obsolete while still on the books. As a result, when presented with the opportunity to treat a patient or send her elsewhere, some providers push their own technology, perhaps long after others have discarded it as outdated or useless. This same phenomenon occurs with treatments in which a provider may have a vested interest, such as an undisclosed intention to publish outcomes.

A physician who performs treatments with older technology is not necessarily practicing bad medicine. Ethical problems arise when patients are encouraged to undergo treatment that is known to be ineffective, markedly more expensive or inconvenient than the alternatives, or outright dangerous just because the provider wants to recoup the cost of the machinery.

In contrast to other professionals, such as attorneys and journalists, doctors are not universally required to offer disclosure of fi nancial conflicts of interest that may affect their care of patients. Dr. Jerome Kassirer, former editor of the New England Journal of Medicine, calls this fact one of the great scandals of our time. Although fi nancial conflicts of interest are common in cosmetic medicine and do not necessarily lead to poor patient care, a prospective patient will have little idea of what should be offered if he or she has not investigated the options.

Concern over improper relationships between physicians and various industries has stimulated public and professional debate such as occurred after the recent decision by the American Academy of Dermatology to allow partial corporate funding of training programs. Proponents of those relationships point out that other sources of funding are not forthcoming and that there is already a workforce shortage in the specialty. Opponents feel that despite efforts to prevent individual doctors-in-training from feeling beholden to a particular pharmaceutical company, there is an inevitable confl ict of interest that will prevent newly minted dermatologists from giving objective treatment recommendations to their patients.

PHYSICIANS AND PATIENTS IN THE MEDIA SPOTLIGHT

Competitiveness in the cosmetic medical market leads providers to adopt retail methods to increase sales, which may include using their own patients to help promote their services. A physician who hires a marketing expert will be encouraged to consider every patient who comes to the office as a potential advertising tool. “Did you ever operate on someone who was a domestic violence victim?” the physician will be asked. “That always makes for a great story.” This widespread propensity for viewing patients as marketing material at the very least raises questions about some providers’ motivations. Perhaps nowhere do medical professionals promote themselves more eagerly than on reality shows, where the true stars are the providers, not the patients. Although some claim not to receive direct payment for appearing on the shows or for providing medical care, all the providers obviously have services for sale, and some have even gone on to appear in product commercials.

Cosmetic medical care providers may seek to increase their visibility by agreeing to underwrite contest prizes or donate services for local Extreme Makeover knockoffs. Whereas one might question the judgment of anyone who would choose a doctor just because she or he won a prize that consisted of surgery by that individual, the issues raised by providers “giving away” services are both medical and ethical. Consider the young woman who bared her breasts on a radio station’s Web site and won breast augmentation surgery by a local “cosmetic surgeon.” How do you suppose she reacted when she discovered that the surgeon was an obstetrician/gynecologist, not a plastic surgeon? What if that practitioner’s “offi ce-based surgical facility” was not accredited by any recognized organization? And what if that young woman was psychologically not a good candidate for a cosmetic procedure? Did the surgeon notice or care? The scenario sounds like the infamous and catastrophic wedding engineered by another recent reality show, in which it was later discovered that the groom had misled the bride about practically everything. Truthful disclosure is hardly guaranteed in these highly publicized fantasycome- true events, even when a patient’s health is at stake. Some professional organizations, including the ASPS, have specifi cally prohibited their members from participating in contests and similar activities, but the rules have little if any impact on nonmembers.

Patients on Television: A Different Standard of Care?

Cosmetic surgery and related procedures are portrayed on television in ways that many physicians and professional medical organizations decry as distorted and misleading, raising numerous ethical concerns. Because reality television shows are credited with bringing large numbers of prospective patients into physicians’ offices, a closer look at this phenomenon is warranted.

By virtue of their claims to portray “reality,” some entertainment shows do claim kinship with documentaries. However, in its ideal form, a true documentary searches for truth and respects ethical issues that attend the use of human subjects in media presentations. Most observers of the reality show genre seem to agree that the presentation of truth and balance tends to take a backseat to entertainment value, and the producers of the shows have as much as admitted this. Unfortunately, as media writer Steven Lagerfeld points out, television is a uniquely compelling medium and does not encourage its viewers to distinguish between fact and fi ction.3 Academics studying audience responses to reality television have discovered that most viewers do understand that there is an element of artifi ciality in88 volved in all of these shows; even so, viewers assume a certain degree of authenticity and are always looking for the “moments of truth.”4 Viewers are more likely to believe that shows about lifestyle subjects or medical issues—and cosmetic surgery shows fit into both of these categories—are more “real” (because one can “see” what is going on); have more educational content,5 especially when physicians are prominently featured; and thus have more value. People also tend to be less skeptical of claims about subjects with which they have little personal familiarity. Because “educational” for most people means “truthful,” it follows that audiences are positioned to be more easily misled by misinformation or deception on shows covering medical topics. In the case of cosmetic surgery reality shows, viewers with limited or no personal exposure to cosmetic medicine are especially likely to accept uncritically a “real” television portrayal as an accurate representation of a typical patient experience.

Physicians and others have raised ethical concerns about the way these shows distort reality and disregard critical features of a healthy physician–patient relationship, largely through compression and “sanitation” of the time line. In twenty minutes of airtime, a patient undergoes (or should undergo) a thorough consultation that includes a discussion of risks and possible outcomes, preoperative evaluation and counseling, preparation, one or more major operative sessions, and recovery (which in real life can be painful and quite prolonged). The patient’s postoperative adjustment is not addressed. Not only does this portrayal skew reality for the viewer, but it completely ignores the inconveniences, miscommunications, disappointments, complications, personal upheavals, economic strains, and occasionally even tragedies that can occur as the result of any major surgery.

The Value of Bribery

A cosmetic surgery reality show manages to bribe providers and patients. As was discussed earlier the ASPS endorsed Extreme Make over in exchange for what was in effect an advertisement in the closing credits. Shows with a contest or makeover format in which the patient has no fi nancial risk easily bribe applicants with the possibility of being on the show. After all, who wouldn’t be tempted by free cosmetic surgery, dental work, and the extra perks: a famous surgeon, luxurious surroundings for preparation and recovery, a new wardrobe, and professional makeup and hair care? Many people would worry about being fired for taking two months off to have cosmetic surgery, but not these folks. The employers of show contestants may not be too happy about losing a worker for that long, but perhaps they decide that a chance to share the spotlight of national publicity is worth it.

Although the participants in televised makeovers are extensively prescreened for their personal appeal, for the dramatic attraction of their stories, and to see if the transformation of their partic ular physical features can be completed within the time frame, one can easily imagine how the chosen recipient of extensive free cosmetic surgery and other services would be reluctant to compromise his or her eligibility for the show by questioning the treatment plan offered. The fact that one’s conversations with the health-care providers are recorded, edited, and later broadcast to the world at the discretion of the producers surely tempers any inclination one might have to request alternative procedures.

Television’s ultimate disregard for the patients and the pressure on families to “do whatever it takes” to get their loved one chosen for the show appears to have had tragic results for a family in Texas. According to press reports, a prospective Extreme Makeover participant filed suit against the show in September 2005 after her sister committed suicide, allegedly as a result of mental distress caused by comments she had made on camera about the participant under pressure from the advance film crew. The participant had progressed so far as to travel to Los Angeles, but she was rejected as a suitable candidate because her medical needs did not fi t the “format,” and it was the combination of the late rejection and the unfl attering comments that could not be unspoken that allegedly triggered the sister’s suicide. Regardless of what prove to be the facts of the case, one cannot help but feel chilled by the despair that the two sisters must have suffered as the dream they were encouraged to cultivate turned to ashes.

Certain cosmetic procedures may be described as minimally invasive; these are procedures such as injections, laser treatments, dermabrasion, and chemical peels that may cause less severe injury than a major operation. Minimally invasive does not necessarily mean minimally risky—patients have died from procedures that are sometimes dismissed as minor—and certain procedures, like liposuction, are considered invasive surgery even though they are performed through very small incisions. In fact, the size of skin incisions per se has little to do with the invasiveness or risks of a procedure. It is also inappropriate to consider procedures such as full-face ablative laser resurfacing and phenol chemical peels to be minimally invasive, as both create signifi cant burns. Noninvasive procedures are those in which there is no significant penetration of or damage to skin and underlying tissues. These procedures include certain laser and light-based treatments, microdermabrasion, and numerous newer procedures that may or may not have any measurable effects. Nonphysicians in nontraditional medical facilities such as spas and salons offer a variety of minimally invasive and noninvasive procedures.

Because many cosmetic medical services are not surgical and many providers are not surgeons, I frequently use the general terms “provider” and “practitioner” to refer to anyone offering cosmetic medical care services.

Cosmetic surgery is any invasive surgical procedure performed by anyone, regardless of training, for the purposes mentioned above. Most people do not understand the distinction between a cosmetic surgeon and a plastic surgeon. Cosmetic surgeon means the same thing in this writing as it does in the marketplace: it refers to any physician, regardless of qualifications, who performs cosmetic operations. Aesthetic surgery and aesthetic surgeon are terms used interchangeably with “cosmetic surgery” and “cosmetic surgeon.” In this book I use the term plastic surgeon only in reference to physicians fully trained in plastic surgery.Plastic surgery is used to denote the spectrum of operations typically performed by plastic surgeons, which includes operations on virtually all body parts rather than on a defined anatomic area (for example, the head and neck region or the eye region) or on an organ system (such as the digestive system or the skin). Many people have no idea what plastic surgeons do beyond cosmetic surgery. Plastic surgeons can replant an amputated finger and keep it alive, build a missing ear from scratch using other body parts, close a gaping leg hole that resulted from a motorcycle accident, repair an infant’s cleft lip and palate, and treat the wounds of a child burned in a house fi re. Most people do not know that the first successful kidney transplant was performed by a plastic surgeon who won a Nobel Prize for this accomplishment. Plastic surgeons also perform breast reconstructions and reductions, treat facial trauma and burns, perform hand surgery, correct congenital deformities, treat skin cancers, execute many forms of tissue transfer to heal wounds, and perform all types of cosmetic surgery.

Certain features of cosmetic medical care make the physician– patient encounter quite different from most other kinds of medical interactions:

• By definition cosmetic procedures are performed for the purpose of making a visible change to a body area.

• The patient initiates the encounter as the result of a psychological desire rather than a physical injury or disease process.

• The patient is positioned to maintain more autonomy in the decision-making process than is typical in a disease-driven treatment plan. Having said that, individual patients maintain or relinquish that autonomy to different degrees.

• Most patients are adult Caucasian women.

• All fees are prepaid or financed. Insurance coverage rarely applies.

• It is completely elective and, for most people, optional.

• Some potential patients feel guilt or embarrassment about seeking a cosmetic change; some insist on secrecy.

• The patient may undergo minimal pretreatment medical evaluation.

• The benefits of treatments may be exaggerated by providers.

• The risks of treatments are often downplayed by both providers and patients, as the consultation is a sales pitch and the patient is already interested in buying.

• Many procedures are performed in a physician’s office, a spa, or a salon; hospitalization is generally unnecessary or short term.

• A good outcome means that the patient is happy rather than “cured,” although happiness does not always correlate with a good physical result.

Cosmetic Vendors

Who is rendering cosmetic medical care in the twenty-fi rst century? There is a revolution going on. The availability and popularity of minimally invasive cosmetic procedures has turned nonphysicians into physicians, nonsurgeons into surgeons, and surgeons into cosmeticians. If you don’t believe it, just take a walk through your local yellow pages, read your local newspaper advertisements, or surf the Internet. It is no wonder that prospective patients do not know whom to trust.

There are an estimated 23,000 self-designated cosmetic surgeons in America today and an untold number of other practitioners offering less invasive cosmetic medical services. Several factors encouraged the expansion of cosmetic medicine in recent decades. Rules regarding physician advertising loosened; even mainstream cosmetic surgeons are now able to court their customers directly and do not have to rely on other physicians for referrals. Provision of cosmetic medical services has become an attractive way to boost income for many physicians. Last but not least, aging baby boomers are leading a wave of increased public demand for cosmetic medical services. Some, although no longer most, cosmetic medical care is rendered by board- certified plastic surgeons. Of the approximately 5,000 board- certified plastic surgeons in the United States and Canada, most perform both cosmetic and reconstructive procedures. The distinction between cosmetic and reconstructive plastic surgery is not rigid, and the techniques learned in one aspect of the specialty are often used to good advantage in other areas. From a practical standpoint insurance companies are mainly responsible for the push to classify procedures as strictly reconstructive or strictly cosmetic. Until recently, most cosmetic surgery was performed by plastic surgeons, partly as a natural outgrowth of our training to solve physical defects of form and coverage, regardless of location on the body, and partly out of an attempt by plastic surgeons to rescue cosmetic surgery from back rooms and beauty shops. The efforts by military doctors in World War I to find ways to treat war injuries gave birth to the formal specialty of plastic surgery, which has roots in older specialties such as otolaryngology, general surgery, ophthalmology, and dentistry. Plastic surgery remains the only specialty whose members are trained to perform cosmetic procedures on all body areas. Perhaps for this reason, the public today still equates plastic surgery with cosmetic surgery rather than with dramatic reconstructions. Many surgeons (and others) find a cosmetic practice appealing, for obvious reasons: The hours are predictable, most patients are healthy, the stress is low compared to other types of medical practice, and the pay is very good. Even though most doctors still fi nd rewards in taking care of sick and injured people, many surgeons from various specialties have increased their volume of cosmetic cases in recent years at least in part owing to the following specific circumstances:

• The volume of reconstructive cases in most plastic surgery practices has gradually but steadily lessened. Skin cancer reconstructions in ever-younger patients may be the only category that is expanding. Legislation mandating seat belts, air bags, lower speed limits, and stiffer drunk-driving penalties has reduced the rates of severe facial trauma. Burn centers and other specialized tertiary treatment facilities have taken patients with certain complex problems out of the care of community surgeons; lower birthrates have led to a drop in the prevalence of cleft lips and palates; technological developments have allowed many large wounds to be treated effectively without major reconstructive surgery; and numerous procedures that were developed by plastic surgeons have been incorporated into the training and practice of physicians in other specialties. As a result, larger than ever numbers of plastic surgeons report that cosmetic surgery composes more than half their workload. In geographic areas oversaturated with physicians or where insurance panels are closed to new doctors, cosmetic surgery may be what keeps some surgeons in business. Similar shifts are occurring in other specialties. As people stop smoking, the rates of head and neck cancers have gone down; antibiotics help patients avoid surgery by treating sinus and ear infections and tonsillitis; allergists and audiologists have taken over the care of many patients with allergy and hearing problems. These changes have all reduced patient and surgical case volume for otolaryngologists (also called ear, nose, and throat [ENT] or head and neck surgeons), some of whom have started to perform more cosmetic procedures. Dermatology has incorporated progressively greater amounts of cosmetic surgery into its training programs to the point of facing a manpower crisis for nonsurgical dermatologists. Likewise, ophthalmologists who had devoted substantial portions of their practices to the performance of LASIK operations face declining fees and stiffer competition for these patients, and some have increased their volume of cosmetic surgery procedures to compensate.

• Insurance reimbursement for reconstructive procedures has declined dramatically.

• Medical practice overhead expenses have skyrocketed in recent years, mainly because of repeated double-digit malpractice insurance premium rate hikes (the typical surgeon’s annual premium has doubled or tripled over the past decade and is now in excess of $50,000). By shifting to an offi ce-based cosmetic practice physicians in some states avoid paying malpractice insurance premiums altogether.

• The demand for cosmetic surgery and other procedures has increased such that even busy surgeons doing little cosmetic work regularly receive calls from patients requesting cosmetic procedures. Physicians from surgical specialties not known for their expertise in cosmetic procedures are among the many taking weekend courses, attending seminars, and meeting with sales reps with the goal of incorporating cosmetic procedures into their repertoire. The big boom in cosmetic medical products and minimally invasive procedures has encouraged nonsurgeon physicians to join the gold rush and add these goods and services to their practices. One cosmetic surgeon reported that he knew personally of a pathologist (one trained to do tissue and postmortem examinations) doing cosmetic procedures, despite never having examined a live patient in practice until he retired to a Sun Belt state. Not to be left behind, nonphysician wheelers and dealers set up clinics and spas, hire medical directors, and sell cosmetic services to whomever they can entice across their thresholds.

Although no one has a handle on the numbers, it is obvious that the number of cosmetic procedures performed in this country every year far exceeds the workload capacity of the qualifi ed boardcertified physicians currently in practice, even imagining that they are all working around the clock.