Cosmetic medicine would virtually cease to exist without media. Like most nonessential pursuits, cosmetic medical care has no intrinsic value outside the framework of our culture and our times. If Armageddon comes tomorrow, people will still need doctors to repair their injuries, treat their heart attacks, and take out their sick gallbladders, but they will forget about their basement renovations, golf club memberships, and facelifts. Cosmetic medicine is popular now because it can be.

Even though we each have opinions about the very idea of cosmetic medicine in the same way that we judge other aspects of our culture, few of us can escape the impact of the pure weight of media messages about personal appearance ideals and cosmetic medical options. To paraphrase writer and academician Thomas de Zengotita, we are so manifestly unequal to the solicitations lavished upon us, it is no wonder that, trying to live up to it all, we enslave ourselves to regimens of self-improvement.

It all began nearly two centuries ago. The nineteenth-century invention of photography fundamentally altered the way people receive information, with an impact at the time analogous to that of digital technology today. Before tintypes and daguerreotypes, individuals may have had some exposure to sketches, portraiture, and written descriptions of physical appearance and attire, but most people took their cues about desirable personal appearance from direct observation of others in the community. By the 1880s, however, photographs were reproduced in magazines and brought astonishing new imagery to the masses. The dissemination of images that were portrayed as cultural ideals initiated the public’s infatuation with visual media. As historian Kathy Peiss puts it, this historical phenomenon “began a long-term pro cess of educating the eye, channeling desires, and creating an identification between repre sen ta tion and viewer that would serve the sale of goods and foster new perceptions of beauty in the culture at large.”3 Later, when pictures of glamorous stars of the new motion picture industry made the pages of magazines and newspapers, the already profitable print industry was transformed.

MEDIA AND COSMETIC MEDICINE

The modern age of media and medicine began after World War II. By then medicine had become more professionalized and scientifi c, evidenced by standardization and improvements in medical education, surgical techniques, anesthesia, and drugs, especially antibiotics. The public had little access to medical information outside of what doctors provided, and physicians were widely respected and even revered. Doctors did not maintain their aura for long, however. As a result of shifting social and economic relationships between physicians and patients, doctors have gradually lost much of their traditional authority.

Some cultural observers attribute the progressive decline in medical authority to a long ago rejection by the public of the characteristically paternalistic attitudes of physicians (which was passed down from generation to generation through every doctor’s training ordeal and undoubtedly persists in some programs) and the wide availability to the general public, especially through the Internet, of all sorts of medical information. Today’s patients are less likely to defer automatically to a physician’s professional advice, and many physicians bemoan the increasing numbers of patients who ignore a seasoned medical opinion in favor of their own, often ill-informed, ideas. These tales are more than anecdotal: a recent national survey showed that more than half the respondents had questioned or ignored their doctors’ recommendations. De Zengotita refers to this cultural shift of authority in medical decision making from the experts (the “whitecoats”) to the individual as the democratization of therapy. This shift has occurred throughout all of medicine but is especially evident in cosmetic medicine. Even more significantly, patient autonomy in cosmetic medical decision making is increasingly powered by a cultural mandate: Be all that you can be.

Medical issues do not always fare well in media. Media outlets compete fiercely, and there is a lot of airtime to fill. As a result reporters and writers try to outdo each other with the dramatic and the spectacular rather than with issues and their complexities. Television reportage is particularly prone to misrepresentation and hyperbole; the nature of the medium lends it to the production of mini-stories rather than in-depth analyses. These sound bites are very tasty and compelling but, like french fries, they are not good for us. They cannot substitute for more involved, nuanced discussions that help viewers get a true understanding of medical subjects. Cosmetic medical care has hardly been immune to distortion by the press. Considering the fact that a large number of people admit to relying on television for most or all of their news, it is not surprising that the average person has a skewed idea about what cosmetic medicine, especially surgery, really entails.

Magazines and Newspapers

After World War II, as the United States began what de Zengotita calls a “long march toward a therapeutic society,” the public devoured stories about cosmetic surgery. Postwar American psyches were highly receptive to this idea of regeneration, both national and personal. In 1946 journalist Robert Potter wrote a series of articles in American Weekly entitled “Farewell to Ugliness,” playing on the title of Ernest Hemingway’s antiwar novel A Farewell to Arms. One of the captions could be the original story line for a cosmetic surgery reality TV show: “To the homely girl, life may seem an endless succession of Embarrassments, Frustrations, and Anguish until she decides, one day to . . . have a plastic surgery operation. Then a remodeled nose, a rounded chin, may alter her personality—and her whole life.”4 Readers, it seems, never tire of tales about beauty and the quest to obtain it, and cosmetic surgery has all the extra thrilling elements of a great yarn: sex, danger, violence, mystery and unveiling, immorality, vanity, and greed.

Women’s magazines have always focused on beauty and bodies, and our current obsession with makeovers is really an extension of the diet and exercise craze of the 1970s and 1980s that was also heavily covered in the popular press. Today there are dozens of popular magazines targeting women, and nearly all of them have more articles and ads about skin care, weight loss, cosmetic medical treatments, and other beauty industry offerings than about any other subject category. (Similarly, appearance and health-related magazines successfully appeal to men.) According to sociologist Deborah Sullivan, this emphasis reflects “both a response to increasing reader interest in physical appearance and beauty product advertisers’ demands for a ‘supportive editorial atmosphere’ and ‘complimentary copy’ in exchange for their advertising revenue.”

The fact that women’s magazines are one of the major sources of public information about cosmetic medicine has proved to be a twoedged sword for patients and providers. Critics dismiss the generic category of “women’s magazines” as being little more than advertising catalogs; those who have analyzed the content of health articles in these magazines report that the information is often alarming, misleading, and based on scientifically unsupported claims. Newspapers, hardly immune to the siren call of cosmetic medicine, have taken note of the economic implications of its popularity. The Wall Street Journal, for example, continues to feature cosmetic medicine–related articles, often on its front page, even though the initial buzz about Extreme Makeover and its clones has long faded away.

The Internet

The World Wide Web has only begun to infl uence how we seek, obtain, and even manipulate our individual health care. The rapidity of change within this technology, still in its infancy, is dizzying. Even now a potential patient seeking a cosmetic change can browse the Web and choose his or her own path of discovery. Unedited surgeries, for example, have been broadcast online for several years. It should be pointed out that at this time the vast majority of information about cosmetic medicine on the Web is commercial.

Radio and Television

Radio, once the king of media, still maintains a niche in the coverage of health-related topics, but it cannot compete with the impact television has when covering an inherently visual subject like cosmetic medicine. Even in its early years the power of television as a visual medium lay in its ability to create instant cultural icons and expectations. Sitcoms, those programming staples of the early years, regularly sent the message that beauty was the key to success. Everyone over a certain age remembers the old shows that parodied the clueless boss for whom the beautiful but brainless secretary could do no wrong while the passed-over older women in the office looked on and fumed. (The setup may have been funny, but the message was not lost on working women, who were well aware that the best jobs always seemed to go to the most attractive applicants.)

The invention of television also provided organized medicine with an unprece dented opportunity to influence the portrayal of doctors in media and thus provide them with burnished images and not entirely earned credibility that has lasted for decades. Physicians at midcentury, already unhappy to see doctors featured in ads to sell guns and cigarettes, managed by way of the AMA to infl uence the development of the Television Code between 1952 and 1963 as it pertained to depictions of doctors and other health professionals. Advertisers got around a ban on actors playing doctors by using real doctors and later managed to have their cake and eat it, too, by using the actors in fictional shows to push products (remember “I am not a doctor, but I play one on TV”?). However, the AMA, at least in the short term, prevailed and was able to sterilize the images of doctors in the media. It is hard to believe now, but by 1963 television broadcasters were prohibited from showing advertisements that used either real doctors or actors portraying doctors.

In the early years of television the AMA was also able to infl uence characterizations of fictional doctors, from Drs. Kildare and Ben Casey to Marcus Welby. Until Frank Burns in M*A*S*H and the doctors of St. Elsewhere, TV doctors shared a fairly consistent image: heroic virtues; brilliant diagnostic abilities; an unlimited fund of knowledge and access to all sorts of cutting edge and experimental treatments; good looks; eloquence; and charisma. They were also obsessively attentive to their patient’s (they seemed to have only one at a time) medical and personal problems, for all of which the doctors seemed to have solutions. They were always willing to sacrifi ce without complaint any personal needs and always willing to break the rules in order to rescue the patient. Early shows perpetuated other myths about medicine: surgery can cure nearly everything, doctors don’t really care whether or not they get paid, hospitals are exciting places to be. And of course there was drama: Sick people on television are healthy one minute and require emergency care the next; medical decision making happens quickly and is either heroic (by the good doctor) or dangerously mistaken (by the bad doctor). By the end of the episode, of course, the good doctor prevails.6–8 By the end of the 1960s, even though most authority fi gures had been knocked off their pedestals, doctors still commanded respect. Even Hawkeye Pierce was a good doctor in the mode of Kildare and Casey with a little frat boy thrown it. Today’s TV doctors are very human, even poster children for bad behavior. The soap opera Nip/ Tuck, which is as much about plastic surgery as Dallas was about the oil industry, has lead characters so outrageous that they make J. R. Ewing and his business rivals look like choirboys.

It is helpful to understand how televised images of doctors have been manipulated, because people get a lot of medical information from television. In fact, polls indicate that most people get more information from media sources, especially television, than they do from their physicians. That information is not coming just from news stories or documentaries—one of the prime sources of televised medical information is daytime soap operas. Most importantly, people tend to act on medical information they get on TV, sometimes to the extent of changing their behavior.

The latest television genre to target consumers of health care, particularly cosmetic medicine, is reality TV. Reality shows have dominated television for the last several years, and if we recall An American Family and The Real World, we have to acknowledge that, as media professors Susan Murray and Laurie Ouellette point out, a generation of youth has already been raised in the “language” of reality TV.9 Today’s crop of cosmetic surgery reality shows has proven to be a very effective vehicle for pushing medical and beauty products and services.

The reality format itself originated outside of the United States (Extreme Makeover is owned by the Dutch company Endemol), but since its introduction reality TV has become a global phenomenon. The recognizable atmosphere of reality television shows derives from the filming of nonactors supposedly behaving “naturally” in an often contrived setting in anticipation of a more or less predetermined outcome. The appeal is that viewers recognize themselves in the participants. Televised transformations have become so popular that “extreme makeover” and “nip and tuck” have entered the popular lexicon to describe renovations not only of bodies but of bedrooms and boardrooms.

COSMETIC SURGERY ON TELEVISION

Dr. Crum may have had a good local audience for his facelift demonstration in 1931, but most of the world had to read about it in the newspapers. Today, millions of people across the globe can tune in to watch cosmetic medical providers perform and promote innumerable procedures, products, and services from TV Makeoverland. Like the reality genre itself, cosmetic surgery reality shows range from the purportedly educational to the carnivalesque. The fi rst, Extreme Makeover, debuted on ABC in September 2003. Its formula is pretty much the Cinderella story, or perhaps Queen for a Day (for those old enough to remember that show from the late 1950s). Extreme Makeover knockoffs have included MTV’s I Want a Famous Face, which follows people trying to have enough surgery to look like somebody else, and Fox’s The Swan, in which a cast of characters is winnowed down to makeover patients, then to beauty pageant contestants. Others are Bravo’s Miami Slice and E!’s Dr. 90210. Somewhat more in the documentary/educational format, but still exhibiting many of the genre’s disturbing features are shows like Discovery Channel’s Plastic Surgery: Before and After and various shows on The Learning Channel. Most shows focus on cosmetic procedures, although some also present stories about reconstructive plastic surgery.

One would be hard pressed to label any of today’s television portrayals of cosmetic surgery as educational in the traditional documentary sense. Almost without exception these shows lead the list of medical programs that, to quote one of the leading experts on the documentary genre, have deteriorated from “discourses in sobriety” to shows infused with a “lightness of being.”10 Rather than addressing issues of social import, shows of this type are aimed at the individual in his or her capacity as a consumer. Topics are market driven rather than chosen based on public benefit. Cosmetic surgery on televi sion mainly reflects the appetite of the audiences for fairy tales, transformation stories, voyeurism, sex, and blood. For the unconvinced, let’s conduct our own “reveal” of the man behind the curtain—the wholly synthetic pro cess by which these stories are put together in order to maximize entertainment value.

Anatomy of a Cosmetic Surgery Reality Show

If you have read The Ugly Duckling or similar transformation fairy tales, you know the basic story line of a cosmetic surgery reality show. In human terms, a dowdy commoner is rescued by the cosmetic surgery prince hero (usually a good-looking and charismatic surgeon) and launched into a new life, one that is well deserved and will presumably be glorious and fun filled. The stories exploit the universal fantasy of the unappreciated, as media critic James Poniewozik captured so well: “If someone with a gifted eye took the time, that person would see [my] true beauty and uniqueness, would probe past the lie of [my] drab exterior and bring the simmering true [me] to the surface.”

The shows are full of rituals, rituals repeated for each participant and on every episode. In keeping with the transformation formula the “chosen one” must first be humiliated. The story first focuses on her (or his) presumed mortification because of her body and emphasizes her apparent self-loathing. She is filmed at unfl attering camera angles, often slouching, rarely smiling, with messy hair and unbecoming clothes. During her early interviews, the advance team pays inordinate attention to the depths of her despair. Before she can make the cut, however, she and her loved ones must express even more painful feelings and voice hurtful comments that they ordinarily would not dream of making so that the writers can set up the drama, the washing away of the stain of ugliness that leads to rebirth. Later, after traveling to the show’s location, the featured physician’s opinion is exaggerated for maximum dramatic impact—a twenty-one-year-old girl is pronounced to have the skin of a sixtyfive- year- old, et cetera.

The participant is easily persuaded to undergo numerous cosmetic procedures such as breast enlargement, tummy tuck, liposuction, nose recontouring, chin enhancement, tooth veneers, microdermabrasion, peels, and a variety of other treatments by the featured surgeon and others (dentist, dermatologist, aesthetician, and so on). The procedures themselves do not garner much airtime, nor does the postoperative period, although the high-tech setting of the operating room is prominently featured. Postoperative pictures, so often worth a thousand words, are surprisingly downplayed in many cases, perhaps because the outcomes are not as dramatic as desired. The before and after photo stills and videos are flashed on the screen but often from odd angles, and a viewer can never really evaluate the results, certainly not in the highly stylized “reveal” at the story’s climax. After surgery, bandages become a fashion statement. Patients are shown walking the streets in their facial slings and nasal splints long after these appliances are medically necessary. At this point they are props, waiting to be discarded for the fi nale. The postoperative period is portrayed not as a time of rest and recuperation but as a whirlwind schedule of marathon workout/weight- loss sessions, shopping, and visits to the hair- and makeup stylists. In some shows the patient is hidden away until her unveiling before a crowd of cheering supporters. Viewers are privy to just a few seconds of her “exit” interview, while she is still flush with the excitement of her public presentation, and never hear from her again. The only clue that there could be more to her story than will ever be made public is a fl eeting glimpse of her children’s worried faces.

The patients/contestants are not the only ones “created” as characters. Some shows freely incorporate the personal story lines of the featured providers, dirty laundry and all. Yet we are assured of the quality of the medical care offered through a variety of implicit and explicit messages; credentials are flashed on the screen, and compassion is implied by staged scenes of hugging and cavorting with patients and mention of charity work. Stories featuring reconstructive procedures by the same providers prove them capable of providing “real” medical care.

Every story has an emotional hook, like the core “beat” of a fi ctional piece. The progression of each story line is like a TV drama: intense, emotional, exciting yet predictable, rhythmic, and satisfying; even the ads are timed to fi t the pattern. The drama of the surgeries themselves is often heightened by the sheer number of procedures. The most fl amboyant programs are fashion shows, veritable catwalks of “miracle” procedures that can make the uninitiated viewer’s jaw drop. The routine or mundane aspects of care, no matter how critical, are deemphasized or ignored. The patient’s ordeal is neatly packaged into less than twenty minutes of actual airtime, making the makeover pro cess feel like a quick and fairly easy fi x. The fact that procedures are performed only if they will fit into the show’s production schedule is not disclosed. Complications and disappointments do not get airtime.

There are uncanny and slightly unnerving similarities between the more theatrical of the makeover shows and what have been generically called the Frankenfl icks.12 These similarities, of course, are what make the shows fun to watch and also why they feel repetitive after a while. As with the old horror movies such as Frankenstein and Dr. Jekyll and Mr. Hyde, the shows capitalize on the public’s fascination with the spectacle of a person undergoing interventions in the name of medicine that include force (surgery), drugs, and powerful, incomprehensible technologies. Even the fi lming techniques have much in common. The viewer gets repeated shots of the deformed parts; the preoperative despair of the patient/protagonist is made clear; the mostly offstage transformation is revealed in dramatic snippets; in the obligatory mirror scene the patient fi nally sees the new her/him; and, at last, it is time for the denouement. Of course, in the television shows the endings are always happy, but the viewer can’t help feeling anxious in anticipation. There is a certain thrill and liberating pleasure in the vicarious experience of watching someone complain about, display, and ultimately eliminate a displeasing physical feature. This is therapy—Dr. Joyce Brothers in the form of a scalpel-wielding surgeon.

Just how have cosmetic surgery reality television shows made an impact on viewers? The shows certainly appear to have sparked an explosion in interest in cosmetic medicine. Watching someone who could be a neighbor or a coworker get a makeover has to make a viewer wonder, Why not me? A recent survey of people who had contacted a plastic surgery professional society Web site showed that seeing surgical results on television was a major stimulus for them to investigate surgery for themselves.

In order to assess how a reality show about cosmetic surgery might be interpreted by a viewer who could someday be a patient, one must consider how that interpretation is inevitably framed by the show’s producers, whose decision making about the editing of the fi lm or video footage is ultimately about assigning value—entertainment and promotional value. Even though a viewer may feel that he or she can “see for myself ” what is happening to a patient on a reality show, that seeing is a mediated experience, a secondhand visual version of events created by the producers to simulate a fi rsthand experience. How the footage is put together for broadcast depends entirely on what message the producers want to send. We all draw on our knowledge and experiences to “translate” the snippets of footage pasted together to form one of these shows into a complete and coherent story, but the dramatic tension is so profound at times (we have to admit that some of these producers know what they are doing) that it can be nearly impossible for most viewers to look beyond the stories already created for us. Of course, viewers do not know what “lies on the cutting room floor,” and what is left out may be extraordinarily more interesting than what is left in. In the end, although most physicians will see beyond the manufactured story line, the average viewer will more readily identify with the emotions experienced by the patient.

The most disturbing artifice of a cosmetic surgery reality show is that an “average” person is subjected to completely “unaverage” medical circumstances in order to service the conceit of television entertainment. Somehow viewers know this and yet they deny it. They can’t help being sucked into the fantasy of easy makeovers. And the reality is that the participants, for all their everyday characteristics, are hardly average. In fact they are handpicked from hundreds of applicants to the casting calls. They are thoroughly evaluated for personal appeal, stories that can be sufficiently dramatized to be entertaining, and physical features that can be substantially altered yet camera-ready within a relatively short time frame. Despite editing and coaching (“just be yourself ”), both the patients and the doctors appear very self-conscious. The doctors have clearly been chosen because of their good television “personas,” but we still can’t help noticing that they are well aware of the presence of the cameras. Even though sequences may appear spontaneous, it is no secret that many scenes are chosen from multiple takes. Incredibly, some footage seems to have been chosen purely for the sake of prurient interests; one of the supposedly more educational shows finally lost its last shred of credibility when, in the course of one episode, it showed a surgeon talking to his office staff with the camera focused on his female assistant’s chest (presumably enhanced by him) and in the next scene having a conversation about his sex life.

Viewers of makeover shows cannot always determine what is important and what is theater, or necessarily understand that cosmetic surgery reality television does not reflect real life any more than do cop shows or cooking shows. This blurring of the distinction between TV and reality has created problems for some real doctors and their patients.

Reality Television Plastic Surgery and Real Plastic Surgeons Cosmetic surgeons acknowledge that the popularity of cosmetic surgery reality shows has benefited their practices. Some see no problem here and are thrilled with the extra business. Others are dismayed by so many patients starting out with extremely unrealistic expectations that are hard to shake. When viewers of reality television see dramatic results accomplished in a short time with little discomfort and no complications, some become prospective patients expecting nothing less.

Former ASPS president Dr. Rod Rohrich not long ago called cosmetic surgery reality television a blessing and a curse—a blessing because the shows have increased public interest in plastic surgery, or at least the cosmetic surgery segment of it, and a curse because, as he put it, “never before have expectations been so idealistic on the part of the public.” He went on to say that during the previous year he had responded to a barrage of media calls and interviews about the shows and that plastic surgeons were seeing a flood of patients demanding multiple simultaneous procedures and having unrealistic expectations regarding results and recovery. “Even though it can have incredible benefits,” Dr. Rohrich stated publicly, “cosmetic surgery is real surgery with real complications and calls for real plastic surgeons trained to perform these procedures. Just because a patient saw a procedure on television or read about it in the newspaper does not make it real, accurate, or even desirable for them.”14 Increasing numbers of surgeons concur with Dr. Rohrich and report more prospective patients demanding dramatic surgery and seeming to have little inclination to dwell on possible risks or adverse outcomes. “I’m starting to see patients whose attitude toward a complicated procedure is very light,” said Dr. Peter Fodor, former president of the American Society for Aesthetic Plastic Surgery (ASAPS), in an interview for Self in 2004. “They don’t even have the patience to listen to what it takes to do [a major procedure] safely. They just want the same miraculous transformation they saw on television.”15 Canadian doctors have been less delicate, reportedly complaining that the programs are turning plastic surgery into a freak show, a carnival, a spectator sport.16 Many physicians from both countries fear that the shows, although stimulating business in the short run, will ultimately be a disaster for the profession, if for no other reason than because doctors appear to be manipulating psychologically vulnerable people for television ratings.

Even though this book is about the larger arena of cosmetic medical care by many kinds of providers, it is impossible to avoid the fact that one reality show scored points by linking itself to professional plastic surgery organizations. The story is this: The fl ood of media messages about cosmetic medical quick fi xes and miracle cures had begun long before anyone ever heard of Extreme Makeover and its clones, and by 2003 cosmetic medicine was already imbedded in the public consciousness as a personal option. Competition among providers was heating up. Coming into this milieu, Extreme Makeover was able to negotiate an agreement in which the show would use, and promote using, only Board-certified plastic surgeons, and the names of the surgeons’ professional organizations would appear on screen. The result: The show gained credibility by appearing to be endorsed by the ASPS and the ASAPS (misnamed in on-screen credits as the nonexistent Aesthetic Society of Plastic Surgeons), and all cosmetic surgeons gained business because of interest generated by the program. Since then, these same physician organizations have had to step back in dismay as the promise that the shows would be realistic evaporated while the members themselves continue to be linked in apparent complicity with the shows’ producers and intent. In fact, there is plenty of consternation within the ranks of plastic surgery about current practices by cosmetic surgeons and the repercussions for the specialty and for medicine as a whole. Most of these concerns are not made public, and leaders of professional organizations and editors of professional journals have been delegated the task of alternately boosting the specialty and gently admonishing the black sheep to behave. The roots of the controversy go back to the very origins of plastic surgery, but politics aside, the ethical concerns are very real and should matter to us all.

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.