Cosmetic Surgery (part 1) – Christian Medical & Dental Fellowship of Indonesia (CMDFI)

Cosmetic Surgery

By Rhona Knight

_{Society appears to agree with the Ben Sherman advert, ‘Looking good isn’t important, it’s everything’. A person’s value is often seen as being dependent on looks, ability, income, and image.¹ If uncertain what ‘looking good’ is about, we look at the faces and bodies that fill the screens and magazines. These show that young, slim and beautiful is the order of the day for women, while a lithe, well-muscled and toned Adonis is the ideal male.² For those struggling to achieve the perfect face and body, adverts for breast augmentation, Botox, hair transplant and buttock implants indicate ‘cosmetic surgery is here to help’.}

Cosmetic surgery is big business

The saying goes that no one ever lost money by over estimating women’s vanity. The same could probably be said of men. In 2011, the UK cosmetics product industry was valued at €8.3 billion.³ Cosmetic interventions are also a booming business, worth €2.3 billion in 2010, with an estimated worth of €3.6 billion by 2015.⁴ Non-surgical interventions, for example dermal fillers. Botox and lasers, ‘which can have major and irreversible adverse impacts on health and wellbeing’⁵, account for 90% of procedures.⁶

Is there a problem?

According to the UK paper Metro, 30% of people feel most judged by body shape, 22% by by dress sense and 21% by clothing brands.⁷ The comic Francensa Martinez’s five step advice on how to appear normal in today’s society includes ‘be dissatisfied with your body’.⁸ Eating disorders are an ongoing problem, impacting on individuals and occupational groups, for example modelling, horse racing and now Formula One.⁹ Maybe this helps us understand the rather chilling 2012 data from the Girl Guide Association about how unhappy girls are with their appearance.¹⁰ It may also shed some insights into steroid abuse and ‘bigorexia’ – muscle dysmorphia – in men.

While many may seek cosmetic surgery as a technological way of achieving wellbeing, for others it is about addressing unhappiness, and creating and maintaining appearance. For other still, it is about the retention of youth. If, in addition, adverts for cosmetic surgery increase dissatisfaction with appearance¹¹, it follows how this, along with idealised views of what is normal and a consumer culture, can all combine to prey on vulnerable people.

Slippery terminology

Terms like plastic surgery, cosmetic surgery, and aesthetic surgery are often used interchangeably.

Plastic surgery, however, typically describes therapeutic procedures ranging from those used to cope with life threatening emergencies to the removal of skin cancers in a way that minimises disfigurement. It is also used to describe restorative surgery, for example after mastectomy.

Cosmetic surgery is defined in varied ways.¹² The British Association of Aesthetic Plastic Surgeons ¹³ (BAAPS) uses the word aesthetic to describe cosmetic procedures done by plastic surgeons, whereas the Royal College of Surgeons ¹⁴ uses the terms cosmetic practice and cosmetic surgery, these being most commonly used and understood by patients.

Perhaps the most helpful definition is found in Good Medical Practice in Cosmetic Surgery / Procedures:¹⁵

_{Cosmetics Surgery comprises operations or other procedures that revise or change the appearance, colour, texture, structure or position of bodily features to achieve what patients perceive to be more desirable.}

The aim of any cosmetic surgical invention is important to identify. It may be therapeutic, restorative or enhancing. A therapy is a ‘treatment intended to relieve or heal a disorder’¹⁶, for example the removal of a facial skin cancer. Restoration is about returning something to its original condition ¹⁷, for example using certain techniques to remove a cancer but retain appearance. Enhancement is about further improvement ¹⁸, becoming better than well. In cosmetic surgery, therapy and restoration effectively enable the patients to remain within or move toward the norm of the population of which they are a part. Restoration does not, therefore, include anti-aging procedures, which are about moving towards the norm of a different – often younger – population, which can be seen as enhancement.

This File assumes a holistic bio-psycho-socio-spiritual view of the person. It will not cover surgical procedures indirectly aiming to retain or alter appearance, for example, gastric banding to aid weight loss or termination of pregnancy to prevent alteration of body shape.

What is normal?

Concern about appearance is not new. Make up, clothing, footwear, tattooing and many other permanent and non-permanent interventions have been used for millennia to change and ‘enhance’ appearance. Sushruta (600 BC), one of the earliest recorded surgeons, known by many as the ‘Father of plastic surgery’¹⁹, is believed to have been the first person to describe rhinoplasty for cosmetic reasons.²⁰

Yet many seeking cosmetics surgery are not seeking enhancement, but instead wish to appear more ‘normal’. In any population, there will be those at the extremes of the normal distribution curve, whether in height, nose size or breast size. It is not unusual for plastic surgeons to meet patients with physical features at these extremes of normal, who feel self-conscious about their appearance. Whereas technology to address this concern used to be limited, the improvements which now enable restoration of normal function with less associated risk in other clinical areas, for example knee and hip replacements, can also enable those at the extremes of the normal distribution curve in appearance become ‘more normal’.

Holistic health and wellbeing

While papers may tell of a ‘Cosmetic patient’s suicide after surgery “hell”‘²¹, many GPs and plastic surgeons can relate other stories of patients adversely impacted in social, physical and psychological ways by an aspect of their appearance. For some this can result in mood disorders and suicidal ideation, for others it can result in social pain or isolation, being subject to bullying and ridicule. While breast augmentation has been associated with an increased suicide risk ²², lack of access to surgery can also have a similar impact. Kerrie Jewel²³, who felt suicidal as a result of her 40HH breast size, had been asking unsuccessfully for a NHS breast reduction for 25 years: ‘I don’t want to look like a top model. I only want to be like normal people and not get teased.’ in a similar way, the development of breast issue in men can have adverse social and psychological impact ²⁴, as can prominent ears in children.²⁵

The broader context

All of these stories are set in a broader context. While many UK plastic surgeons and GPs performed cosmetic procedures for many years on the NHS, from the removal of an unsightly mole to more major operations, most healthcare commissioners no longer approve referrals for cosmetic surgery. As a result, much of the booming industry in aesthetic surgery resides in the domain of private health care where an increasing number of NHS practitioners, both in primary and secondary care, are now providing private cosmetic procedures, tacitly affirming that such access is needed.

However, the private cosmetics sector is poorly regulated and comprehensive outcome data is hard to find. Not all procedures are provided by registered doctors who are bound by their codes of practice and whose performance is reviewed annually in appraisal. Procedures are also provided by many other, often unregistered, practitioners from varied backgrounds. It appears to some that much cosmetic surgery is more financially, than therapeutically, motivated, aiming to maximise profit in a consumer market. Yet when things do go wrong in the UK it is often the NHS that has to deal with adverse outcomes and pick up the costs.²⁶

In the context of this paper, the words of the cosmetic surgeon Atiyeh et al help crystallise the dilemma:

_{Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the healthcare system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients?²⁷}

Cosmetic surgery: is it safe?

The regulation and safety of cosmetic surgery appears to be a big concern. On the face of it, a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), highlighted several patient safety concerns.²⁸ They also noted that while a number of patients were likely to have unrealistic expectations of cosmetics surgery and deep-seated problems, in only 4% of sites was it normal practice for a patient to see a Clinical Psychologist.²⁹

The Expert Group on The Regulation of Cosmetic Surgery: Report to the Chief Medical Officer³⁰, noting unacceptable methods of advertising, made 20 recommendations and concluded that, ‘Although there is no one authoritative source of evidence to show that significant harm is caused to patients by cosmetic surgery, evidence from numerous bodies, as related in this report, suggests that there are grounds for concern.‘

The 2013 Department of Health review suggested that ‘a person having a non-surgical cosmetic intervention has no more protection and redness than someone buying a ballpoint pen or a toothbrush‘.³¹ Bruce Keogh, in the final part of the foreword to this report, urges ‘the Government, regulators, provider organisations and professionals … to make sure that individuals’ health and safety is prioritised ahead of commercial interest‘.³²

Professional values and codes of practice

Most healthcare professionals are bound by codes of practice. Such codes go back millennia, from the Code of Hammurabi and the Hippocratic Oath to key documents relating to cosmetic surgery which include the Independent Health Advisory Service Good Medical Practice in Cosmetic Procedures ³³ and Professional Standards for Cosmetic Practice.³⁴ The latter document, published in 2013, summarised cosmetics practice guidance for three professional groups: nurses, dentists and surgeons:

_{Practitioner should adhere to the process of patient care outlined in this document, which highlights the importance of preparing the patient before the procedure, ensuring that [the] patients has a full understanding of the risks involved in the procedure, consideration of the need for a psychological assessment and the pre- and post-operative requirements of the procedure.}

Noting the increasing number of requests for genital surgery in under-18s, it advises that high levels of anxiety, if appearances are within normal limits, should trigger psychological referral.