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Slide 1-

Cosmetic Surgery: Past, Present and Future Martin T Donohoe, MD, FACP
Slide 2-

Cosmetic Surgery is a Branch of Plastic Surgery Plastic surgeons repair congenital malformations (e.g., cleft lip and palate), disfiguring wounds, animal bites, burn injuries, and perform reconstructions after surgeries for chronic and/or malignant conditions Cosmetic surgery is largely elective and designed to augment “normal” appearance
Slide 3-

Plastic Surgery Charities Operation Smile - correcting congenital defects in patients in the developing world Face-to-Face: The National Domestic Violence Project (sponsored by the Am Acad of Facial Plast and Reconstr Surgeons) – for domestic violence victims Interplast
Slide 4-

History of Reconstructive and Cosmetic Surgery 600 BC: Hindu surgeon reconstructs nose using a piece of cheek By 1000 AD: rhinoplasty common Due to common practice of cutting off noses and upper lips of enemies 16th Century: Gaspare Tagliacozzi (“the father of plastic surgery”) reconstructs noses slashed off during duels by transferring flaps of upper arm skin Also used to reconstruct “saddle nose” deformity of congenital syphilis
Slide 5-

History of Reconstructive and Cosmetic Surgery 1798: Term plastic surgery (from the Greek "plastikos," fit for molding), coined by Pierre Desault 19th century: developments in anesthesia and antisepsis make plastic surgery safer, techniques improve Skills developed during the World Wars I and II applied to victims of birth defects and automobile and industrial accidents
Slide 6-

History of Reconstructive and Cosmetic Surgery Eugenics movement, post-WWII prosperity, rise of movies/TV all increase popularity of cosmetic surgery 1923: first modern rhinoplasty 1931: first public face lift
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History of Reconstructive and Cosmetic Surgery 1950s: first hair transplants 1990s onward: more procedures carried out in doctors’ offices and free-standing surgical centers 2000s: Aesthetic medicine, medi-spas, luxury clinics < 500 medi-spas in 2003, 1750 in 2011
Slide 8-

Medi-Spas Generate over $1 billion revenue annually in US Offer cosmetic procedures, massage, aromatherapy, cosmeceuticals Many physicians not board-certified, often just take a brief course Overseas medical spa tourism increasing
Slide 9-

Motivations for Cosmetic Surgery External: avoidance of ethnic prejudice; fear of age discrimination; coercion by spouse/parent/boss Internal: desire to diminish unpleasant feelings like depression, shame, or social anxiety; to alter a specific feature they dislike; desire for a more youthful, healthy look that signals fertility (women); interest in developing a strong, powerful look that may facilitate career advancement
Slide 10-

Motivations for Cosmetic Surgery 20% of women and 10% of men describe themselves as unattractive Much higher than in the 1990s
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Arguments for Cosmetic Surgery Aging as a physical illness Well done face lift takes 9 yrs off appearance Aging as a mental illness Substitution of happiness for health as the goal of medical treatment A business service provided to those who desire it, can pay, and accept the risks involved
Slide 12-

Representations of Cosmetic Surgery in Women’s Magazines (2008 study) Only 48% of articles in magazines like Cosmo and O, The Oprah Magazine discuss the impact of cosmetic surgery on emotional health Most articles link cosmetic surgery with enhanced emotional well-being, regardless of the patient’s pre-existing emotional health
Slide 13-

Cosmetic Surgery < 8% of members of American Academy of Cosmetic Surgery are plastic surgeons 50,000 – 100,000 physicians who are not plastic surgeons perform cosmetic surgery
Slide 14-

2015 National Plastic Surgery Statistics Total cosmetic surgical procedures: 1.7 million Total cosmetic minimally-invasive procedures: 14.2 million Total reconstructive procedures: 5.8 million Total Expenditures: $13.3 billion - Source: American Society of Plastic Surgeons
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Cosmetic Surgery (2015) 92% of patients women 72% Caucasian; 11% Hispanic; 9% African-American; 7% Asian-American 2/3 report family incomes < $50,000 More popular on West Coast
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Cosmetic Surgery 45% of patients have multiple procedures done at the same time Extremes known as “drastic plastic” 50% of patients are repeat patients
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Cosmetic Surgery Deaths/Complications rare but occur E.g., infections, bleeding, hyponatremia, allergic reactions, anesthetic complications Revision rates as high as 10% E.g., face lift lasts 10 yrs
Slide 18-

Cosmetic Surgery – Surgeon’s Fees 2015 prices – Physician Fee, Does not include anesthesia, OR facilities, other costs 1.7 million surgical procedures: Liposuction: $3,009 Rhinoplasty: $4,771 Breast augmentation: $3,822 Blepharoplasty (eyelid reconstruction): $2,880 Abdominoplasty (“tummy tuck”): $5,502 Face lift: $6,759
Slide 19-

Cosmetic Surgery – Surgeon’s Fees 2015 prices – Physician Fee, Does not include anesthesia, OR facilities, other costs 13 million minimally-invasive procedures: Botox procedure: $382 (physician’s fee; drug costs $300-$1,000/session) Chemical peel: $636 Microdermabrasion: $138 Laser hair removal: $290 Vein sclerotherapy (stripping): $337
Slide 20-

Cosmetic Surgery: Other Procedures Breast reductions Chemical peel Forehead lift Upper arm lift Silicone injections for fuller buttocks/lips/breasts/muscle atrophy Illegal and dangerous Injections of mesenchymal stem cells into face
Slide 21-

Cosmetic Surgery: Other Procedures Buttock lift Thigh lift Liposuction “The Mommy Makeover” increasingly popular (abdominoplasty and liposuction)
Slide 22-

Most popular cosmetic surgical procedures for men (2015 stats) Rhinoplasty: 53,248 Blepharoplasty: 29,906 Breast reduction: 27,456 Liposuction: 25,656 Facelift: 11,963
Slide 23-

Other popular procedures for men Botox injections Scalp reduction (for male pattern baldness) Cheek implants Ear reshaping Pectoral implants Chin augmentation (implants) Calf implants
Slide 24-

Most popular cosmetic surgical procedures for women (2015 stats) Breast augmentation: 279,143 Silicone implants – 80% Saline implants – 20% Liposuction: 196,395 Blepharoplasty: 174,028 Rhinoplasty: 164,731 Abdominoplasty: 123,003
Slide 25-

Cosmetic Surgery Worldwide Countries with the most plastic surgeons: US, Brazil, China, India, and Japan Country with the most cosmetic surgery operations per capita = Brazil City in America with the most plastic surgeons per capita = San Francisco
Slide 26-

History of Breast Augmentation With a few exceptions, large breasts in vogue since antiquity Brassieres and corsets used to enhance size 19th Century: surgical breast enlargements attempted using ivory, glass, metal, rubber, and paraffin
Slide 27-

History of Breast Augmentation 1895: Czerny performs first reported successful human mammary reconstruction actress who had undergone removal of a fibroadenoma transplanted lipoma from her hip 1903: Charles Miller inserts "braided silk, bits of silk floss, particles of celluloid, vegetable ivory, and several other foreign materials” granulomatous (foreign body) inflammatory reactions disfiguring and painful
Slide 28-

History of Breast Augmentation 1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins used; use of paraffin caused cancers Early 1950s: liquid silicone injections used 1962: first US woman to receive encapsulated silicone breast implants
Slide 29-

History of Breast Augmentation 1992: FDA bans silicone breast implants except in strictly controlled trials for breast cancer reconstructive surgery due to reports linking the implants with a variety of connective tissue diseases and neurological disorders. Subsequent analyses show no such links
Slide 30-

History of Breast Augmentation 2005: FDA allows silicone breast implants back on market (with registry) A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation; 20% will require removal within 10 yrs Silicone implants can absorb/concentrate some environmental toxins from the body Today: fat transfer, newer generation silicone implants, saline implants, dermal fillers 20% of breast implants done in breast cancer patients
Slide 31-

History of Breast Augmentation 2007: Stem cells and fat derived from liposuction used to grow breast tissue in clinical trials in Europe 2008: Israeli surgeon develops “breast lift procedure” involving internal titanium bra with silicone cups 2008: MyFreeImplants.com Facilitates communication and funding
Slide 32-

Breast Implant Complications (most to least common) Capsular contracture Implant rupture Hematoma Wound infection Increased risk of anaplastic large cell lymphoma (but overall risk very low)
Slide 33-

Breast Implant Complications After Surgery Cosmetic implants – 12% after 5 yrs; 20% after 10 yrs After prophylactic mastectomy – 30% after 5 yrs; 40% after 10 yrs After mastectomy for breast cancer – 34% after 5 yrs; 50% after 10 yrs Latest trend: microsurgical breast reconstruction using implants or autologous tissues
Slide 34-

Poly Implant Prosthe Controversy PIP was world’s third largest maker of breast implants worldwide Shut down in 2010, government safety alerts in 2011/12 Contained industrial-grade silicone 300,000 to 400,000 implanted worldwide
Slide 35-

Poly Implant Prosthe Controversy Disproportionately high rupture rates can cause inflammation and irritation No evidence for increased cancer risk, unlikely to cause long-term health problems Some authorities recommend removal PIP boss Jean Claude Mas arrested in France, may face manslaughter charges
Slide 36-

Breast Implants and Imaging Breast implants decrease sensitivity of screening mammography among asymptomatic women, but do not increase false-positive rate nor affect tumor prognostic characteristics For women with silicone implants, some recommend screening for silent ruptures with MRI 3 yrs post-implant, then every two years Expensive, may not effect long-term health No special screening for those with saline implants
Slide 37-

New Breasts for Graduating Seniors 7,840 breast augmentation procedures performed on 13-19 year olds in 2015 Phenomenon suggests poor parenting, through the capitulation of financially well-endowed parents to the whims of their children, who likely have self-esteem problems and are not yet emotionally (nor perhaps even physically) mature
Slide 38-

Breast Augmentation for Females Under Age 18 US and EU: breast augmentation surgery allowed on those under age 18 only for medical reasons Yet 50% of procedures done for purely cosmetic reasons
Slide 39-

Headline from The Onion: Plastic Surgeon General Warns of Small Breasts Epidemic
Slide 40-

Penile Size Ancient Greeks believed small penis was superior Later, phallic identity and phallocentrism increasingly popular – “penis is central to man’s identity, virility”
Slide 41-

Penile Size 55% of men satisfied with their penile size; 85% of women satisfied with their partner’s size No correlation between shoe size and penile length
Slide 42-

Penile Size and Penile Reconstructive Surgery 1971: First penile augmentation surgery Girth enhancements with fat injections, Alloderm (derived from human skin) Penile lengthening procedures Complications: scar, keloid, penile lumps, sexual dysfunction, further penile shortening Augmentation procedures not sanctioned by American Urological Association First penile transplant (cancer) - 2016
Slide 43-

Cosmetic Surgery Odds and Ends Most common cosmetic procedure in Asia = eyelid surgery, to create a crease above the eye (up to 60% of Korean women) “Smile lift” – popular in South Korea, curves lips into permanent smile Trisomy-21 surgery (covered in ethical issues slide show)
Slide 44-

Reconstructive Surgery – The Latest Hand transplants Face transplants 2005: first procedure on female dog-mauling victim (nearly 40 worldwide through late 2016, 2 associated deaths) 15-20 hour procedure (including 5 hours for harvest); involves multidisciplinary team Ethical issues Lifelong immunosuppression required
Slide 45-

Cosmetic Neurology Interventions to enhance the cognitive and emotional brain functions of the neurologically non-diseased Currently being pursued by the pharmaceutical industry (via drugs to increase intelligence) and the military (via interventions to create more effective soldiers)
Slide 46-

Cosmetic Military Neurology “Go-go pills" (amphetamines) used by US soldiers in WW II Modafinil (wakefulness-promoting agent) improves pilot alertness and performance in helicopter flight simulations. Many military pilots today rely on caffeine and other stimulants, including amphetamines, to complete missions
Slide 47-

Cosmetic Neurology Raises concerns about: Distributive justice Informed consent In the military setting or in children
Slide 48-

Cosmetic Surgery – The Fringes The Jewel Eye: implantation of tiny platinum jewels into conjunctiva (20 minutes, $3900) Am Acad Ophth warns not proven safe Umbilicoplasty, lengthening/shortening toes to improve “toe cleavage”, other Cinderella surgeries on the feet (to allow women to wear pointy-toied shoes), fracturing and resetting jaw to alter smile, forehead implants
Slide 49-

Cosmetic Surgery – The Fringes Mustache implants – popular in Middle Eastern men Vampire facial (Kim Kardashian) – injection of 2 tablespoons of blood into face
Slide 50-

Cosmetic Surgery – The Fringes Foreskin restoration Skin tightening/vein stripping to improve look of “ring selfies” Boot bulge (calf reduction) liposuction to allow women to fit into knee-high boots
Slide 51-

Cosmetic Surgery – The Fringes Vaginal rejuvenation (aka “aesthetic vaginal surgery,” aka labiaplasty) - tightening/alteration of angle/dimensions, partial labial excisions, fat injection into labia) Over 5,000 procedures in 2014 in U.S. Complications include infection, altered sensation, dyspareunia, adhesions, and scarring ACOG: “safety and effectiveness have not been documented”
Slide 52-

Cosmetic Surgery – The Fringes Hymen reconstructive surgery The Jade Lady Membrane Man-Made Hymen Marketed in China Blood-colored fluid released during sex Labial dyes (“My New Pink Button”) “G spot” injections
Slide 53-

Cosmetic Surgery – The Fringes Furries: lovers of anthropomorphized animals Surgical enhancements Conventions Deliberate amputations of body parts Apotemnophilia – attraction to the idea of being an amputee (a paraphilia) Not to be confused with acrotomophiliacs – sexually attracted to amputees
Slide 54-

Cosmetic Surgery – The Fringes Wings, chimeras, and stem-cell cosmesis Sarah Burge (born 1959) holds world plastic surgery record: Over 100 procedures Cost = $850,000 Celebrity plastic surgery: Michael Jackson, Pamela Lee, Meg Ryan, Cher (?), many others
Slide 55-

Prime Time Cosmetic Surgery ABC TV’s “Extreme Makeover” Fox TV’s “The Swan” MTV’s “I Want a New Face” FX’s Nip Tuck
Slide 56-

Pets Neuticles (artificial pet testicles) “To boost your pet’s self-image” Over 500,000 sold through 2012 No FDA-approved artificial testes for humans, so cancer victims buy and have plastic surgeon install
Slide 57-

Pets We value our pets, but… In 2008, almost 1200 people purchased stem cell surgery for their dogs Pet cloning Pet jewelry $5.5 billion/yr pet pharmaceutical market
Slide 58-

Conclusions Body modification common today and throughout history Risks involved Obesity a major public health problem The body modification and weight loss industries marred by hucksterism, false claims and conflicts of interest
Slide 59-

Conclusions Beauty has different definitions in different times and in different cultures The health professions can play a constructive role in supporting safe and healthy behaviors and promoting realistic ideals of beauty More education needed at all levels
Slide 60-

Covered in Other Slide Shows Ideals of beauty and body modification Female genital cutting Body weight and the obesity epidemic Ethical and policy issues
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References Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at http://www.medscape.com/viewarticle/529442 Donohoe MT. Cosmetic surgery past, present, and future: scope, ethics and policy. Medscape Ob/Gyn and Women’s Health 2006;11(2): posted 8/28/06. Available at http://www.medscape.com/viewarticle/542448
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Contact Information Public Health and Social Justice Website http://www.phsj.org martindonohoe@phsj.org