Women’s Health in Context: Cosmetic Surgery Past, Present, and Future: Scope, Ethics, and Policy

Plastic, Reconstructive, and Cosmetic Surgery

Each year plastic and reconstructive surgeons improve the lives of millions of patients with congenital malformations (such as cleft lip and cleft palate), disfiguring wounds, animal bites, and profound burn injuries, as well as those requiring reconstruction after surgery for malignancy or other chronic conditions. This column will not focus on these forms of plastic surgery, but rather on cosmetic surgery, or elective procedures to enhance those not encumbered by such disfiguring conditions.

External motivators for cosmetic surgery include the desire to avoid ethnic prejudice; fear of age discrimination; and direct or subtle, indirect coercion by a spouse, parent or boss.^[2] Internal motivators include the desire to diminish unpleasant feelings of depression, shame or social anxiety; the wish to alter a specific disliked feature; the yearning for a more youthful, healthy look that signals fertility (usually in women); and the hope to create a strong, powerful appearance that will facilitate career advancement.^[2]

A Brief History of Cosmetic Surgery

As early as 600 BC, a Hindu surgeon reconstructed a nose using a piece of cheek.^[3] By 1000 AD, rhinoplasty was common, due to the barbaric custom of cutting off the noses and upper lips of one's enemies. In the 16th century, Gaspare Tagliacozzi, known as "the father of plastic surgery," reconstructed noses slashed off by swords during duels by transferring flaps of upper arm skin. This procedure was also used to correct the saddle nose deformity of syphilis.^[3]

The term plastic surgery, from the Greek "plastikos" (fit for molding), was coined by Pierre Desault in 1798 as a label for procedures to repair facial deformities.^[4] In the 19th century, developments in anesthesia and antisepsis made plastic surgery safer and allowed for improvements in technique. Plastic surgeons further honed their skills during the 2 world wars, then applied their techniques to victims of birth defects and automobile and industrial accidents.^[3] The American eugenics movement, with its "Better Baby Contests," post-World War II prosperity, and the advent of motion pictures and television all helped to usher in the modern era of cosmetic surgery.^[2] The first modern cosmetic rhinoplasty was performed in 1923, followed by the first public face lift in 1931.^[2]

The Scope of Contemporary Cosmetic Surgery

Procedures and Patients. In 2005, there were 10.2 million cosmetic procedures performed in the United States, an increase of 11% from 2004 and a 38% compared with 2000.^[5] This number includes 3,839,387 Botox treatments, 1,033,581 chemical peels, 837,711 microdermabrasions, 782,732 laser hair removals, 589,768 vein sclerotherapies (strippings), 323,605 liposuctions, 298,413 rhinoplasties (nose jobs), 291,350 breast augmentations, 230,697 blepharoplasties (eyelid reconstructions), 134,746 abdominoplasties, 114,250 breast reductions, 793 vaginal rejuvenation procedures, 337 calf augmentations, and 206 pectoral implants.^[5] Forty percent of those undergoing cosmetic procedures are repeat patients; 34% have multiple procedures at the same time.^[5]

Eighty-four percent of patients undergoing cosmetic procedures last year were white; 90% were female.^[5] The top 5 minimally invasive procedures among women were Botox injection, chemical peel, laser hair removal, microdermabrasion, and sclerotherapy. The top 5 surgical procedures were breast augmentation, liposuction, nose reshaping, eyelid surgery, and tummy tuck (see below for statistics on males).^[5]

In 2005, 51% of US cosmetic surgery patients and 69% of patients getting minimally invasive procedures were aged 51 years or older. Two thirds of patients reported family incomes below $50,000. Total physician fees for cosmetic procedures, not including anesthesia, operating room facilities, and other related expenses, were estimated at $9.4 billion.^[5]

Today, an increasing number of cosmetic surgery procedures are performed in doctors' offices and free-standing surgical centers (as opposed to hospitals), and more procedures are being carried out simultaneously.^[6] This increases the risk of rare but potentially fatal infections and anesthetic reactions. Furthermore, some practitioners have not completed the full 5 years of residency training required for certification by the American Board of Plastic Surgery, but (legally) perform procedures, for which they might be inadequately trained, merely to augment their income.^[6]

Complications. Complications of cosmetic surgery are rare, but include infection, bleeding, fluid and salt imbalance, and allergic and anesthetic reactions which are sometimes fatal. The recent death of a noted author has heightened public awareness that getting cosmetic surgery is not in the same category as getting a facial or herbal wrap.^[6]

Cosmetic Surgery Abroad. Cosmetic surgery's popularity is spreading throughout the developed world. South Korea has the highest ratio of cosmetic surgeons to citizens worldwide, but Brazil has the most cosmetic surgical procedures per capita.^[4] The most popular cosmetic procedure in Asia is eyelid surgery. Argentina has the highest ratio of breast enlargements worldwide.^[4] Next door in Brazil, breast reduction is more popular.^[7]

Breast Augmentation: Then and Now

Procedures and Complications. Large breasts have been in vogue since antiquity, with the exception of a few brief periods in history. Uplifting brassieres and corsets were used at times to enhance the perceived size of breasts. Then, in the 19th century, surgical breast enlargements were attempted using ivory, glass, metal, rubber, and paraffin.^[8] In 1895, Czerny did the first reported successful human mammary reconstruction, on an actress who had undergone removal of a fibroadenoma (benign lesion), by transplanting a lipoma from her hip to reconstruct the breast. In 1903, surgeon Charles Miller inaugurated breast augmentation surgery in the United States when he began opening women's chests and inserting "braided silk, bits of silk floss, particles of celluloid, vegetable ivory, and several other foreign materials."^[9] The granulomatous (foreign body) inflammatory reactions produced by such odds and ends must have been disfiguring and painful. By the 1950s, petroleum jelly, beeswax, shellac, and epoxy resins had been tried. In the early 1950s, liquid silicon injections were used to restore breast contour.^[8] The first US woman to receive encapsulated silicon breast implants was Timmie Jean Lindsey, who was boosted from a B to a C cup in 1962.^[4]

In 1992, the US Food and Drug Administration (FDA) banned the use of 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 thorough analyses have shown no such links.^[8,10] Even so, breast augmentation with silicone implants is associated with a number of local adverse events, including hematoma, infection, scarring, contracture, rupture, pain, and loss of sensation. A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation.^[11] Reoperation rates are 20%-26% and removal rates are 12%-14% at 5 years.^[12] Complications are more common among individuals undergoing breast reconstruction following cancer surgery than in those having purely cosmetic procedures.

Since 1998, federal law has required insurance companies to cover breast reconstruction after mastectomy.^[13] In 2005, the FDA reversed itself, allowing silicone breast implants back on the market under certain conditions, including a registry to track complications.^[14] Even so, saline implants, subject to fewer complications, are employed much more frequently today.

Breast augmentation also decreases the sensitivity of screening mammography among asymptomatic women, but does not increase the false-positive rate nor affect the prognostic characteristics of breast cancers.^[15] Differences between saline and silicone implants for mammography sensitivity and tumor characteristics are unknown.^[15]

New Breasts for Graduating Seniors. In the United States, breast augmentation surgery can be performed on those under age 18 for medical reasons only.^[12,16] The European Union Parliament is backing an age limit of age 18 on breast implants for cosmetic reasons; its recommendations are likely to be adopted by the European Commission.^[17] Nevertheless, there is a growing trend of parents giving implants as gifts to their graduating 18-year-old adolescents. The number of 18-year-olds who underwent breast-implant surgery nearly tripled from 2002 to 2003, to 11,326.^[16] This 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.

Men, Cosmetic Surgery, Steroids, and the Adonis Complex

Men are increasingly undergoing cosmetic surgery to enhance appearance, combat the effects of aging, and improve chances for employment in competitive job markets.^[18] The most common minimally invasive procedures are Botox injection, microdermabrasion, laser hair removal, chemical peel, and laser skin resurfacing.^[5] The most popular surgical procedures among men are rhinoplasty, hair transplantation, liposuction, blepharoplasty, and breast reduction for excessive gynecomastia.^[5] Face lifts, ear corrections, and penile enlargements are becoming increasingly popular.^[7]

Still, men undergo far fewer procedures than women. One reason may be that male appearance is often judged in terms of muscularity, and there are other approaches to "buffing up," eg, through the use of anabolic steroids. These illegal substances have been used by an estimated 3 million or more American men since the 1960s when they became available on the black market.^[19] Two thirds of users are noncompetitive recreational body builders or nonathletes who use steroids for cosmetic enhancement (increased muscle mass and "virile" appearance).^[20] By one estimate, 15%-40% of regular gymnasium attendees have used anabolic steroids.^[21] "Victims" of the "Adonis complex,"^[19] these men place themselves at risk of cardiomyopathy, atherosclerosis, hypercoagulopathy, hepatic dysfunction, and psychiatric and behavioral disturbances through anabolic steroid use.^[20,21]

Especially troubling is the rise in steroid use among high school athletes, who may get the drugs from their coaches. The use of anabolic steroids to improve performance was first documented in elite athletes in the 1950s.^[21] The International Olympic Committee has banned use of steroids, and athletes competing in national and international competitions undergo routine drug testing.^[21] Other procedures athletes use to enhance performance are well known, such as blood doping and injecting erythropoietin to increase red cell mass and, theoretically, oxygen-carrying capacity. Such methods are of doubtful efficacy and carry their own health risks.

New procedures are on the horizon. The time may come soon when perfectly healthy pitchers choose to undergo the so-called "Tommy John surgery" (until now performed only to repair ruptured arm ligaments), which can make an elbow even stronger than it naturally was, allowing hurlers to achieve higher throwing velocities.^[22] Other predicted enhancements include the removal, re-engineering, and re-insertion of leg, arm, and shoulder muscle cells to add strength,^[22] and gene enhancement.^[23]

The Future and the Fringes of Cosmetic Surgery

The following describes procedures at the fringes of cosmetic surgery, along with a look at predicted future methods of bodily enhancement:

The JewelEye. Reminiscent of the use of antimony to create conjunctival sparkle among the ancient Egyptians, Romans, and Persians,^[9] the JewelEye, invented by a Dutch ophthalmologist, consists of implanting tiny platinum jewels into the sclera, at a cost of $3900 for the 20-minute procedure.^[24] The American Academy of Ophthalmology has warned that the procedure has not been proven safe.^[24]

Genitalia Redesign. Genitalia redesign is performed on both men and women. Foreskin restoration (circumcision reversal) has been around since the 2nd century BC, can be performed both surgically and with taping and stretching, and is alleged to return the penis to its natural appearance and to enhance sexual pleasure.^[25] Cosmetic phalloplasty, building on procedures to correct penile deformities such as Peyronie's disease and hypospadias, is now widely promoted on the Internet to men who want to increase the size of their penis.^[26] Other enhancement procedures involve injecting fat or dermal allografts. Postsurgical instructions for penile lengthening procedures sometimes involve the use of stretching devices such as penile weights. Understandably, results have been generally disappointing; size is only augmented for the flaccid state, and complications are common.^[26]

Female genital reconstructive procedures include vaginal tightening, alteration of the vaginal angle, partial excision of "floppy" or "overgrown" vaginal labia, and the injection of fat into the labia to enhance plumpness.^[27] The "Jade Lady Membrane Man-Made Hymen," marketed in China, can be inserted 20 to 30 minutes before intercourse. The combination of natural body fluids and a red dye produce a bloody-type discharge which, according to the package insert, when accompanied by moans of pain, creates the illusion that the female is a virgin, and therefore, a more desirable partner.^[28]

Face Transplantation. In November 2005, French surgeons performed the first-ever partial face transplant on a 38-year-old female victim of a horribly disfiguring dog bite.^[29] The operation was successful, but the patient will require life-long immunosuppressant medications to prevent rejection. These drugs will place her at increased risk of cancer, infections, and diabetes. Physicians at the Cleveland Clinic in Ohio and at the Royal Free Hospital in London have received permission to perform the world's first-ever complete face transplant, an operation that will require up to 15 hours (including 5 hours for the harvest) and a multidisciplinary team of surgeons.^[29]

Facial transplants could significantly improve the quality of life of the severely disfigured, but raise questions of identity -- both to self and to others, particularly those who knew the deceased donor. Patient selection, cost, and reimbursement are other potential issues.^[30] Candidates should undergo intensive psychological screening to eliminate those with behaviors that may decrease graft viability (eg, tobacco smoking). Presumed consent, supported by many for other organ donations given the current long waiting lists, will likely not be acceptable for face donation for obvious reasons.^[30] Concerns have also been raised that outside the United States, the procedure may be exploited by profiteering plastic surgeons willing to service criminals on the lam or those who have succumbed to the notion that they are irrevocably "ugly."

Prime Time Cosmetic Surgery. Cosmetic surgery has recently gone prime time, with the American Broadcasting Corporation's show, "Extreme Makeover." In episodes of the program, participants chosen from the ranks of hundreds of thousands of willing "patients" undergo multiple surgical enhancements before a national audience of millions of voyeurs.^[30] Other, similar offerings have included Fox TV's "The Swan" and MTV's "I Want a Famous Face," on which young men and women undergo cosmetic "enhancements" to make them look like stars such as Brad Pitt, Jennifer Lopez, and even Elvis Presley. And speaking of celebrities, Michael Jackson (with a reported 4 nose jobs, a chin implant, eyelid surgery, facelift, lip reduction, and assorted touch-ups)^[7] and Cher (who may have undergone rib removal to create the illusion of a thinner waistline)^[9] are among the celebrities well known for their predilection for bodily reconstruction.

Aptoemnophila. Aptoemnophiles, first described in 1977, constitute a small group of individuals who have an attraction to the idea of changing their identities by becoming amputees.^[31] This rare paraphilia sometimes leads the afflicted to self-amputation; a few physicians outside of the United States have occasionally accommodated amputee seekers by removing limbs for "cosmetic purposes," although this practice would no doubt place the operating doctor in legal jeopardy. Aptoemnophiliacs should be distinguished from acrotomophiliacs, another rare group who are sexually attracted to amputees.

Furries. Furries, lovers of anthropomorphized animals, sometimes adopt the personae of animals, either through costumes or body modification.^[32] For example, some tiger furries cover their bodies with striped tattoos, get dental implants with canines sharpened to resemble tiger teeth, have plastic whiskers implanted, wear special contact lenses to make their eyes appear oval, and have mouth, nose, and ear surgery to make themselves more catlike.^[33] Extreme furries live as much as possible like animals, have annual conventions, host Internet sites, and have even been profiled on the television series "CSI."^[32]

Cosmetic Surgery for Pets. Cosmetic surgery for pets is particularly popular in Brazil and appears to be spreading to other countries.^[34] For example, some owners of show dogs "correct" perceived imperfections in ears, teeth, and tails to optimize chances for winning. There is no legal consensus over whether such cosmetic surgery for pets should be classified as body modification or mutilation, and therefore be subject to animal cruelty laws.^[34]

Over 100,000 neutered male dogs and cats in 37 countries have had artificial testicular implants called Neuticles surgically implanted in their scrotums, ostensibly to help them "retain their macho swagger."^[35] Some US farmers, in hopes of winning best in show at state fairs, have taken to injecting cows' udders with isobutane gas (to increase the size) and covering the teats with silver protein to smooth out wrinkles.^[36] Those 15% of US dairy cows injected with recombinant bovine growth hormone also have enlarged mammary glands, which are prone to inflammation and infection (mastitis).(Donohoe MT. Genetically modified foods: health and environmental risks, the corporate agribusiness agenda, and Oregon politics; submitted to Open Spaces, April 2006).

Cosmetic Neurology. Interventions to enhance the cognitive and emotional brain functions of the neurologically nondiseased are currently being pursued by the pharmaceutical industry (via drugs to increase intelligence) and the military (via interventions to create more effective soldiers).^[37] Cosmetic military neurology dates back to the use of "go-go pills" (amphetamines) by US soldiers in World War II. Military investigators have found that Modafinil (a wakefulness-promoting agent) improves pilot alertness and performance in helicopter flight simulations.^[38] Many military pilots today rely on caffeine and other stimulants, including amphetamines, to complete missions.^[37,38] Cosmetic neurology raises concerns about distributive justice and, in the military setting or when used in children, informed consent.

Wings, Chimeras, and Stem-cell Cosmesis. At least 1 surgeon has proposed the surgical construction of wings that someday may be functional, a development foreshadowed by the musings of Renaissance genius Leonardo da Vinci.^[39] Another physician has promised to create a human/animal chimera, albeit not through surgery but through genetic engineering, just as the military has studied the prospects of engineering a class of super-soldiers.^[40]

Beauty salons in Russia have been offering stem-cell cosmetic surgery where fetal, embryonic, or adult stem cells are injected as treatment for baldness and wrinkles.^[41] The efficacy and safety of such procedures are dubious at best. There have been reports of the use of stem cells obtained from the aborted fetuses of poor women who are paid about $200 to undergo late-term cesarean abortions. The fetus is then traded and sold on the black market.^[41]

Medscape Ob/Gyn. 2006;11(2) © 2006  Medscape

Cite this: Women’s Health in Context: Cosmetic Surgery Past, Present, and Future: Scope, Ethics, and Policy - Medscape - Aug 29, 2006.