The cosmetic surgery field continues to expand both in the number of doctors performing procedures as well as in the types of procedures being performed. Conventional cosmetic procedures, such as breast augmentation, facelifts and tummy tucks, are well known and represent a few of the mainstream procedures. There are many other niche procedures, like earlobe reduction, lip lifts and nipple reductions to name a few, that are not as well known but are also commonly done. But like everything else in life, cosmetic enhancement marches forward and new innovations regularly appear.
I was asked recently to be interviewed on a local radio show about the internet news article which appeared on the cosmetic surgery topic of ‘Toebesity’. While normally I might not have read this article even if I came across it perusing the internet, I was actually aware of it and had read it. A friend of mine who works for an internet marketing firm had sent it to me as a joke, incredulous that such an entity could actually exist.
Toebesity refers to the surgical procedure of defatting the toes. For those bothered by a fat toe or two, they can be reduced in size. I was aware of toe shortening but not actual toe size reduction. While I am not a podiatrist or a foot and ankle surgeon and do not perform this procedure, I can not comment on its merits and the risks involved in doing it. But I am not surprised that it exists or has been developed. Ultimately if there is a concern, a surgical procedure will appear to try and change it.
The normal comment to such a procedure would be ‘who would want to do that’…or ‘someone must be crazy if that bothers them’. But what you learn with a lot of experience in cosmetic procedures is that there is no accounting for what or why some physical feature bothers people. Trying to understand thereasons why a certain physical feature is concerning cannot be logically done by another person.. Such concerns are undoubtably muiltifactorial but are deeply emotional. How you may feel about their physical concerns is just that…how you feel about it.
This is well illustrated to me by a set of procedures completely opposite to that of the toes…skull reshaping. I perform a fair number of skull or head reshaping procedures over the pasts few years and the number is growing. These are largely not reconstructive skull procedures per se, like from a craniotomy or a traumatic accident, but are cosmetic concerns about the way their head is shaped. Such issues may be a flat spot on the back of their head, protruding brow bones or a prominent midline skull ridge to name a few. Some of these issues are obvious to outside observers while others are clearly more discreet and are more ‘internalized’ concerns.
But what strikes me about the issue of skull reshaping is the deep emotional concerns and scars that their physical issue has caused them. Patients write me and describe why they want the procedure and how much it has bothered and embarrassed them over the years. Some of these skull issues have appeared as men lose their hair or now completely shave their head, exposing the full shape of their skull. Others, however, have hair and modify their hairstyles to try and hide these concerns.
The point being is that people have physical concerns and will try to change them if a surgery exists to address it. Like skull reshaping, just because cosmetic toe surgery is new doesn’t mean it doesn’t have great emotional value to certain people. The number of people wanting toe modifications today are small, but twenty years from now the procedure may be quite common. Placing breast implants in 1969 was far from how it is perceived and practiced today. Cosmetic surgery continues to evolve and really does cover the gamut of all concerns from head to toe.
What makes anyone want to have cosmetic surgery? Such motivation lies in the combination of physical concerns, whether from aging or from genetics, and the hope of a relatively quick improvement. Even if the physical improvement is not permanent, and many cosmetic surgery results are not, the desire for physical change and self-image improvement can be very compelling.
But behind what constitutes a physical problem and what can be done with it is a world of medical marketing. Cosmetic plastic surgery today has some similarities to any other retail product in that advertising, promotions and many other sales techniques are used to both educate and recruit patients. Beautiful models and scenery, before and after photographs of good results and the allure of discounts for having the procedure by a certain time period encourages patients to consider surgery and helps shape their expectations.
But the outcomes from any plastic surgery procedure can have little to do with any marketing associated with it. The variables of each patient’s specific anatomy, how they respond to injury and heal, and the technical maneuvers the surgeon performs all contribute to what the final result will look like.
The reality is that few plastic surgery procedures turn out perfect. In fact, it would be fair to say that almost all procedures performed have some features to them that are less than a patient expected or had something develop that they did not anticipate. In essence, there is often some discrepancy between what results occurred and what the promise of its marketing implied. This discrepancy is often very small but again no cosmetic surgery operation creates perfect results.
In the spirit of the statement ‘no plastic surgery operation creates perfect results’ is a more useful axiom that I like to discuss with every patient during a consultation. ‘Cosmetic plastic surgery is all about trading off one problem for another…you just have to be sure that you can live with the other problem(s) better than what you currently have.’ A good educated patient will be informed and understand what those potential trade-offs are. That is the crux of an informed surgical consent.
Examples abound of the assured aesthetic trade-off principle for every cosmetic surgery procedure and often they are not just one. For example, getting larger breasts with implants implies that eventually one will need to replace them as every medical device eventually fails. Liposuction reduces fat collections but will always leave some residual skin irregularities or asymmetries. Having a facelift comes with the understanding that the results will eventually be lost as aging continues. A tummy tuck buys one a long low horizontal scar to replace undesired abdominal skin and fat. Similarly, a breast lift trades off scars for a more uplifted and better shaped breast.
While many may acknowledge that some of these trade-offs exist for their chosen procedure. It is often not understood that these trade-offs may result in the need or desire for revisional or further surgery down the road. This is why the general revisional surgery rate in plastic surgery is much higher than most patients are aware…the trade-offs or the imperfections are usually the culprits.
Plastic surgery is not unique to just humans. Dogs and cats undergo routinue physical alterations such as tail docking, ear cropping, ear straightening declawing, facelifts, nose jobs, testicle replacement and even braces. Many of these procedures, while effective, are very controversial. Unlike cosmetic surgery in humans which is elective, these changes in animals are involuntary submissions. There are also issues of changing the natural look of the animal which is usually more for the benefit of the owner in many cases.
Each year more and more Americans, as well as those around the world, undergo cosmetic surgery. While there are many considerations that go into why and how one may head to the operating room table to change their facial appearance or body shape, cost is always a significant issue.Even amongst the most ardent detractors of cosmetic surgery, if cost was removed as an obstacle some would soften their opinion.
In a recent published study from Harris Interactive on behalf of Coupon Cabin, their survey study showed that nearly one fourth (23 %) of American adults said they would have cosmetic surgery if not for its costs. Not surprisingly, more women (28%) than men (18%) stated they would. The management of such costs over the past decade has been softened by the emergence of numerous health financing companies, Care Credit being one of the most well known. Such financing has allowed many to have cosmetic surgery and pay for it just like a car or major home appliance.
The impact of financing for cosmetic surgery over the past decade has been huge and is one of the major factors in the frequency and popularity of these surgical manipulations. I have seen the percent of patients who finance cosmetic surgery in my own practice change from around 10% in 2000 to over 40% by 2010. This does not include patients who pay for their surgery on their own credit cards. Whether they pay it off before interest accrues or effectively finance it by paying off over time is unknown.
But the past few years has seen the emergence of a new method of affording cosmetic procedures, the coupon. Coupons or the ‘daily deal’ has rapidly emerged asa method for doctors and aesthetic practices to entice new patients by offering a cosmetic procedure at a lower cost for a limited time period. Popularized by Groupon, numerous clones of the same concept have rapidly sprung up. This has become particularly popular in lower cost procedures done in the office such as Botox, injectable fillers and skin treatments. According to this survey report, nearly 10% of women between the ages of 18 and 44 said they had used a coupon to help pay for a recent cosmetic procedure. Equally relevant is that an additional 22% of adults said they would consider doing it even though they had not yet done it.
Couponing, if you will, has spread from their historic use in the grocery store to cosmetic care today. Between the high costs of surgical and non-surgical procedures and the recent and ongoing economic recession, many people shop for the best deal using the coupon approach. More significant savings are usually realized on lower cost procedures (under a few hundred dollars) than more costly ones due to the overhead expenses of the providers. This is why actual surgery appears less frequently than something like Botox in a coupon sales approach.
Coupons for cosmetic procedures, while sparking great interest from consumers, is highly controversial amongst cosmetic practitioners. While the coupon company earns a nearly equal amount from the coupon sale as the provider, the doctor has to do all the work and assume all the risks of making a satisfied patient. If there is unhappiness with a coupon-generated service, the doctor must accommodate the patient secondarily not the coupon company. In addition, the theory of generating a repeat patient based on exposure to the practice because of a coupon is largely theoretical. These new coupon patients are coming in for the deal and often nothing more. Coupons do not generate patient loyalty…other than to the next coupon deal.
The interest in cosmetic plastic surgery worldwide is reflected in the increasing numbers of people who have undergone such changes over the past decade. This is not just a U.S. phenomenon but is seen in many countries ranging from Brazil to Estonia. People are interested in looking and feeling better in record numbers. There is a lot of reasons why this is occurring from advancements in surgical techniques and materials to the internet and marketing.
There is no single reason that explains the rise in cosmetic surgery but one can not exclude the power of celebrity and star influence. Just as you read about them in the supermarket checkout counter or on innumerable internet websites, how the many stars and entertainers look and what they do commands a lot of attention. Their influence is undoubtably greatest on the young, who are the most impressionable. But many are known to those much older even if by comparison they don’t want to look like them.
In the November issue of the Journal of Adolescent Health, a study was published on ‘Adolescents, Celebrity Worship and Cosmetic Surgery’. The purpose of the reported study was to determine if young adults who admired celebrities was a predictor of whether cosmetic surgery was done later. Over 130 adults filled out questionnaires which measured their attitudes towards a celebrity that they admired and their attitude and experience to cosmetic surgery. Eight months later, they were then asked whether they had undergone cosmetic surgery. The investigators found that intense personal admiration for the body shape of celebrity was a strong predictor of future cosmetic surgery being done.
To a plastic surgeon today, this study is no surprise. In the eighteen to thirty-five year old age group, it is extremely common for a prospective patient to ask if they get the shape of a body part of a certain celebrity. Or they may use a picture or advertisement of a celebrity or model to show what they would like. Some of the most typical examples are the lips of Angelina Jolie, the buttocks of Kim Kardashian, the nose of Jennifer Aniston or the breasts of Halle Berry. Conversely, celebrities can serve as the antithesis of what a young adult wants such as the nose of Michael Jackson, the lips of Melanie Griffith, or the breasts of Heidi Montag.
While one may disagree with such attention to highly visible and well known people, their influence is undeniable. This is nothing new and has always been this way. It is only extremely evident today because of the internet and the instantaneous access to endless venues that choose to highlight them. Perhaps the coverage of poor or undesired cosmetic surgery outcomes will also serve to educate that these procedures have real risk of complications and are not as simple as airbrushing or Photoshopping one’s desired result.
The great boom in plastic surgery over the past decade has been largely spurned by the use of injectable treatments and lasers for aesthetic facial rejuvenation. This has arisen to a shift in the average age of patients seeking cosmetic changes with a younger age group than ever before. Recent statistics put forth by the American Society of Aesthetic Plastic Surgery confirms what most of us have known for some time…patients are getting younger.
According to the Society’s numbers, Generation Xers as defined by those 31 to 45 years of age accounted for nearly 45% of all reported procedures. Conversely, the Baby Boomers as defined by ages 51 to 64 accounted for less than 30% of all reported procedures. This is a major shift from a decade ago and throws out the historic perception of plastic surgery being for the older crowd.
With this younger patient population, it is now clear that Americans are thinking in droves about early treatment and prevention of facial aging. While facelifts and other true surgical approaches will always be around, much more effort in numbers is directed towards minimalistic techniques. Whether it is light therapies, fractional laser resurfacing, Botox, fillers or skin tuck-up procedures, people now want to embark on treatments early to allay the both the onset and the severity of the physical signs of aging.
One aspect that underlies much of these newer aesthetic facial treatments is skin rejuvenation. Besides light, laser and chemical peels, there has been a virtual explosion of topical agents. Many of these skin therapies have provided antioxidant, growth factor and even purported stem cell compositions. Women, and a few men, are investing in their skin early with the knowledge that they will need to make a continuing effort over their lifetime.
From a surgical standpoint, this newer generation is more body conscious than ever before. From breast implants, Smartlipo fat removal to mommy makeovers, women are being driven by the trends seen in the fashion world and Hollywood. Men, particularly those younger, want to have a more defined facial shape and athletic-appearing bodies.
One thing that is very clear in the shift to the younger ages is that patients are no longer seen as a one-time surgical effort, but rather more of a lifetime. What starts as Botox and skin care today may eventually become a tummy tuck or a facelift a decade later. This makes seeing patients as a concept over decades rather than an isolated surgical procedure. Patients should also see their plastic surgeon as a lifetime resource, providing suggestions and solutions to their aging concerns over their lifetime.
Inadequate training and poor judgment account for a disproportionate number of complications and unsatisfactory results that occur annually from cosmetic surgery procedures. With so many different types of doctors doing cosmetic surgery, how can one make a safe and wise choice? In days gone by, the use of the terms such as ‘board-certified’ and ‘specializing in’ were enough to demonstrate to the public a doctor’s expertise, but today that is not enough. Often these physician descriptors can actually be confusing and even deceiving.
I would advise potential patients to research the following categories for any cosmetic surgeon that they are going to see. Some but not all of information can be obtained but doing a little research online.
What Are They Board-Certified In?
Are they board-certified in plastic surgery or another specialty? Many new cosmetic surgeons are board-certified but not in plastic surgery. Their board certification may be in General Surgery, Dermatology, Oral Surgery or Ob-Gyn to name a few. Some may even have an additional board-certification in cosmetic surgery. But this self-created board should not be assumed to be equivalent to those certified by the American Board of Plastic Surgery. There is a significant difference between board-certified plastic surgeons and board-certified cosmetic surgeons that makes them not equivalent at all.
In established medicine, board certification is the result of doctors being educated through long-established training programs sanctioned by the American Board of Medical Specialties. This governing board sets the standards for the education, training and testing of doctors. Of the 24 recognized specialties and boards, plastic surgery is one of them but cosmetic surgery is not. Years of residencies done in hospitals under experienced physician mentors is what is needed to qualify for plastic surgery board certification. Cosmetic surgery allows one to use their basic training in any medical specialty, with or without some private training, to quality for their boards. This is why knowing whether the doctor has hospital privileges for certain cosmetic procedures is so valuable to know. (if you can access that information)
The American Board of Plastic Surgery is the only cosmetic surgery board recognized by the American Board of Medical Specialties. The two exceptions are the American Board of Facial Plastic and Reconstructive Surgery, which is a sub-specialty of otolaryngology-head and neck surgery and the American Board of Opthalmologic Plastic Surgery, which is a subspecialty of ophthalmology. This does not mean, however, that facial plastic surgeons are trained to be doing breast augmentations or ophthalmologists are trained in facelifts or rhinoplasty surgery.
How Often Does The Doctor Do Your Procedure of Interest?
This is a hard piece of information that is not easy to ascertain. Certainly asking the doctor seems the most obvious route to learning how many they have done, but that is not the exclusive source I would use. Look at their websites and see how many before and afters of the procedure are posted. Ask for before and after photographic results and to talk to some more recent patients. (done in the past 3 to 6 months) Word of mouth still remains as a good method of recommendation. Willingness to easily and quickly divulge this information is a good sign. Hesitancy or avoidance of doing so would be of concern.
The premise of asking or having an idea of how often the surgeon performs the procedure has, at its foundation, that there is some magical number. In reality, there is no specific number for any procedure but it should suggest some degree of frequency of it being performed. This will vary based on the type of cosmetic surgery procedure and how commonly it is requested and performed on a more global basis.
Is The Surgery Being Done In a Nationally Accredited Facility?
Hospitals are obviously certified and have to meet highs standards of care and comply with stringent regulations. Surgery centers can be quite different and you want to go to one that has been accredited by either the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This accreditation and a state license to operate means the facility adheres to safe and clean operating conditions. Doctor’s office are fine for minor surgery but most are not accredited for more significant surgeries and any anesthesia that may be needed.
Who Is Doing The Surgery?
I am often surprised after a long consultation that a new patient asks me if I would be doing their surgery. Not understanding who else would be (and having had this long discussion why I would let someone else do it), I have come to learn that this may not always be standard practice. In some cosmetic practices or centers, most of the interaction may be done with other people than the surgeon themselves or they may not see the surgeon until the day of the surgery. Insist that you meet with the ‘real’ surgeon before the day of surgery.
Is The Lowest Cost A Good Choice?
The cost of cosmetic surgery is always of concern and no one wants to overpay for their procedure(s). But the cost of cosmetic surgeries is influenced by market factors just like any other retail business. This makes a fairly consistent price range for procedures in any given geographic region. If after getting several consultations one price is considerably lower than another, the question should be why. Where are the costs being reduced to offer such a lower price? This is what makes the whole concept of Groupon and other discount programs for cosmetic surgery so unnerving. (or they should be to patients)
A front page article in USA today reviewed a burgeoning problem in the world of cosmetic surgery…a growing number of complications spurned by surgeons of dubious training backgrounds. As insurance reimbursements have continued downward to abysmal levels, doctors who are trained in many other medical specialities than plastic surgery are either doing or opening their own cosmetic surgery practices.
Because federal and state laws have little to no governance over what goes on in an office setting, cosmetic operations are popping up everywhere. When combined with the ease of having a professional and slick-looking presence on the internet, it is seemingly hard for the public to separate legitimate from questionable doctors and practices. With a growing age and body conscious society, there is no shortage of potential patients who are willing to spend money on a wide variety of cosmetic procedures.
We live in world now where just about anything seemingly goes. ER doctors and internists are performing liposuction, Ob-Gyns are inserting breast implants, Dermatologists are practicing facelifts and Eye doctors are having their hand at rhinoplasties, to name just a few incongruous combinations that a decade ago were unthinkable.
The unsuspecting general public understandably asks how can this be? With no oversight in a doctor’s office or in some private surgery centers, any doctor with a medical license can do whatever they want. With the allure of cash payment upfront and no interference from insurance companies which don’t oversee cosmetic surgery, little more than a doctor’s conscience separates some cosmetic operations from prospective patients.
For those procedures that require expensive equipment to perform, the manufacturers actually exacerbate this problem. They will sell any piece of equipment, lasers and liposuction machines as the most common devices, to any doctor that has a medical license regardless of their background. With such devices that cost anywhere from $25,000 to $150,000, they apparently need to expand their potential sales market. In my city of Indianapolis, I know of ENT surgeons that perform breast augmentations in their own facilities. When asking the local sales representative why would a breast implant manufacturer sell breast implants to a doctor with no formal breast surgery training, he shrugs and says we have to because that is company policy.
When you don’t have good training and a long history of satisfied patients, one of the most appealing pitches is that of a lower cost. Offering steep discounts over many board-certified plastic surgeons, lower prices help drive many non-discerning patients through the doors. With the growing discount concept like Groupon, price will continue to be a driving motivation for new cosmetic patients. But lower prices almost always reflect that the procedure will be done in the office under local or sedation anesthesia where costs can be saved. But it may also reflect that the doctor lacks adequate training and qualifications to perform the procedure in a hospital-associated or accredited facility.
While on the surface this appears nothing more than a turfbattle between board-certified plastic surgeons and cosmetic surgeons, the issues go way beyond trying to stifle competition. This is an issue of adequate training, competency, and patient safety. Being trained in a plastic surgery residency program (cosmetic surgery has no residency program and is not a recognized specialty of the American Board of Medical Specialities) assures patients that the doctor has already done his/her learning on other patients beforehand.
As of Jan. 1 this year, a new law took effect in California whose intent is to provide greater safety for patients undergoing plastic surgery.
Known as the “Donda West Law”, it is named after rap artist Kanye West’s mother who died a day after cosmetic surgery in 2007. According to reported autopsy results, Donda West died of pre-existing coronary artery disease and other unspecified postoperative events a day after she had undergone a tummy tuck, breast surgery and liposuction. The exact details of these events is not known by this writer but the surgeon who performed this surgery has apparently surrendered his medical license, suggesting there are deeper issues at work here as well.
This new law requires a physical examination within 30 days before a procedure and clearance from a doctor, nurse practitioner or physician’s assistant before cosmetic surgery is performed. In essence, this makes it illegal for doctors to perform elective cosmetic surgery without a physical examination and clearance from a medical professional.
This new law will actually change very little in most plastic surgeon’s practices because reputable plastic surgeons do take a medical history and perform a physical examination before any major procedure. But it does bring to light and reinforce several important concepts about cosmetic surgery and a patient’s preparedness for it.
First, a cosmetic procedure like Donde West went through is major surgery. It should be viewed in the same light by a patient as having a hip replacement or gastric bypass surgery. While it may not be exactly the same, the extent of the procedure does pose risks which can be magnified based on one’s medical history or pre-existing health conditions. It is therefore paramount that any medical problems be well controlled, one should try and be in the best physical condition as possible and make sure that your own physician is aware of what you doing. While the desire for privacy and discretion is understandable, this should not be done at the expense of your own health.
Secondly, while not every procedure needs laboratory testing beforehand, many do and that expense should be seen as just part of the procedure. In an otherwise healthy person (no known medical problems) under age 50, no laboratory testing is needed. This will change based on if the patient has medical problems. For any patient over 50 years of age, preoperative labs are needed and include blood work and and EKG. More may be needed if other medical problems warrant it.
Lastly, be concerned if this information is not required of you before any major cosmetic surgery. Taking a medical history and filling out such on forms is almost always the very first step you do even before you ever see a plastic surgeon in their office.
While the potential changes that cosmetic surgery can create can be somewhat euphoric when one is pondering the procedure(s), the most important consideration is your safety. If a plastic surgeon suggests that you should not have the operation or recommends a less extensive approach than you want, you would be wise to heed those suggestions. This is usually an issue in major body contouring surgery. In some cases, doing the procedure in stages is both easier and safer for you. It may cost somewhat more to do so and be an additional inconvenience to your life, but that is a small sacrifice to pay for your health.
We are exposed everyday to incredulous claims about health and cosmetic products and services. Advertisements from radio to infomercials bombard us on the weakest aspect of our inner selves…how we look and feel. We all want to look better and feel healthier and to do it with the least effort possible. It is this cross between desire and effort that results in many retail sales that usually benefit the manufacturer or seller the most.
I saw an infomercial just yesterday on an abdominal stimulator device. Being able to read abook, watch TV, or even eat dinner while the device delivers perfect abs certainly seems appealing. With testimonials by six-pack endorsees and seeing their abdominal muscles twitch through their nearly transparent skin made even me as a physician a near believer. After all, their muscles were actually moving and surely that is more muscle activity than I can produce with a series of half-hearted sit-ups. But the price was the clincher…$14.95! Six-packs at the price of less than a week of Starbucks…how could one go wrong?
Or the radio commercial from earlier in the week where another topical potion espouses that it can make cellulite disappear…and it starts with just the first application! Atter all, it was so successful that it was given away in bags at a recent film festival. The demon of many a women’s belly and thigh skin, the search for an effective treatment for cellulite and stretch marks has been more elusive than real evidence on Ghost Hunters.
But grandiose claims about cosmetic surgery are not so apparent. Because these services are provided by physicians and always cost more than $19.95, the public’s acceptance of treatment claims is far less discriminating. The use of needles, sophisticated lasers, and actual surgery strongly suggest that the desired outcome will surely happen.
The last decade has seen the merging of two highly compatible themes- busy lifestyles and non-invasive to minimally-invasive cosmetic procedures. The potential for big improvement in appearance with little to no recovery time is the cosmetic holy grail. The concept of a little effort (time, money, and pain) with a big result is what most patients want. But short of Botox and injectable fillers, most other hyped ‘quickie’ cosmetic treatments fail to deliver so successfully.
Lunchtime surgery and weekend recoveries, while providing some benefits, do not produce results that are as dramatic and long-lasting as many of the established and well known cosmetic surgery procedures. One really cannot get inches off one’s waistline in a few weeks without real liposuction or a tummy tuck, breasts will not grow larger with pills, and that neck wattle won’t disappear with a laser treatment or an injection. The allure of some of these procedures is much like an infomercial…promising much with little effort and cost.
Marketing is an essential part of elective plastic surgery procedures. But when the promotional content gets ahead of proven medical science, it is almost always too good to be true.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.