Elective Cosmetic Surgery

Over the past few decades, the demand and acceptance for plastic/cosmetic surgery has changed.

The market for plastic surgery has exploded as the procedures become more affordable and less

invasive. The general public is beginning to see this as an acceptable solution when age begins

to have a visible impact on a person’s sense of physical beauty. Today, according to the

Freedonia Group (2004), the US plastic surgery market is, currently, over $1 billion.

“US demand for cosmetic surgery products will grow 11.2 percent yearly through 2007, driven by new product approvals, favorable cultural and demographic trends, and improved technology. Nonsurgical products (e.g., injections, dermabrasion) will lead gains while those procedures without real alternatives (e.g., implants) remain strong.”

The obvious trend, as indicated by the abovementioned predicted growth rates, is for a strong

demand of cosmetic procedures to help slow the aging process. “A recent study showed that

among working women plastic surgery is the third most common reason for asking for a bank

loan- behind buying a car or paying for a holiday” (Fracassini, 2000).

The recent demand increase can be partially attributed to a shift in public perception. Today,

cosmetic or plastic surgery is more readily acceptable by the public. Being seen as beautiful is

thought to bring rewards in terms of social acceptance, recognition, increased self-esteem, as

well as other positive effects (Berscheid and Gangstead, 1982; Eagly, Ashmore, Makijani and

Longo, 1991). This gradual shift in acceptance can be traced back to the early 1960’s. In 1923,

the public was surprised and confused when actress Fanny Brice had a nose job as a publicity

stunt (Haiken, 1997). During the 20’s, the attitude toward plastic surgery was one of

nonacceptance. Four decades later in the 1960’s, when Barbara Streisand first started to gain

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recognition and popularity, one question frequently asked was why has she not “fixed” her nose.

This question still remains unanswered today.

Once the idea of plastic surgery gained public acceptance, the concept of cosmetic surgery as a

business came into play. According to the World Health Organization (1948) “health is a state

of complete physical, mental, and social well-being and not merely the absence of disease or

infirmity.” This definition allows the cosmetic surgery industry to regard their practice as a

method to improve the mental and physical health of a patient rather than removing a flaw

(Haiken, 1999).

The ability to alter a person’s appearance through surgery has been a controversial issue. Many

people state that the ability to change a flawed feature to improve self-perception has a positive

impact on physical and mental health. Others contend that surgical procedures are short term

fixes that do not promote nor advocate lifestyle changes such as healthy eating, increased

exercise and reduced sun exposure. The surgical fix often conforms to an unrealistic sense of

beauty that is portrayed in the media.

The positive effect of an increase in plastic/ cosmetic surgery acceptance can be demonstrated in

use of the techniques to improve self image. Plastic or cosmetic surgery

“will not change your life, it may give you greater self-confidence and add to your sense of well-being….Commonly stated good reasons for seeking cosmetic surgery include the following: "I want to do it for myself.", "I look into the mirror and I don't recognize that person.", "I feel young, I exercise, but I don't look the way I feel.", or "People keep telling me I look tired or angry" (Haines, 2005).

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Many individuals are using cosmetic surgery to improve physical appearance in hopes to build

confidence and self esteem. According to the America Society of Plastic Surgeons, the top five

procedures in 2005 were liposuction (324,000), nose reshaping (298,000), breast augmentation

(291,000) eyelid surgery (231,000), and tummy tuck (135,000). While these procedures are used

to create a body that satisfies the individual, they also conform to the current societal norm of

beauty.

By using medicine as a tool to improve the outward physical quality of our lives, the question of

‘when do you reach success’ often comes up for debate. Medicine is constantly evolving to

utilize breakthroughs in technology which result in faster, easier, less invasive ways to improve

the physical appearance. These breakthroughs often are seen by the patient as additional

incentives to have a procedure. So, if technology and medicine are constantly evolving, the

question that must be asked is ‘when is success reached or is success a moving target?’

According to Carl Elliott (2005),

“the end point to success becomes less clear because there is no cap on just how high our quality of life can be. We envy people whose quality of life seems better, but we have no reliable way of comparing our quality of life to theirs.”

Even though we keep raising the bar of what is considered success, is it wrong to allow an

individual to seek happiness though elective plastic surgery? According to Michael Bermant

(2005), “appearances and deformities are important to anyone who engages in social interaction.

Teens as well as adults have valid cosmetic conditions that can benefit from plastic surgery.”

Bermant goes on to say that if a procedure is done early, it can help to prevent or to reduce

emotional distress.

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When researching plastic surgery on the American Society of Plastic Surgeons website, some

interesting patient stories can be found. The first story involved an individual who had

liposuction. She had large deposits of fat that were difficult to remove through diet and exercise.

When dieting in the past, she had lost weight in the ‘wrong’ part of the body and she did not

want to lose any additional weight in her chest. She determined that liposuction was the best

solution. Four months post-operation, she loves the new look. Recovery time was fast and pain

was minimal. She is currently exercising to maintain her figure.

The second story relates the experience of a woman who had a face lift. She was unhappy with

the visible signs of aging and wanted to look younger. The surgery was not painful, but she

indicated that aftercare was difficult and she recommended that a healthcare professional be

hired to help with the details of postoperative care. She had a lot of bruising, numbness, and

swelling. Twenty days after surgery, most of her face was still numb and her jaw was tight

which prevented her from eating normally. Despite the pain, the discomfort and the additional

cost of hiring someone to help with the postoperative recovery period, the patient is very pleased

with the results and stated that she could not have made a better decision.

These are two real life patient satisfaction stories that state the risk, the pain, and the discomfort

are an acceptable necessary step in reaching happiness/satisfaction with their physical

appearance. Both patients thought the procedure made an improvement to their bodies and each

indicated an increase in satisfaction with their trouble body part. While cosmetic procedures can

reduce emotional stress and increase personal satisfaction, is this a valid argument for

enhancement surgery? It seems that the medical industry is playing into the social stigmas that

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exist today (Elliot, 2005). The industry has the ability to surgically enhance many physical

attributes and will profit when business is strong. As society continues to create market

conditions that emphasize beauty and perfection, the public uses these images as a standard for

measuring their own attributes and self worth. Because an ideal is used as a standard, these

individuals begin to feel inadequate and look to find a cure at any cost.

Today, public exposure to plastic and cosmetic surgery has greatly increased. Reality television

shows, such as Extreme Makeover, take ordinary people and alter their appearance (Hamilton,

2004).

“By profiling ordinary people, they demystify cosmetic surgery and make it psychologically more accessible. Although this vicarious experience may ultimately result in more sophisticated public perception, the condensed format of the programs minimizes the risks and recovery inherent in this type of surgery. Likewise, marketing materials that

emphasize "mini" and "lunchtime" procedures also support a carefree attitude toward elective procedures.”

“With the increasing popularity of plastic surgery, combined with the reality show Extreme Makeover, it could be easy for the general public to overlook the serious nature of elective cosmetic surgical procedures,” said Rod Rohrich, MD, president of the American Society of Plastic Surgeons (2004). “But what the public needs to know is that at the highest level of care, every surgery has risks as well as benefits.”

In the past, a psychological consult was required prior to surgery but this is no longer the case

today (Hamilton, 2004). As the requirements have been greatly relaxed, it is even easier to be

seen as a good candidate for surgery. The American Society for Plastic Surgery is increasing the

amount of money spent on plastic surgery education through direct public marketing (Rohrich

and Goldwyn, 2001). The increase in awareness has led to a greater public acceptance.

According to a survey conducted by Harris Interactive (2003), surgery apprehension decreases

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when people are educated. Surgery is seen as more appealing when new techniques can be used

to alleviate pain, anxiety, infection, and lessen the invasiveness of the procedure.

It is interesting to note that the American Society for Plastic Surgery is heavily involved in

public education. This appears to be a conflict of interest in that a society which is made up of

plastic surgeons is educating the public about the benefits of cosmetic surgery. Research has

proven that an increase in exposure has a direct positive relationship on the number of

procedures performed. Is this really education or a marketing tool disguised as public education?

The Body Miracle Makeover Show set to take place May 5-7th, 2006 in Minneapolis MN is a

marketing tool aimed at the general public (The Body Miracle Makeover Show, 2006). The

Show will introduce men and women to the qualified aesthetic professionals who specialize in

surgical and non-surgical enhancement procedures. The show seeks to improve the public’s

understanding of anti-aging procedures and provides a venue for professions to showcase their

services in an environment focused on education.

As the nature of plastic surgery has shifted from reconstructive surgery to one of self

improvement surgery, there have been two major movements in healthcare: an emphasis in

improving the quality of life of individuals who are considered healthy and an increase in the

number of medical technologies to improve physical appearance, performance, and

psychological state (Elliot, 2005). Individuals see goods and services as a way to shape their

identities. According to Elliot, what we own is a reflection of who we are and we measure our

success through our assets and experiences. Medicine now has an additional tool to enhance a

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person’s appearance and improve the quality of life. The ability to improve physical appearance

though plastic or cosmetic surgery has become another way in which individuals can measure

success through purchase power.

According to a study on the public’s understanding of plastic, cosmetic or reconstructive surgery,

the public views these terms differently in relation to the type of procedures performed but saw

the expense across categories as equal (Hamilton, 2004). Cosmetic surgery is seen as short-

lived, less difficult, and less painful. In addition, it is thought that cosmetic surgery requires less

medical training than plastic or reconstructive surgery.

One of the major differences between elective vs. necessary surgery is the patient’s expectations

related to the outcome. When an elective surgery is aesthetically based, the doctor’s and the

patient’s idea of the ‘good’ outcome can be drastically different. According to Hamilton (2004),

a technically perfect surgery might not meet a patients’ expected outcome due to an unrealistic

expectation of the result. The physician always faces the risk of a miscommunication between

the patient’s expectation and the physical limits of what can be accomplished with surgery. It is

hard to properly communicate desired end results. The physician and the patient may have two

very different criteria and conclusions about what is considered a successful procedure. In

addition, the patient could have a difficult time verbally expressing the desired results in a

detailed manner to the physician; thus, potentially resulting in a dissatisfied patient.

Hamilton (2004) suggests that a patient’s idea of cosmetic surgery to improve appearance can be

better understood by relating the subject to the concept of a brand. A brand conveys a distinct

concept that portrays expectations, beliefs, and quality of the product to the customer.

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Customers, in return, rely on the brand in order to make purchasing decisions. The business of

elective cosmetic or plastic surgery is also heavily influenced by brand perception. Those

seeking elective surgery are both consumers and patients who are looking for a quality product

that will meet their immediate need for physical enhancement.

The importance of branding can best be demonstrated through an example. If Coca- Cola were

to divide their assets into two parts: the brand and secret formula or the physical assets of the

company, the greater value would exist with the brand and secret formula (Winkler, 1999). The

idea of branding is just as significant in medicine as it is in the soft drink industry. Any major

medical institution understands that its name and its reputation is just as important as the

medicine that is practiced. An institution, physician, or a publicly traded company needs to be

concerned with the public perception of what the business represents. In medicine, the brand

helps the patient to establish his/her expectation and satisfaction level (Hamilton, 2004). The

satisfaction level post surgery is vital to the business relationship that exists between the patient

and the physician. In order to help maintain or improve satisfaction levels, physicians must

account for more then just the physical well-being of the patient.

Even though it has become increasing easier to receive plastic surgery, the physician still has an

ethical and medical obligation to ensure patient safety. According to Dr. William Morgan

(2003), there are 49 principles that guide cosmetic surgery. The physician must not do any

procedure that does not improve appearance, make any changes in which the patient is not in

agreement, the procedure must have rapid recovery, the physician must know in their mind,

heart and soul that this procedure is worthwhile, etc… But, according to John Jesitus (2006),

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there is often a fine line in deciding when to treat a patient. A surgeon must look for warning

signs that the patient is not emotionally fit for surgery. These signs include but are not limited to

an unrealistic expectation of body image, obsessive-compulsive behavior, and rudeness or

excessive flattery.

Often, a patient with a high risk of insatiability is hard to identify (Jesitus, 2006). These

individuals could potentially suffer from body dysmorphic disorder. While a physician should

have a certain obligation to help these patients in a manner other then additional surgery, not all

doctors have the same standards. According to the American Society for Aesthetic Plastic

Surgery (ASAPS), only a hand full of physician has qualified for membership in the ASAPS.

Membership is this society hold physicians to a higher standard and expressly prohibits members

from giving a service in return for professional publicity. Unfortunately, it is easy for a cosmetic

surgeon to misrepresent themselves to a patient. A doctor can indicate that he or she is board

certified but he/she does not have to indicate which board. The patient assumes that the

physician is certified by the American Board of Plastic Surgery but this is not always the case.

“Doctors strive to prolong life, and have earned some of the credit for the fact that we are living in a society that is ageing healthily as our life expectancy continues to grow. It is therefore somewhat anomalous that the public face of cosmetic surgery includes promotions which play on the insecurities associated with the superficial consequences of ageing” (Ring, 2002).

The notion that doctors are using ageing as a mechanism for increasing profits is not new (Wolf,

1990). The insecurities of patients are being exploited and used as a key marketing strategy.

Ugly is broadly defined to include an ageing appearance and plastic surgeons have the magic key

to reverse the process.

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According to Women’s Health Queensland Wide (WHQW) (2000), the before and after

photographs used in advertisements are often misleading. The photos are often enhanced to

highlight the results post surgery. Facial expression, make-up, posture, fashion, etc… are used to

create an exaggerated after image. The images do not give the patient any sense of recovery time

and the risk associated with the procedures. In addition, many women use a standard when

looking to enhance a body part. This can often be a problematic since the body make-up of each

individual is different. What looks good on one individual may not look as pleasing on another.

Cosmetic surgery promotes quick fixes rather then long-term life style changes. While cosmetic

surgery is the only way to reduce wrinkles, the use of surgery for weight loss does not promote

the need for a lifestyle change. But in defense of the procedures, a surgical procedure many be

the additional boost that a patient needs for long term lifestyle change. This jump start may be

the missing visual queue that results are attainable and worthwhile.

An increase in social acceptance, an increase in disposal income, new financing options and

medical advances have lead to a dramatic increase in the cosmetic surgery market (Dorn). The

customers are men, women, and teens who seek to improve self-image and personal satisfaction

though surgery. The effects of a procedure can have both positive and negative effects on an

individual. A person’s body image, self-esteem, and confidence can dramatically increased but

these procedures are often not a long term solution. When a patient becomes dissatisfied again,

will surgery be the reliable quick fix to slowing the aging process? While many are happy with

the results of cosmetic procedures, does the ability to alter appearance to compare to a standard

societal model of beauty take away from one’s own sense of self? It is clear that as society

increases its acceptance level of plastic/ cosmetic surgery and the public is more informed

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regarding the procedures available that the usage and revenue of plastic/ cosmetic surgeons

increase as well. But should a physician who has a fiduciary duty to his or her patients be able to

profit from this relationship?

Business Ethic Case Questions

1) Should elective cosmetic services be marketed to solely promote vanity?2) Do plastic surgeons have any moral obligation to discourage plastic surgery for personal

vanity?3) Is a plastic surgeon in the business to help patients or do they focus on the high profit

margins?4) Where do you draw the line in allowing additional plastic surgery?5) Does the risk of surgery differ if the surgery is elective vs non-elective?6) Does the plastic surgeon have a medical obligation to send a patient to counseling when

the patient has a distorted self or body image?7) Even though we keep raising the bar of what is considered success, it is wrong to allow

an individual to seek happiness though plastic surgery?8) Should a society be allowed to educate the public when the results of that education have

a direct positive relationship on procedure/ revenue volume?9) Does the way society depicts beauty cause dissatisfaction with your own personal body

image which as lead to thoughts of cosmetic surgery?10) Is a surgical procedure the right answer when personal lifestyle choice has a strong

probability of reversing the results?

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References

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American Society of Plastic Surgeons. Retrieved April 29, 2006, fromhttp://www.plasticsurgery.org/public_education/patient_profiles.cfm

American Society of Plastic Surgeons. (2005). 2000/2004/2005 National Plastic Surgery Statistics: Constructive and Reconstructive Procedure Trends. Retrieved April 22, 2006, from http://www.plasticsurgery.org/public_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=17870

American Society of Plastic Surgeons. (March 2, 2004). Popularity of Plastic Surgery Does Not Diminish Risks: American Society of Plastic Surgeons Leads the Specialty With Safety Initiatives. Retrieved April 22, 2006, from http://www.plasticsurgery.org/news_room/press_releases/Popularity-Of-Plastic-Surgery-Does-Not-Diminish-Risks.cfm

Bermant, M. (2005). Ethics of Cosmetic Surgery in Adolescents. American Medicine Association. Retrieved April 22, 2006, fromhttp://www.ama-assn.org/ama/pub/category/14697.html

Berscheid, E. and Gangstead, S. (1982). “The Social Psychological Implications of Facial Physical Attractiveness.” Clinics in Plastic Surgery, 9, 289-96.

Body Miracle Makeover Show (2006). Retrieved March 4, 2006 from http://www.thebodymiraclemakeovershow.com/home.asp

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Eagly, A. H., Achmore, R. D., Makhijani, M. G., and Longo, L.C. (1991). “What is beautiful is Good, but: a meta-analytic review of research on the physical attractiveness stereotype,” Psychological Bulletin, 110, 109-28

Elliott, C. (2005). Medicine Goes to the Mall: Enhancement Technologies and Quality of Life. American Medicine Association. Retrieved April 29, 2006, from http://www.ama-assn.org/ama/pub/category/14570.html

Fracassini, A. (2000). “Executives Go Under the Knife to Get Ahead, “Scotland on Sunday, August 6, 6-8.

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Haiken, E. (1997). Venus Envy: A History of Cosmetic Surgery. Baltimore , Maryland: Johns Hopkins University Press.

Haines, C. (Editor for WebMD). (April 2005). Cosmetic Surgery: Is it Right for You? Reviewed by the doctors at The Cleveland Clinic Department of Plastic Surgery. Retrieved April 29, 2006, from http://www.webmd.com/content/article/117/112579.htm

Hamilton, G. (September/October 2004). News release, Archives of Facial and Plastic Surgery. Archives of Facial and Plastic Surgery. 6: 315-320.

Harris Interactive: Social Acceptance of Cosmetic Surgery Grows Among Americans, New Survey Shows. October 23, 2003. Retrieved April 29, 2006, from http://www.surgicenteronline.com/hotnews/3ah2492626.html

Morgan, W. R. Principles and Ethics of Cosmetic Surgery. Retrieved April 29, 2006, from http://www.wrmorganmd.com/axioms.htm

Jesitus, J. (March 2006). Cosmetic ethics: to treat or not to treat? Cosmetic Surgery Times. Retrieved April 29, 2006, from http://www.cosmeticsurgerytimes.com/cosmeticsurgerytimes/article/articleDetail.jsp?id=313317

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Ring, A. L. (2002). Using anti-ageing to market cosmetic surgery: just good business, or another wrinkle on the face of medical practice? Medical Journal of Australia. 176 (12): 589-599

Rohrich, R. J. and Goldwyn, R. M. (July 2001). Standards for Cosmetic Surgery. Plastic and Reconstructive Surgery. 108: 259-260.

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Wolf N. (1990). The Beauty Myth. London: Vintage.

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