Abstract
Response to Letter to the Editor Cork University Plastic Surgery
The authors of the letter to the editor by Cork University Plastic Surgery seem to feel that plastic surgery is the sole arbiter of cosmetic/aesthetic surgery, claiming that by not increasing residency program size over the last decades, other surgical and medical fields have “moved in” to provide cosmetic services. Their view is propped up by data on cosmetic procedures culled from plastic surgery organizations. These data are marginal at best—based on surveys of members of the American Society of Plastic Surgeons (ASPS) and the data from the American Board of Plastic Surgery (ABPS), both U.S.-based organizations. They ignore the significant history and contributions to aesthetic surgery that have come from many sources around the world. And they further fail to recognize that aesthetic surgery is being performed around the world by numerous professionals. I would like to clarify, for them, and for our readers, a bit of the multidisciplinary nature of cosmetic surgery and pose 3 questions that all cosmetic/aesthetic practitioners and organizations should be asking today.
Multiple cosmetic surgery organizations have appeared more than the last 50 years both within the United States and abroad. One of the earliest, organized by the Mexican Plastic Surgeon Dr. Mario Gonzalez-Ulloa, offered a manifesto on aesthetic surgery. In this he condemned plastic surgeons who disparaged cosmetic surgery and called for abandoning the use of cosmetic rather than aesthetic in referring to such surgery. He explained that aesthetic was more artful and cosmetic, more decorative. Gonzalez-Ulloa published widely in both the Spanish and English literature, directed and attended meetings on cosmetic surgery worldwide. While he was a driving force for aesthetic surgery within plastic surgery, this call for acceptance of aesthetic surgery was widely ignored in that field and his manifesto “lost” until republished in the plastic surgery literature in 2002. 1
During this same era, the 1960s and 1970s, another group of surgeons, consisting of plastic surgeons and otolaryngologists formed associations dedicated to cosmetic surgery which were intentionally multispecialty and inclusive. 2 Within 10 years, the American Academy of Facial Plastic and Reconstructive Surgery included more than 1 000 members. In his comprehensive history of cosmetic surgery organizations McCullough describes how, at that time, academic otolaryngology lobbied successfully to make this Academy the exclusive purview of ENT. Following this, a number of members formed a new society, the American Association of Cosmetic Surgeons, led by Richard Webster and John Conley, both plastic surgeons. Their invitation for this new association was sent out widely to all surgeons interested in appearance enhancement, including dermatologists, plastic and ENT surgeons, and so on. This group ultimately formed the American Academy of Cosmetic Surgery in cooperation with liposuction and other cosmetic organizations in 1985.
The debate over who should do cosmetic surgery and how the field should be regulated also dates from the 1960s. McCullough’s article goes on to describe both congressional hearings and an antitrust suit filed against the idea of “cosmetic surgeons” by competing groups of plastic surgeons. The suit filed in Georgia by plastic surgeons resulted in a court ordered $1.5 million settlement paid by the Georgia Society of Plastic Surgeons to the Facial Academy and Cosmetic Association as a penalty for their libel and antitrust activities.
It would be impossible to identify the total number of professional organizations worldwide that today promote cosmetic or aesthetic surgery and medicine. Professional associations and industry sponsor dozens, if not hundreds of meetings annually. This is certainly in keeping with the rapid increase in demand for cosmetic surgery worldwide.
In Vienna, this past August, the World Academy of Cosmetic Surgery Annual Meeting was attended by surgical and medical practitioners from 6 continents and nearly 40 countries. In attendance at the WAOCS meeting were dermatologists, dentists, ENT, plastic surgeons, general surgeons, and a variety of other surgical and nonsurgical specialists.
Cosmetic Surgeons are indeed unique within medicine. They do not treat or seek to cure disease. What they do is reshape and reform the human body in a way designed to improve appearance, increase self-esteem, and enhance patient well-being through beauty. This is the common purpose or cosmetic/aesthetic surgery: enhance patient well-being through improvement in appearance. This international diversity is reflected in surgery and medical management beyond a Eurocentric concept of beauty. Such beauty espoused by Da Vinci and his fellow Renaissance artists has now broadened to a welcome acceptance of all the kinds of ethnic beauty found worldwide. Training in cosmetic surgery not only to address the aesthetic needs of the patient, but recognizes the ethnic diversity of the patient base as well.
Because those who practice cosmetic/aesthetic surgery stand somewhat apart from their colleagues in the medical profession, cosmetic practioners are often regarded in less than respectful ways by their peers. Some call them beauty doctors and consider the whole field rife with charlatans. Despite this, cosmetic surgery is one of the fasted growing fields in medicine. Many of those same colleagues especially plastic surgeons who previously may have disparaged aesthetic surgery are now not just challenging the nature of the profession but also claiming parts of it for themselves instead. These are the plastic surgeons that now claim that only they should be authorized to perform specific procedures and are petitioning government agencies to legislate restrictions on practice.
Internationally there are 3 significant questions facing the practice of cosmetic/aesthetic surgery today:
Who should do what kinds of cosmetic surgery? And as a corollary to that, do we want to/or need to create a distinct credentialing process?
How do we establish the guidelines for risk versus benefit of cosmetic surgery procedures?
How do we determine and help patients choose which among all the invasive and noninvasive techniques, devices and tools available are the ones that are in fact the most safe, efficacious, and cost effective?
Question 1. Who Should Do Cosmetic Surgery?
To what extent does BOARD CERTIFICATION determine what surgeons and physicians can do: pick a procedure: abdominoplasty, breast augmentation, facial rejuvenation? Some claim that ONLY BOARD CERTIFIED Dermatologists should inject toxins and fillers. Or that plastic surgeons are the only ones qualified to do breast augmentation. Or that ONLY, and here it begins to break down. Liposuction was not invented by platic surgeons. It was developed by multiple specialty experts, including gynecologists, general surgeons, dermatologists and only later by adventurous plastic surgeons. No one can truly believe that liposuction “belongs” to any specialty. Facial aesthetic surgery is approached by dentists, oral surgeons, otolaryngologists, plastic surgeons, and so on. Early pioneers in the rhinoplasty field were variously orthopedic surgeons, dermatologists and minimally trained general surgeons. How do we define/control new areas of interest as they evolve? No one in my generation was doing either liposuction or vaginoplasties for aesthetic reasons. Reconstruction was part of plastic surgery while extirpations were gynecologic oncology. Transgender otherwise known as gender transition surgery was even rarer and those practitioners were definitely marginalized by all fields. Today, female genital cosmetic surgery whether by laser, radiofrequency, or surgical interventions is one of the fastest growing areas of aesthetic interest. And I love the fact that, at least in the United States, the plastic surgeons, who scream that gynecologists should not be doing tummy tucks or breast augmentation, are themselves adopting all types of female genital cosmetic surgery, without the slightest hint of irony.
I think we could all agree that no single surgical specialty owns any particular cosmetic procedure. What about Board Certification? What does that mean and how does that apply? While internationally plastic surgeons are rapidly adopting and seeking to control cosmetic surgery, their own training programs have been shown in studies conducted by themselves to be deficient. How many procedures that are first watched, then directed/observed, and then preformed independently constitute sufficient exposure to claim, if not expertise, at least competence? In general, as new devices and techniques are introduced, or as novices gain experience learning to do a new task, 20 procedures is recognized as the turning point. Accuracy, speed, and confidence grow to that point. In studies within American and European plastics residencies, that number is reached by most programs for body and breast procedures but rarely for facial cosmetic procedures and only recently has liposuction become an acknowledged part of the training . . . yet with no other certificate, graduates can promote and perform many procedures for which they have little experience.3-5 The weakness of cosmetic training within plastic surgery is in contrast to the fellowships offered by the American Academy of Cosmetic Surgery, which provide a median of more than 600 cases during the fellowship year. 6
Back to the main questions: how do we define/control new areas of interest as they evolve? I think the answer lies in the 3 pillars of cosmetic organizations like the American Academy of Cosemtic Surgery (AACS) and the World Academy of Cosmetic Surgery (WAOCS): Education, Training, and Experience. Association members are dedicated to teaching, and sharing their experience. Does that mean that we think every member should be able to do every conceivable type of procedure? NO! NO! NO! NO! But we do believe that with sufficient background ANY member can become proficient in the areas of their personal interest. Training, education, and experience. These are the cornerstones of how we should judge capability.
How then to determine competence? This is a more difficult question, and one that most of us would rather avoid. Outcomes are subjective. But self criticism can help. How many of us have looked at postoperative results that are less than satisfactory? Do we analyze those results in trying to improve our practices? Do we bring challenging cases to our colleagues? Do we share both the good and the bad results? If the answer is yes, then we are practicing as we should. Also, do we know how to say no to a patient? If their needs are not within our personal scope, do we know how to refer them on rather than attempt something outside our expertise?
National standards for who should do cosmetic surgery create barriers to some practitioners. Working together as an international community we can at least promote the concept of the procedurally proficient cosmetic surgeon. And, as governmental agencies attempt to impose restrictions, by specialty, on who can do what, the international community should work together to convince regulators that specialty ownership of procedures is neither productive nor appropriate.
Question 2: How Do We Establish the Standards for Risk Versus Benefit of Any Particular Cosmetic Surgery Procedure?
Because most cosmetic surgery occurs outside academic centers, research in cosmetic surgery is limited in many ways. It is often funded by device and pharmaceutical manufacturers, or comprised retrospective case reviews. Few prospective or retrospective studies actually achieve statistical significance due to small sample sizes. There are rare examples of the kind of double-blind randomized trials that are the hallmark of other clinical fields. For instance randomized trials comparing deep plane versus SMAS facelifting results have been published but contain significant flaws. Patients were denied informed consent, or the surgeon was not truly blinded or the numbers too small. There is more science in the injection of toxins and fillers, but these have built in conflict of interest when funded by the industry. Independently funded cosmetic research and valid comparison trials are rare. A review of the U.S. National Clinical Trials database indicates that the majority of registered trials have not been completed and have been simply ended before results are obtained. The good news is that robust clinical outcomes research, by busy private practitioners like Luke Habemma, Guillermo Blugerman, Jacob Haiavy, Angelo Cuzalina, Joe Niamtu, and Gerhard Sattler have given us a robust literature and are models of what cosmetic surgeons should be doing. And academic cosmetic surgeons like Suzan Obagi, Jeffrey Klein, Robert Shumway, and others continue to provide additionally robust valuable information.
Another issue lies in the celebrity culture of certain cosmetic procedures, driven by patient demand. How do we select what we do to which patients? If suddenly everyone wants bigger lips, or a bigger butt, do we approach their desire with permanent, irreversible techniques? Do we accede to patient demand to imitate the appearance of some celebrity? In the course of patient selection we have to consider the risk to the patient, the risk to ourselves, and our reputation, and cost to the patient versus the profit to the practice. How to balance these competing interests? In the United States, we have rampant advertising, not just by cosmetic surgeons, but by the pharmaceutical and device industries. Promotion of less than effective devices for fat reduction, elimination of wrinkles, cellulite, muscle toning, and so on appear online, in print, and other media. Such promotion includes marketing to physicians as a patient recruitment tool, and promotion to patients to direct them to providers. EMSCULPT is the newest toy using electromagnetic frequency, following fast on high intensity focused ultrasound, radiofrequency, cryolipolyis, low level laser therapy, extracorporeal shock wave therapy, vibration exercise, and so on . . . studies of these various modalities can be faulted, for short follow-up times, patient reported satisfaction rates, and claims that minimal measurable changes, 2 cm waist reduction, are achievable. None show changes in body mass index (BMI) or weight per se. Few if any complications are reported with these devices. But is patient satisfaction due to their financial investment? And is physician satisfaction due to their investment? In a stunningly honest recent publication in the Aesthetic Surgery Journal (ASJ), surgeons reported their experience with a radiofrequency device (BODYTITE) in improving patients’ body contour combining REF treatment with or without liposuction. Their final analysis includes financial considerations, including purchase of the machine, yielding $1 875 profit per patient. All authors of this are shareholders in the manufacture of the device. 7
We all understand that the risks of invasive surgery are different than those associated with noninvasive procedures . . . so the risk-benefit ratio must include some assessment of the degree of improvement that the patient desires, combined with each individuals comfort level with one or the other as well as the cost to the patient of obtaining the desired result. Very few studies actually access cost and profit, something that we should be demanding. In an article in the Journal of Current Issues and Research in Advertising, the authors analyzed the content of the 5 most performed cosmetic surgical procedures. They found that the least risky procedures contained more procedural information than the most risky. And they found that half of the sites made no mention of benefits or candidate screening. And most surprising, the commercial sites provided the greatest amount of information. 8 This is important as most patients will now admit that they get their information and base much of their decision-making on the information they obtain from websites. Even well-educated, thoughtful people can be misled.
Question 3: What Are the Best Tools to Use in Performing Cosmetic Procedures?
How do we determine which among all the invasive and noninvasive techniques, devices, and tools available which ones are safe, reliable, and most efficacious, in helping our patients meet their desired goal? There are plenty of articles comparing one or another approach to the patient, most of them doing this through a literature review, meta-analysis, and so on. Few explore much beyond the English language literature and few compare surgical to nonsurgical approaches. The current literature poses an even more vexing problem, the paywall behind which most of the currently published peer review literature hides. It is nearly impossible for the ordinary physician to access the original articles that are referenced in the review articles which are themselves available only if you have access via your library, subscription or pay exorbitant prices for the privilege of reading the material.
A further dilemma arises when we ask how do we provide acceptable “beauty surgery” when increasingly standards of beauty are mutating at an alarming rate—larger lips, bigger buttocks—driven by fads and fashion. Beauty is complicated, part of the currency of power. Beautiful people automatically get certain kinds of “pass” in our society, called the HALO effect. If someone is properly proportioned and meets the contemporary standard of beauty, they are far more likely to be believed, trusted, and hired and to be perceived as successful. The whole issue of cosmetic surgery is complicated by gender-based standards with some arguing that women consuming cosmetic surgery are simply seeking NORMAL bodies alongside others who are seeking to be beautiful.
We ought to ask what is a better result, a natural-looking breast or an obviously augmented breast? Do we want a balanced nose or a tiny turned up tip? What is the ideal color and texture of the skin? When patients create demand for a procedure how quickly should we respond? Celebrity culture is driving cosmetic demand more and more and requiring, in some cases, drastic results. The Brazilian Butt procedure is perhaps the most obvious example of this. And now that Kim Kardashian is renouncing her “big butt,” how soon will demand for butt reductions begin to appear? I want to point out that nowhere else do we see the evolution of patient-driven cosmetic surgery demand than in the field of transgender, or gender-affirming surgery. 10 years ago we could not organize a serious discussion of this, now it is being rapidly included in medical school curricula and specialty transgender or sex reassignment clinics are appearing within academic centers everywhere.
As a final note, we need to discuss the obvious gender imbalance between male surgeons and female patients. This can be mistaken for misogyny. The growing number of women cosmetic surgeons has not changed the way our surgery is practiced. I think they have altered, rightly so, the way the female body is shown on the screen in lectures and the way the female body is discussed. The first prominent purely cosmetic surgeon was a woman, Suzanne Noël, who promoted minimally invasive surgeries, done in an office setting, under local anesthesia. She began this practice in the 1920s, long before such cosmetic surgery was popularized. She believed, and wrote about how such surgery increased women’s confidence and well-being. She continued to practice, and to train many cosmetic surgeons, primarily women, until the 1950s. Today, cosmetic surgery remains a male-dominated field. In the sociology and psychology literature on cosmetic surgery, this is seen as a highly significant issue. I strongly recommend that you take a look at this literature as it will challenge what you believe about beauty and the female body. While some feminists disparage beauty surgery, many of them celebrate the fact of female choice and the opportunity that available surgery provides for physical enhancement. Noël’s original argument, that cosmetic surgery provides women with significant benefits to self-esteem and health remains relevant today.
In this discussion I hope I have shown that the patient should be at the center of our discussions and the center of attention in the clinic. What do they want, not necessarily what can you, the surgeon, do? The patient’s wishes should be taken seriously. There must be room to recognize that the individual patient has the right to self-expression through the desired glamorous body or face, a desire that should be based on some aspect of reality, and within the scope of the surgeon. And that who should do this surgery is not within the province of governmental regulation, but within the scope of practice, based on training, education, and experience of the individual practitioner.
