Cosmetic Surgery Past Present and Future Martin T

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

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

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

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

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

History of Reconstructive and Cosmetic Surgery Eugenics movement, post-WWII prosperity, rise of movies/TV all increase popularity of cosmetic surgery n 1923: first modern rhinoplasty n 1931: first public face lift n 1950 s: first hair transplants n 1990 s onward: more procedures carried out in doctors’ offices and free-standing surgical centers n

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

Arguments for Cosmetic Surgery Aging as a physical illness n Aging as a mental illness n Substitution of happiness for health as the goal of medical treatment n A business service provided to those who desire it, can pay, and accept the risks involved n

Cosmetic Surgery n 91% of patients women n 84% white n 2/3 report family incomes < $50, 000 n More popular on West Coast

Cosmetic Surgery n 34% of patients have multiple procedures done at the same time n “Drastic plastic” n 40% of patients are repeat patients

Cosmetic Surgery n Complications rare but possible n E. g. , infections, bleeding, hyponatremia, allergic reactions, anesthetic complications n Revision rates as high as 10% n E. g. , face lift lasts 10 yrs

Cosmetic Surgery 2007 prices – Do not include anesthesia, OR facilities, other costs n 11. 7 million procedures ($13. 2 billion): 4. 6 million botox shots n 1. 1 million hyaluronic acid fillers n 1 million chemical peels n 897, 000 microdermabrasions n 906, 000 laser hair removals n 590, 000 vein sclerotherapies (strippings) n

Cosmetic Surgery 2007 prices – Do not include anesthesia, OR facilities, other costs n 11. 7 million procedures: 324, 000 liposuctions: $2, 982 n 285, 000 rhinoplasties: $3, 833 n 348, 000 breast augmentations: $3, 816 n 241, 000 blepharoplasties (eyelid reconstructions): $3, 134 n 148, 000 abdominoplasties (“tummy tucks”): $5, 264 n 114, 000 breast reductions: $5, 351 n

Cosmetic Surgery: Other Procedures Face lift n Chemical peel n Forehead lift n Upper arm lift n Buttock lift n Thigh lift n Liposuction n

Most popular procedures for men (2007 stats) Rhinoplasty: 74, 000 n Eyelid surgery: 35, 000 n Liposuction: 33, 000 n Breast reduction: 21, 000 n Hair transplantation: 13, 000 n

Other popular procedures for men Scalp reduction (for male pattern baldness) n Cheek implants n Ear reshaping n Pectoral implants n Chin augmentation (implants) n Calf implants n

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

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

History of Breast Augmentation n 1903 -1950 s: petroleum jelly, beeswax, shellac, and epoxy resins used. n Early 1950 s: liquid silicon injections used n 1962: first US woman to receive encapsulated silicon breast implants

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

History of Breast Augmentation 2005: FDA allows silicone breast implants back on market (with registry) n A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation n Saline implants used much more frequently n

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

Breast Implant Complications (most to least common) n n n Capsular contracture Implant rupture Hematoma Wound infection Breast implants decrease sensitivity of screening mammography among asymptomatic women, but do not increase false-positive rate nor affect tumor prognostic characteristics

Breast Implant Complications Five Yrs After Surgery n Cosmetic implants – 12% n After prophylactic mastectomy – 30% n After mastectomy for breast cancer – 34%

New Breasts for Graduating Seniors n n n 11, 326 procedures performed on 18 -year olds in 2003 US and EU: breast augmentation surgery allowed on those under age 18 only for medical reasons Phenomenon suggests poor parenting, through the capitulation of financially well-endowed parents to the whims of their children, who likely have selfesteem problems and are not yet emotionally (nor perhaps even physically) mature

The Adonis Complex 38% of men want bigger pectorals; 34% of women want bigger breasts n Each year, men spend over $2 billion on health club memberships and $2 billion for home exercise equipment n Tommy John surgery n n To enhance elbow strength and improve pitching velocity

Anabolic Steroid Abuse n Supplement industry booming n 3 million American men have swallowed or injected anabolic steroids since they became widely available in the 1960 s n 2. 8% of current high school males have used (50% increase over last 4 years); rates among girls may be even higher

Cosmetic Surgery Odds and Ends Most common cosmetic procedure in Asia = eyelid surgery, to create a crease above the eye (up to 60% of Korean women) n City in America with the most plastic surgeons per capita = San Francisco n Country with the most cosmetic sugery operations per capita = Brazil n

Cosmetic Surgery – The Latest Hand transplants n Face transplants n 2005: first procedure on female dog-mauling victim n 15 hour procedure (including 5 hours for harvest); involves multidisciplinary team n Ethical issues n n Lifelong immunosuppression required

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

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

Cosmetic Neurology n Raises concerns about: n Distributive justice n Informed consent n. In the military setting or in children

Cosmetic Surgery – The Fringes n The Jewel Eye: implantation of tiny platinum jewels into conjunctiva (20 minutes, $3900) n n Am Acad Ophth warns not proven safe Umbilicoplasty, lengthening/shortening toes to improve “toe cleavage, ” fracturing and resetting jaw to alter smile, forehead implants

Cosmetic Surgery – The Fringes n Genitalia redesign: foreskin restoration, mechanical and cosmetic phalloplasty, vaginal tightening/alteration of angle/dimensions, partial labial excisions, fat injection into labia

Cosmetic Surgery – The Fringes The Jade Lady Membrane Man-Made Hymen n Marketed in China n Blood-colored fluid released during sex n Neuticles (artificial pet testicles) n “To boost your pet’s self-image” n Over 250, 000 sold through mid 2008 n No FDA-approved artificial testes for humans, so cancer victims buy and have plastic surgeon install n

Cosmetic Surgery – The Fringes n n n Furries: lovers of anthropomorphized animals n Surgical enhancements n Conventions Deliberate amputations of body parts n Apotemnophilia – attraction to the idea of being an amputee (a paraphilia) n Not to be confused with acrotomophiliacs – sexually attracted to amputees Wings, chimeras, and stem-cell cosmesis

Prime Time Cosmetic Surgery ABC TV’s “Extreme Makeover” n Fox TV’s “The Swan” n MTV’s “I Want a New Face” n n Celebrity plastic surgery: n Michael Jackson, Pamela Lee, Meg Ryan, Cher (? ), many others

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

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

Covered in Other Slide Shows n Ideals of beauty and body modification n Female genital cutting n Body weight and the obesity epidemic n Ethical and policy issues

References Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s Health 2006; 11(1): posted 4/19/06. Available at n http: //www. medscape. com/viewarticle/529442 n Donohoe MT. Cosmetic surgery past, present, and future: scope, ethics and policy. Medscape Ob/Gyn and Women’s Health 2006; 11(2): posted 8/28/06. Available at http: //www. medscape. com/viewarticle/542448 n

Contact Information Public Health and Social Justice Website http: //www. phsj. org martindonohoe@phsj. org