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Slide 1-

Cosmetic Surgery: Past, Present and Future Martin T Donohoe, MD, FACP
Slide 2-

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 Cosmetic surgery is largely elective and designed to augment “normal” appearance
Slide 3-

Plastic Surgery Charities Operation Smile - correcting congenital defects in patients in the developing world Face-to-Face: The National Domestic Violence Project (sponsored by the Am Acad of Facial Plast and Reconstr Surgeons) – for domestic violence victims Interplast
Slide 4-

History of Reconstructive and Cosmetic Surgery 600 BC: Hindu surgeon reconstructs nose using a piece of cheek By 1000 AD: rhinoplasty common Due to common practice of cutting off noses and upper lips of enemies 16th Century: Gaspare Tagliacozzi (“the father of plastic surgery”) reconstructs noses slashed off during duels by transferring flaps of upper arm skin Also used to reconstruct “saddle nose” deformity of congenital syphilis
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History of Reconstructive and Cosmetic Surgery 1798: Term plastic surgery (from the Greek "plastikos," fit for molding), coined by Pierre Desault 19th century: developments in anesthesia and antisepsis make plastic surgery safer, techniques improve Skills developed during the World Wars I and II applied to victims of birth defects and automobile and industrial accidents
Slide 6-

History of Reconstructive and Cosmetic Surgery Eugenics movement, post-WWII prosperity, rise of movies/TV all increase popularity of cosmetic surgery 1923: first modern rhinoplasty 1931: first public face lift
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History of Reconstructive and Cosmetic Surgery 1950s: first hair transplants 1990s onward: more procedures carried out in doctors’ offices and free-standing surgical centers 2000s: Aesthetic medicine, medi-spas, luxury clinics < 500 medi-spas in 2003, 1750 in 2011
Slide 8-

Medi-Spas Generate over $1 billion revenue annually in US Offer cosmetic procedures, massage, aromatherapy, cosmeceuticals Many physicians not board-certified, often just take a brief course Overseas medical spa tourism increasing
Slide 9-

Motivations for Cosmetic Surgery 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
Slide 10-

Motivations for Cosmetic Surgery 20% of women and 10% of men describe themselves as unattractive Much higher than in the 1990s
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Arguments for Cosmetic Surgery Aging as a physical illness Well done face lift takes 9 yrs off appearance Aging as a mental illness Substitution of happiness for health as the goal of medical treatment A business service provided to those who desire it, can pay, and accept the risks involved
Slide 12-

Representations of Cosmetic Surgery in Women’s Magazines (2008 study) Only 48% of articles in magazines like Cosmo and O, The Oprah Magazine discuss the impact of cosmetic surgery on emotional health Most articles link cosmetic surgery with enhanced emotional well-being, regardless of the patient’s pre-existing emotional health
Slide 13-

Cosmetic Surgery < 8% of members of American Academy of Cosmetic Surgery are plastic surgeons 50,000 – 100,000 physicians who are not plastic surgeons perform cosmetic surgery
Slide 14-

2015 National Plastic Surgery Statistics Total cosmetic surgical procedures: 1.7 million Total cosmetic minimally-invasive procedures: 14.2 million Total reconstructive procedures: 5.8 million Total Expenditures: $13.3 billion - Source: American Society of Plastic Surgeons
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Cosmetic Surgery (2015) 92% of patients women 72% Caucasian; 11% Hispanic; 9% African-American; 7% Asian-American 2/3 report family incomes < $50,000 More popular on West Coast
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Cosmetic Surgery 45% of patients have multiple procedures done at the same time Extremes known as “drastic plastic” 50% of patients are repeat patients
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Cosmetic Surgery Deaths/Complications rare but occur E.g., infections, bleeding, hyponatremia, allergic reactions, anesthetic complications Revision rates as high as 10% E.g., face lift lasts 10 yrs
Slide 18-

Cosmetic Surgery – Surgeon’s Fees 2015 prices – Physician Fee, Does not include anesthesia, OR facilities, other costs 1.7 million surgical procedures: Liposuction: $3,009 Rhinoplasty: $4,771 Breast augmentation: $3,822 Blepharoplasty (eyelid reconstruction): $2,880 Abdominoplasty (“tummy tuck”): $5,502 Face lift: $6,759
Slide 19-

Cosmetic Surgery – Surgeon’s Fees 2015 prices – Physician Fee, Does not include anesthesia, OR facilities, other costs 13 million minimally-invasive procedures: Botox procedure: $382 (physician’s fee; drug costs $300-$1,000/session) Chemical peel: $636 Microdermabrasion: $138 Laser hair removal: $290 Vein sclerotherapy (stripping): $337
Slide 20-

Cosmetic Surgery: Other Procedures Breast reductions Chemical peel Forehead lift Upper arm lift Silicone injections for fuller buttocks/lips/breasts/muscle atrophy Illegal and dangerous Injections of mesenchymal stem cells into face
Slide 21-

Cosmetic Surgery: Other Procedures Buttock lift Thigh lift Liposuction “The Mommy Makeover” increasingly popular (abdominoplasty and liposuction)
Slide 22-

Most popular cosmetic surgical procedures for men (2015 stats) Rhinoplasty: 53,248 Blepharoplasty: 29,906 Breast reduction: 27,456 Liposuction: 25,656 Facelift: 11,963
Slide 23-

Other popular procedures for men Botox injections Scalp reduction (for male pattern baldness) Cheek implants Ear reshaping Pectoral implants Chin augmentation (implants) Calf implants
Slide 24-

Most popular cosmetic surgical procedures for women (2015 stats) Breast augmentation: 279,143 Silicone implants – 80% Saline implants – 20% Liposuction: 196,395 Blepharoplasty: 174,028 Rhinoplasty: 164,731 Abdominoplasty: 123,003
Slide 25-

Cosmetic Surgery Worldwide Countries with the most plastic surgeons: US, Brazil, China, India, and Japan Country with the most cosmetic surgery operations per capita = Brazil City in America with the most plastic surgeons per capita = San Francisco
Slide 26-

History of Breast Augmentation With a few exceptions, large breasts in vogue since antiquity Brassieres and corsets used to enhance size 19th Century: surgical breast enlargements attempted using ivory, glass, metal, rubber, and paraffin
Slide 27-

History of Breast Augmentation 1895: Czerny performs first reported successful human mammary reconstruction 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” granulomatous (foreign body) inflammatory reactions disfiguring and painful
Slide 28-

History of Breast Augmentation 1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins used; use of paraffin caused cancers Early 1950s: liquid silicone injections used 1962: first US woman to receive encapsulated silicone breast implants
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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. Subsequent analyses show no such links
Slide 30-

History of Breast Augmentation 2005: FDA allows silicone breast implants back on market (with registry) A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation; 20% will require removal within 10 yrs Silicone implants can absorb/concentrate some environmental toxins from the body Today: fat transfer, newer generation silicone implants, saline implants, dermal fillers 20% of breast implants done in breast cancer patients
Slide 31-

History of Breast Augmentation 2007: Stem cells and fat derived from liposuction used to grow breast tissue in clinical trials in Europe 2008: Israeli surgeon develops “breast lift procedure” involving internal titanium bra with silicone cups 2008: MyFreeImplants.com Facilitates communication and funding
Slide 32-

Breast Implant Complications (most to least common) Capsular contracture Implant rupture Hematoma Wound infection Increased risk of anaplastic large cell lymphoma (but overall risk very low)
Slide 33-

Breast Implant Complications After Surgery Cosmetic implants – 12% after 5 yrs; 20% after 10 yrs After prophylactic mastectomy – 30% after 5 yrs; 40% after 10 yrs After mastectomy for breast cancer – 34% after 5 yrs; 50% after 10 yrs Latest trend: microsurgical breast reconstruction using implants or autologous tissues
Slide 34-

Poly Implant Prosthe Controversy PIP was world’s third largest maker of breast implants worldwide Shut down in 2010, government safety alerts in 2011/12 Contained industrial-grade silicone 300,000 to 400,000 implanted worldwide
Slide 35-

Poly Implant Prosthe Controversy Disproportionately high rupture rates can cause inflammation and irritation No evidence for increased cancer risk, unlikely to cause long-term health problems Some authorities recommend removal PIP boss Jean Claude Mas arrested in France, may face manslaughter charges
Slide 36-

Breast Implants and Imaging Breast implants decrease sensitivity of screening mammography among asymptomatic women, but do not increase false-positive rate nor affect tumor prognostic characteristics For women with silicone implants, some recommend screening for silent ruptures with MRI 3 yrs post-implant, then every two years Expensive, may not effect long-term health No special screening for those with saline implants
Slide 37-

New Breasts for Graduating Seniors 7,840 breast augmentation procedures performed on 13-19 year olds in 2015 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
Slide 38-

Breast Augmentation for Females Under Age 18 US and EU: breast augmentation surgery allowed on those under age 18 only for medical reasons Yet 50% of procedures done for purely cosmetic reasons
Slide 39-

Headline from The Onion: Plastic Surgeon General Warns of Small Breasts Epidemic
Slide 40-

Penile Size Ancient Greeks believed small penis was superior Later, phallic identity and phallocentrism increasingly popular – “penis is central to man’s identity, virility”
Slide 41-

Penile Size 55% of men satisfied with their penile size; 85% of women satisfied with their partner’s size No correlation between shoe size and penile length
Slide 42-

Penile Size and Penile Reconstructive Surgery 1971: First penile augmentation surgery Girth enhancements with fat injections, Alloderm (derived from human skin) Penile lengthening procedures Complications: scar, keloid, penile lumps, sexual dysfunction, further penile shortening Augmentation procedures not sanctioned by American Urological Association First penile transplant (cancer) - 2016
Slide 43-

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) “Smile lift” – popular in South Korea, curves lips into permanent smile Trisomy-21 surgery (covered in ethical issues slide show)
Slide 44-

Reconstructive Surgery – The Latest Hand transplants Face transplants 2005: first procedure on female dog-mauling victim (nearly 40 worldwide through late 2016, 2 associated deaths) 15-20 hour procedure (including 5 hours for harvest); involves multidisciplinary team Ethical issues Lifelong immunosuppression required
Slide 45-

Cosmetic Neurology Interventions to enhance the cognitive and emotional brain functions of the neurologically non-diseased Currently being pursued by the pharmaceutical industry (via drugs to increase intelligence) and the military (via interventions to create more effective soldiers)
Slide 46-

Cosmetic Military Neurology “Go-go pills" (amphetamines) used by US soldiers in WW II Modafinil (wakefulness-promoting agent) improves pilot alertness and performance in helicopter flight simulations. Many military pilots today rely on caffeine and other stimulants, including amphetamines, to complete missions
Slide 47-

Cosmetic Neurology Raises concerns about: Distributive justice Informed consent In the military setting or in children
Slide 48-

Cosmetic Surgery – The Fringes The Jewel Eye: implantation of tiny platinum jewels into conjunctiva (20 minutes, $3900) Am Acad Ophth warns not proven safe Umbilicoplasty, lengthening/shortening toes to improve “toe cleavage”, other Cinderella surgeries on the feet (to allow women to wear pointy-toied shoes), fracturing and resetting jaw to alter smile, forehead implants
Slide 49-

Cosmetic Surgery – The Fringes Mustache implants – popular in Middle Eastern men Vampire facial (Kim Kardashian) – injection of 2 tablespoons of blood into face
Slide 50-

Cosmetic Surgery – The Fringes Foreskin restoration Skin tightening/vein stripping to improve look of “ring selfies” Boot bulge (calf reduction) liposuction to allow women to fit into knee-high boots
Slide 51-

Cosmetic Surgery – The Fringes Vaginal rejuvenation (aka “aesthetic vaginal surgery,” aka labiaplasty) - tightening/alteration of angle/dimensions, partial labial excisions, fat injection into labia) Over 5,000 procedures in 2014 in U.S. Complications include infection, altered sensation, dyspareunia, adhesions, and scarring ACOG: “safety and effectiveness have not been documented”
Slide 52-

Cosmetic Surgery – The Fringes Hymen reconstructive surgery The Jade Lady Membrane Man-Made Hymen Marketed in China Blood-colored fluid released during sex Labial dyes (“My New Pink Button”) “G spot” injections
Slide 53-

Cosmetic Surgery – The Fringes Furries: lovers of anthropomorphized animals Surgical enhancements Conventions Deliberate amputations of body parts Apotemnophilia – attraction to the idea of being an amputee (a paraphilia) Not to be confused with acrotomophiliacs – sexually attracted to amputees
Slide 54-

Cosmetic Surgery – The Fringes Wings, chimeras, and stem-cell cosmesis Sarah Burge (born 1959) holds world plastic surgery record: Over 100 procedures Cost = $850,000 Celebrity plastic surgery: Michael Jackson, Pamela Lee, Meg Ryan, Cher (?), many others
Slide 55-

Prime Time Cosmetic Surgery ABC TV’s “Extreme Makeover” Fox TV’s “The Swan” MTV’s “I Want a New Face” FX’s Nip Tuck
Slide 56-

Pets Neuticles (artificial pet testicles) “To boost your pet’s self-image” Over 500,000 sold through 2012 No FDA-approved artificial testes for humans, so cancer victims buy and have plastic surgeon install
Slide 57-

Pets We value our pets, but… In 2008, almost 1200 people purchased stem cell surgery for their dogs Pet cloning Pet jewelry $5.5 billion/yr pet pharmaceutical market
Slide 58-

Conclusions Body modification common today and throughout history Risks involved Obesity a major public health problem The body modification and weight loss industries marred by hucksterism, false claims and conflicts of interest
Slide 59-

Conclusions Beauty has different definitions in different times and in different cultures The health professions can play a constructive role in supporting safe and healthy behaviors and promoting realistic ideals of beauty More education needed at all levels
Slide 60-

Covered in Other Slide Shows Ideals of beauty and body modification Female genital cutting Body weight and the obesity epidemic Ethical and policy issues
Slide 61-

References Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at http://www.medscape.com/viewarticle/529442 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
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Contact Information Public Health and Social Justice Website http://www.phsj.org martindonohoe@phsj.org