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Women's Health in Context
Women’s Health in Context: Cosmetic Surgery Past, Present,
and Future: Scope, Ethics, and Policy
Martin Donohoe, MD, FACP
Medscape Ob/Gyn & Women's Health. 2006;11(2) ©2006 Medscape
Posted 08/28/2006
Introduction
The preceding article in this series discussed historical ideals of beauty and body modification
and described in detail current approaches to altering appearance, such as the use of cosmetics,
tanning, tattooing, body piercing, botulinum toxin, and dermal fillers. [1] This essay will discuss the
history and scope of cosmetic surgery; describe a procedure, breast augmentation, in detail;
analyze trends in male enhancement, going beyond cosmetic surgery into muscle building and
augmentation of athletic performance; offer a glimpse of the fringes and future of cosmetic
surgery; list some contemporary ethical and policy issues in cosmetic surgery; note a few
humanitarian ventures undertaken by plastic surgeons; and conclude with thoughts on the role of
health professionals and the media in defining ideals of beauty.
Plastic, Reconstructive, and Cosmetic Surgery
Each year plastic and reconstructive surgeons improve the lives of millions of patients with
congenital malformations (such as cleft lip and cleft palate), disfiguring wounds, animal bites, and
profound burn injuries, as well as those requiring reconstruction after surgery for malignancy or
other chronic conditions. This column will not focus on these forms of plastic surgery, but rather
on cosmetic surgery, or elective procedures to enhance those not encumbered by such
disfiguring conditions.
External motivators for cosmetic surgery include the desire to avoid ethnic prejudice; fear of age
discrimination; and direct or subtle, indirect coercion by a spouse, parent or boss. [2] Internal
motivators include the desire to diminish unpleasant feelings of depression, shame or social
anxiety; the wish to alter a specific disliked feature; the yearning for a more youthful, healthy look
that signals fertility (usually in women); and the hope to create a strong, powerful appearance that
will facilitate career advancement.[2]
A Brief History of Cosmetic Surgery
As early as 600 BC, a Hindu surgeon reconstructed a nose using a piece of cheek.[3] By 1000 AD,
rhinoplasty was common, due to the barbaric custom of cutting off the noses and upper lips of
one's enemies. In the 16th century, Gaspare Tagliacozzi, known as "the father of plastic surgery,"
reconstructed noses slashed off by swords during duels by transferring flaps of upper arm skin.
This procedure was also used to correct the saddle nose deformity of syphilis. [3]
The term plastic surgery, from the Greek "plastikos" (fit for molding), was coined by Pierre
Desault in 1798 as a label for procedures to repair facial deformities. [4] In the 19th century,
developments in anesthesia and antisepsis made plastic surgery safer and allowed for
improvements in technique. Plastic surgeons further honed their skills during the 2 world wars,
then applied their techniques to victims of birth defects and automobile and industrial accidents. [3]
The American eugenics movement, with its "Better Baby Contests," post-World War II prosperity,
and the advent of motion pictures and television all helped to usher in the modern era of cosmetic
surgery.[2] The first modern cosmetic rhinoplasty was performed in 1923, followed by the first
public face lift in 1931.[2]
The Scope of Contemporary Cosmetic Surgery
Procedures and Patients. In 2005, there were 10.2 million cosmetic procedures performed in
the United States, an increase of 11% from 2004 and a 38% compared with 2000.[5] This number
includes 3,839,387 Botox treatments, 1,033,581 chemical peels, 837,711 microdermabrasions,
782,732 laser hair removals, 589,768 vein sclerotherapies (strippings), 323,605 liposuctions,
298,413 rhinoplasties (nose jobs), 291,350 breast augmentations, 230,697 blepharoplasties
(eyelid reconstructions), 134,746 abdominoplasties, 114,250 breast reductions, 793 vaginal
rejuvenation procedures, 337 calf augmentations, and 206 pectoral implants. [5] Forty percent of
those undergoing cosmetic procedures are repeat patients; 34% have multiple procedures at the
same time.[5]
Eighty-four percent of patients undergoing cosmetic procedures last year were white; 90% were
female.[5] The top 5 minimally invasive procedures among women were Botox injection, chemical
peel, laser hair removal, microdermabrasion, and sclerotherapy. The top 5 surgical procedures
were breast augmentation, liposuction, nose reshaping, eyelid surgery, and tummy tuck (see
below for statistics on males).[5]
In 2005, 51% of US cosmetic surgery patients and 69% of patients getting minimally invasive
procedures were aged 51 years or older. Two thirds of patients reported family incomes below
$50,000. Total physician fees for cosmetic procedures, not including anesthesia, operating room
facilities, and other related expenses, were estimated at $9.4 billion. [5]
Today, an increasing number of cosmetic surgery procedures are performed in doctors' offices
and free-standing surgical centers (as opposed to hospitals), and more procedures are being
carried out simultaneously.[6] This increases the risk of rare but potentially fatal infections and
anesthetic reactions. Furthermore, some practitioners have not completed the full 5 years of
residency training required for certification by the American Board of Plastic Surgery, but (legally)
perform procedures, for which they might be inadequately trained, merely to augment their
income.[6]
Complications. Complications of cosmetic surgery are rare, but include infection, bleeding, fluid
and salt imbalance, and allergic and anesthetic reactions which are sometimes fatal. The recent
death of a noted author has heightened public awareness that getting cosmetic surgery is not in
the same category as getting a facial or herbal wrap.[6]
Cosmetic Surgery Abroad. Cosmetic surgery's popularity is spreading throughout the
developed world. South Korea has the highest ratio of cosmetic surgeons to citizens worldwide,
but Brazil has the most cosmetic surgical procedures per capita.[4] The most popular cosmetic
procedure in Asia is eyelid surgery. Argentina has the highest ratio of breast enlargements
worldwide.[4] Next door in Brazil, breast reduction is more popular.[7]
Breast Augmentation: Then and Now
Procedures and Complications. Large breasts have been in vogue since antiquity, with the
exception of a few brief periods in history. Uplifting brassieres and corsets were used at times to
enhance the perceived size of breasts. Then, in the 19th century, surgical breast enlargements
were attempted using ivory, glass, metal, rubber, and paraffin.[8] In 1895, Czerny did the first
reported successful human mammary reconstruction, on an actress who had undergone removal
of a fibroadenoma (benign lesion), by transplanting a lipoma from her hip to reconstruct the
breast. In 1903, surgeon Charles Miller inaugurated breast augmentation surgery in the United
States when he began opening women's chests and inserting "braided silk, bits of silk floss,
particles of celluloid, vegetable ivory, and several other foreign materials."[9] The granulomatous
(foreign body) inflammatory reactions produced by such odds and ends must have been
disfiguring and painful. By the 1950s, petroleum jelly, beeswax, shellac, and epoxy resins had
been tried. In the early 1950s, liquid silicon injections were used to restore breast contour. [8] The
first US woman to receive encapsulated silicon breast implants was Timmie Jean Lindsey, who
was boosted from a B to a C cup in 1962.[4]
In 1992, the US Food and Drug Administration (FDA) banned the use of 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
thorough analyses have shown no such links.[8,10] Even so, breast augmentation with silicone
implants is associated with a number of local adverse events, including hematoma, infection,
scarring, contracture, rupture, pain, and loss of sensation. A minimum of 15% of modern silicone
implants will rupture between the third and tenth year after implantation. [11] Reoperation rates are
20%-26% and removal rates are 12%-14% at 5 years.[12] Complications are more common among
individuals undergoing breast reconstruction following cancer surgery than in those having purely
cosmetic procedures.
Since 1998, federal law has required insurance companies to cover breast reconstruction after
mastectomy.[13] In 2005, the FDA reversed itself, allowing silicone breast implants back on the
market under certain conditions, including a registry to track complications. [14] Even so, saline
implants, subject to fewer complications, are employed much more frequently today.
Breast augmentation also decreases the sensitivity of screening mammography among
asymptomatic women, but does not increase the false-positive rate nor affect the prognostic
characteristics of breast cancers.[15] Differences between saline and silicone implants for
mammography sensitivity and tumor characteristics are unknown. [15]
New Breasts for Graduating Seniors. In the United States, breast augmentation surgery can be
performed on those under age 18 for medical reasons only.[12,16] The European Union Parliament
is backing an age limit of age 18 on breast implants for cosmetic reasons; its recommendations
are likely to be adopted by the European Commission.[17] Nevertheless, there is a growing trend of
parents giving implants as gifts to their graduating 18-year-old adolescents. The number of 18year-olds who underwent breast-implant surgery nearly tripled from 2002 to 2003, to 11,326.[16]
This 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.
Men, Cosmetic Surgery, Steroids, and the Adonis Complex
Men are increasingly undergoing cosmetic surgery to enhance appearance, combat the effects of
aging, and improve chances for employment in competitive job markets. [18] The most common
minimally invasive procedures are Botox injection, microdermabrasion, laser hair removal,
chemical peel, and laser skin resurfacing.[5] The most popular surgical procedures among men
are rhinoplasty, hair transplantation, liposuction, blepharoplasty, and breast reduction for
excessive gynecomastia.[5] Face lifts, ear corrections, and penile enlargements are becoming
increasingly popular.[7]
Still, men undergo far fewer procedures than women. One reason may be that male appearance
is often judged in terms of muscularity, and there are other approaches to "buffing up," eg,
through the use of anabolic steroids. These illegal substances have been used by an estimated 3
million or more American men since the 1960s when they became available on the black
market.[19] Two thirds of users are noncompetitive recreational body builders or nonathletes who
use steroids for cosmetic enhancement (increased muscle mass and "virile" appearance). [20] By
one estimate, 15%-40% of regular gymnasium attendees have used anabolic steroids. [21]
"Victims" of the "Adonis complex,"[19] these men place themselves at risk of cardiomyopathy,
atherosclerosis, hypercoagulopathy, hepatic dysfunction, and psychiatric and behavioral
disturbances through anabolic steroid use.[20,21]
Especially troubling is the rise in steroid use among high school athletes, who may get the drugs
from their coaches. The use of anabolic steroids to improve performance was first documented in
elite athletes in the 1950s.[21] The International Olympic Committee has banned use of steroids,
and athletes competing in national and international competitions undergo routine drug testing.[21]
Other procedures athletes use to enhance performance are well known, such as blood doping
and injecting erythropoietin to increase red cell mass and, theoretically, oxygen-carrying capacity.
Such methods are of doubtful efficacy and carry their own health risks.
New procedures are on the horizon. The time may come soon when perfectly healthy pitchers
choose to undergo the so-called "Tommy John surgery" (until now performed only to repair
ruptured arm ligaments), which can make an elbow even stronger than it naturally was, allowing
hurlers to achieve higher throwing velocities.[22] Other predicted enhancements include the
removal, re-engineering, and re-insertion of leg, arm, and shoulder muscle cells to add
strength,[22] and gene enhancement.[23]
The Future and the Fringes of Cosmetic Surgery
The following describes procedures at the fringes of cosmetic surgery, along with a look at
predicted future methods of bodily enhancement:
The JewelEye. Reminiscent of the use of antimony to create conjunctival sparkle among the
ancient Egyptians, Romans, and Persians,[9] the JewelEye, invented by a Dutch ophthalmologist,
consists of implanting tiny platinum jewels into the sclera, at a cost of $3900 for the 20-minute
procedure.[24] The American Academy of Ophthalmology has warned that the procedure has not
been proven safe.[24]
Genitalia Redesign. Genitalia redesign is performed on both men and women. Foreskin
restoration (circumcision reversal) has been around since the 2nd century BC, can be performed
both surgically and with taping and stretching, and is alleged to return the penis to its natural
appearance and to enhance sexual pleasure.[25] Cosmetic phalloplasty, building on procedures to
correct penile deformities such as Peyronie's disease and hypospadias, is now widely promoted
on the Internet to men who want to increase the size of their penis. [26] Other enhancement
procedures involve injecting fat or dermal allografts. Postsurgical instructions for penile
lengthening procedures sometimes involve the use of stretching devices such as penile weights.
Understandably, results have been generally disappointing; size is only augmented for the flaccid
state, and complications are common.[26]
Female genital reconstructive procedures include vaginal tightening, alteration of the vaginal
angle, partial excision of "floppy" or "overgrown" vaginal labia, and the injection of fat into the
labia to enhance plumpness.[27] The "Jade Lady Membrane Man-Made Hymen," marketed in
China, can be inserted 20 to 30 minutes before intercourse. The combination of natural body
fluids and a red dye produce a bloody-type discharge which, according to the package insert,
when accompanied by moans of pain, creates the illusion that the female is a virgin, and
therefore, a more desirable partner.[28]
Face Transplantation. In November 2005, French surgeons performed the first-ever partial face
transplant on a 38-year-old female victim of a horribly disfiguring dog bite.[29] The operation was
successful, but the patient will require life-long immunosuppressant medications to prevent
rejection. These drugs will place her at increased risk of cancer, infections, and diabetes.
Physicians at the Cleveland Clinic in Ohio and at the Royal Free Hospital in London have
received permission to perform the world's first-ever complete face transplant, an operation that
will require up to 15 hours (including 5 hours for the harvest) and a multidisciplinary team of
surgeons.[29]
Facial transplants could significantly improve the quality of life of the severely disfigured, but raise
questions of identity -- both to self and to others, particularly those who knew the deceased
donor. Patient selection, cost, and reimbursement are other potential issues. [30] Candidates
should undergo intensive psychological screening to eliminate those with behaviors that may
decrease graft viability (eg, tobacco smoking). Presumed consent, supported by many for other
organ donations given the current long waiting lists, will likely not be acceptable for face donation
for obvious reasons.[30] Concerns have also been raised that outside the United States, the
procedure may be exploited by profiteering plastic surgeons willing to service criminals on the lam
or those who have succumbed to the notion that they are irrevocably "ugly."
Prime Time Cosmetic Surgery. Cosmetic surgery has recently gone prime time, with the
American Broadcasting Corporation's show, "Extreme Makeover." In episodes of the program,
participants chosen from the ranks of hundreds of thousands of willing "patients" undergo multiple
surgical enhancements before a national audience of millions of voyeurs. [30] Other, similar
offerings have included Fox TV's "The Swan" and MTV's "I Want a Famous Face," on which
young men and women undergo cosmetic "enhancements" to make them look like stars such as
Brad Pitt, Jennifer Lopez, and even Elvis Presley. And speaking of celebrities, Michael Jackson
(with a reported 4 nose jobs, a chin implant, eyelid surgery, facelift, lip reduction, and assorted
touch-ups)[7] and Cher (who may have undergone rib removal to create the illusion of a thinner
waistline)[9] are among the celebrities well known for their predilection for bodily reconstruction.
Aptoemnophila. Aptoemnophiles, first described in 1977, constitute a small group of individuals
who have an attraction to the idea of changing their identities by becoming amputees. [31] This rare
paraphilia sometimes leads the afflicted to self-amputation; a few physicians outside of the United
States have occasionally accommodated amputee seekers by removing limbs for "cosmetic
purposes," although this practice would no doubt place the operating doctor in legal jeopardy.
Aptoemnophiliacs should be distinguished from acrotomophiliacs, another rare group who are
sexually attracted to amputees.
Furries. Furries, lovers of anthropomorphized animals, sometimes adopt the personae of
animals, either through costumes or body modification. [32] For example, some tiger furries cover
their bodies with striped tattoos, get dental implants with canines sharpened to resemble tiger
teeth, have plastic whiskers implanted, wear special contact lenses to make their eyes appear
oval, and have mouth, nose, and ear surgery to make themselves more catlike.[33] Extreme furries
live as much as possible like animals, have annual conventions, host Internet sites, and have
even been profiled on the television series "CSI."[32]
Cosmetic Surgery for Pets. Cosmetic surgery for pets is particularly popular in Brazil and
appears to be spreading to other countries.[34] For example, some owners of show dogs "correct"
perceived imperfections in ears, teeth, and tails to optimize chances for winning. There is no legal
consensus over whether such cosmetic surgery for pets should be classified as body modification
or mutilation, and therefore be subject to animal cruelty laws.[34]
Over 100,000 neutered male dogs and cats in 37 countries have had artificial testicular implants
called Neuticles surgically implanted in their scrotums, ostensibly to help them "retain their macho
swagger."[35] Some US farmers, in hopes of winning best in show at state fairs, have taken to
injecting cows' udders with isobutane gas (to increase the size) and covering the teats with silver
protein to smooth out wrinkles.[36] Those 15% of US dairy cows injected with recombinant bovine
growth hormone also have enlarged mammary glands, which are prone to inflammation and
infection (mastitis).(Donohoe MT. Genetically modified foods: health and environmental risks, the
corporate agribusiness agenda, and Oregon politics; submitted to Open Spaces, April 2006).
Cosmetic Neurology. Interventions to enhance the cognitive and emotional brain functions of
the neurologically nondiseased are currently being pursued by the pharmaceutical industry (via
drugs to increase intelligence) and the military (via interventions to create more effective
soldiers).[37] Cosmetic military neurology dates back to the use of "go-go pills" (amphetamines) by
US soldiers in World War II. Military investigators have found that Modafinil (a wakefulnesspromoting agent) improves pilot alertness and performance in helicopter flight simulations. [38]
Many military pilots today rely on caffeine and other stimulants, including amphetamines, to
complete missions.[37,38] Cosmetic neurology raises concerns about distributive justice and, in the
military setting or when used in children, informed consent.
Wings, Chimeras, and Stem-cell Cosmesis. At least 1 surgeon has proposed the surgical
construction of wings that someday may be functional, a development foreshadowed by the
musings of Renaissance genius Leonardo da Vinci.[39] Another physician has promised to create a
human/animal chimera, albeit not through surgery but through genetic engineering, just as the
military has studied the prospects of engineering a class of super-soldiers.[40]
Beauty salons in Russia have been offering stem-cell cosmetic surgery where fetal, embryonic, or
adult stem cells are injected as treatment for baldness and wrinkles.[41] The efficacy and safety of
such procedures are dubious at best. There have been reports of the use of stem cells obtained
from the aborted fetuses of poor women who are paid about $200 to undergo late-term cesarean
abortions. The fetus is then traded and sold on the black market.[41]
Ethical and Policy Issues Related to the Ideal of Beauty and Body Modification
The current pervasiveness of body modification and cosmetic surgery raises a number of
provocative and controversial ethical and policy questions. Space precludes a full discussion of
each, but such questions include:

What roles do culture, the media, sexism, and racism play in individual and public
perceptions of beauty? Individual and collective perceptions of ideal body weight? The
response of society to outliers and development of pathological behaviors? The desire for
cosmetic surgery?

Is aging defined as a physical and/or mental illness?[42] If so, is the substitution of
happiness for health an appropriate goal for cosmetic enhancement? Does this
enhancement constitute medical treatment? Or is cosmetic surgery simply a business
service provided to those who desire it, can pay for it, and are willing to accept the risks
involved?

How do providers and insurers define medical necessity as it relates to cosmetic
surgery?

A sizable minority of physicians admits to "gaming the system" by manipulating
reimbursement rules so their patients can receive treatments or undergo procedures the
physician deems necessary.[43] How often do cosmetic surgeons "shade the truth" in
attempting to obtain coverage for services they perceive to be necessary for their
patients?

How much revenue-generating cosmetic surgery is too much for underfunded, university
dermatology (or plastic surgery) departments?[44] What are appropriate arrangements for
using such revenue to cross-subsidize indigent care?

To augment lagging revenues and offset budget deficits, states have begun taxing
cosmetic procedures; New Jersey's levy is 6%.[45] Should cosmetic surgery be subjected
to the same sort of consumption taxes as cigarettes and gasoline?

Many endocrinologists treat short-statured, non-growth hormone-deficient children with
growth hormone.[46] Is it appropriate for parents to consent to such "treatment" and for
physicians to offer it? Provision of growth hormone may augment height and enhance
social acceptability (and ability to make the basketball team), but can carry potential longterm side effects such as diabetes and hypertension.[47]

Should surgeons correct the physiognomy of children with Trisomy 21, giving them a
"normal" appearance while leaving their underlying neurologic defects and distorted
voices unchanged? How will such surgery affect their emotional development and
integration into society?

What cosmetic procedures are acceptable in consenting adolescents? [48]

Should cosmetic surgery be used to transform racial characteristics, by (as one author
put it) "transforming a Black nose into an aquiline nose better befitting a British butler," or
by rounding off the eyelids of Asians?[49]

How should professional societies regulate the evolving field of genetic aesthetic
enhancement? What, if any, differences exist between eugenics and genetic aesthetic
enhancement?

What are the appropriate actions of health professionals, lawyers, teachers, ethicists and
governments in responding to ideals of beauty and body weight, and to unhealthy
behaviors and unsafe and/or unethical cosmetic surgical practices?
Body modification, ranging from the fairly innocuous ("tattoos") to the patriarchal and abusive
(female genital cutting or female genital mutilation), has been common throughout history and
remains widespread today. Some have argued that while ultimately it would be ideal for society to
overcome its prejudicial attitudes regarding external appearance, it may at times be unreasonable
to expect 1 individual to stand alone and not undergo cosmetic enhancement in order to alter
public opinion. The typical example of this is a woman who, in her 40s or 50s, has developed
age-related wrinkles, sagging eyelids, jowls, and a drooping bosom. She may (quite correctly)
argue that it is more difficult for her to gain employment in professions where she will interact
frequently with the public, or that she is less likely to be promoted.[2] Is it fair to ask this woman,
whose income may support both her and her children, to forgo cosmetic reconstruction and
attempt to overcome established prejudices in order to "show others" that she is able to succeed
on the basis of her intrinsic worth?
Humanitarian Ventures in Plastic and Reconstructive Surgery
Many plastic, reconstructive, and cosmetic surgeons have applied their skills to laudable
humanitarian endeavors. These include Operation Smile, where participating physicians correct
congenital defects in poor patients in the developing world, and Face to Face: The National
Domestic Violence Project (sponsored by the American Academy of Facial Plastic and
Reconstructive Surgeons), which assists victims of partner abuse and sexual assault. [50] The
Plastic Surgery Educational Foundation, the educational and research arm of the American
Society of Plastic Surgeons, also helps to support plastic surgeons that volunteer abroad to help
the impoverished.[51]
Conclusions
Cosmetic surgery, a field with a fascinating history, is now widespread and includes a number of
different techniques to enhance appearance. Recent developments raise a number of ethical and
policy questions related to body modification. Health professionals have an important and
constructive role to play in supporting safe and healthy behaviors and in promoting realistic ideals
of beauty. The media should more positively portray characters with values based upon personal,
intellectual, and emotional attributes, rather than on superficial (and fleeting) outward physical
characteristics. And government, medical societies, and the media must confront the hucksterism
and false claims rampant in the body modification industry. One can only hope that with more
education and increases in enlightened discussion at all levels -- from the preschool years to the
Golden years -- society can become more egalitarian and less superficial in definitions of beauty
and worth.
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Martin Donohoe, MD, FACP, Adjunct Lecturer, Community Health, Portland State University,
Portland, Oregon; Staff Physician, Department of Internal Medicine, Kaiser Sunnyside Medical
Center, Portland, Oregon
Disclosure: Martin Donohoe, MD, FACP, has disclosed no relevant financial relationships.
Public Health and Social Justice Website
http://www.phsj.org
[email protected]