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

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

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

4. History of Reconstructive and Cosmetic Surgery 600 BC: Hindu surgeon reconstructs nose using a piece of cheek 600 BC: Hindu surgeon reconstructs nose using a piece of cheek By 1000 AD: rhinoplasty common By 1000 AD: rhinoplasty common Due to common practice of cutting off noses and upper lips of enemies 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 16 th 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 Also used to reconstruct “saddle nose” deformity of congenital syphilis

5. History of Reconstructive and Cosmetic Surgery 1798: Term plastic surgery (from the Greek "plastikos," fit for molding), coined by Pierre Desault 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 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 Skills developed during the World Wars I and II applied to victims of birth defects and automobile and industrial accidents

6. History of Reconstructive and Cosmetic Surgery Eugenics movement, post-WWII prosperity, rise of movies/TV all increase popularity of cosmetic surgery Eugenics movement, post-WWII prosperity, rise of movies/TV all increase popularity of cosmetic surgery 1923: first modern rhinoplasty 1923: first modern rhinoplasty 1931: first public face lift 1931: first public face lift

7. History of Reconstructive and Cosmetic Surgery 1950s: first hair transplants 1950s: first hair transplants 1990s onward: more procedures carried out in doctors’ offices and free-standing surgical centers 1990s onward: more procedures carried out in doctors’ offices and free-standing surgical centers 2000s: Aesthetic medicine, medi-spas, luxury clinics 2000s: Aesthetic medicine, medi-spas, luxury clinics

8. Medi-Spas Generate over $1 billion revenue annually in US Generate over $1 billion revenue annually in US Offer cosmetic procedures, massage, aromatherapy, cosmeceuticals Offer cosmetic procedures, massage, aromatherapy, cosmeceuticals Overseas medical spa tourism increasing Overseas medical spa tourism increasing

9. Motivations for Cosmetic Surgery External: avoidance of ethnic prejudice; fear of age discrimination; coercion by spouse/parent/boss 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 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

10. Motivations for Cosmetic Surgery 20% of women and 10% of men describe themselves as unattractive 20% of women and 10% of men describe themselves as unattractive Much higher than in the 1990s Much higher than in the 1990s

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

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

13. 2009 National Plastic Surgery Statistics Total cosmetic surgical procedures: 1.5 million Total cosmetic surgical procedures: 1.5 million Total cosmetic minimally-invasive procedures: 11 million Total cosmetic minimally-invasive procedures: 11 million Total reconstructive procedures: 5.2 million Total reconstructive procedures: 5.2 million - Source: American Society of Plastic Surgeons

14. Cosmetic Surgery 91% of patients women 91% of patients women 66% Caucasian; 17% Asian-American; 12% Hispanic; 5% African-American 66% Caucasian; 17% Asian-American; 12% Hispanic; 5% African-American 2/3 report family incomes < $50,000 2/3 report family incomes < $50,000 More popular on West Coast More popular on West Coast

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

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

17. Cosmetic Surgery 2009 prices – Do not include anesthesia, OR facilities, other costs 12.5 million minimally-invasive procedures ($10 billion): 12.5 million minimally-invasive procedures ($10 billion): 4.8 million botox procedures 4.8 million botox procedures 1.2 million hyaluronic acid fillers 1.2 million hyaluronic acid fillers 1.1 million chemical peels 1.1 million chemical peels 910,000 microdermabrasions 910,000 microdermabrasions 890,000 laser hair removals 890,000 laser hair removals 390,000 vein sclerotherapies (strippings) 390,000 vein sclerotherapies (strippings)

18. Cosmetic Surgery 2009 prices – Do not include anesthesia, OR facilities, other costs 11.7 million surgical procedures: 11.7 million surgical procedures: 341,000 liposuctions: $2,769 341,000 liposuctions: $2,769 256,000 rhinoplasties: $4,216 256,000 rhinoplasties: $4,216 289,000 breast augmentations: $3,331 289,000 breast augmentations: $3,331 203,000 blepharoplasties (eyelid reconstructions): $2,809 203,000 blepharoplasties (eyelid reconstructions): $2,809 115,000 abdominoplasties (“tummy tucks”): $4,936 115,000 abdominoplasties (“tummy tucks”): $4,936 104,000 face lifts: $6,396 104,000 face lifts: $6,396

19. Cosmetic Surgery: Other Procedures Breast reductions Breast reductions Chemical peel Chemical peel Forehead lift Forehead lift Upper arm lift Upper arm lift

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

21. Most popular cosmetic surgical procedures for men (2009 stats) Rhinoplasty: 66,000 Blepharoplasty: 30,000 Liposuction: 22,000 Breast reduction: 17,000 Hair transplantation: 13,000

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

23. Most popular cosmetic surgical procedures for women (2009 stats) Breast augmentation: 289,000 Rhinoplasty: 190,000 Liposuction: 176,000 Blepharoplasty: 173,000 Abdominoplasty: 111,000

24. Cosmetic Surgery Worldwide Countries with the most plastic surgeons: US, China, Brazil, and India Countries with the most plastic surgeons: US, China, Brazil, and India Country with the most cosmetic sugery operations per capita = Brazil Country with the most cosmetic sugery operations per capita = Brazil City in America with the most plastic surgeons per capita = San Francisco City in America with the most plastic surgeons per capita = San Francisco

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

26. History of Breast Augmentation 1895: Czerny performs first reported successful human mammary reconstruction 1895: Czerny performs first reported successful human mammary reconstruction actress who had undergone removal of a fibroadenoma actress who had undergone removal of a fibroadenoma transplanted lipoma from her hip 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” 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 granulomatous (foreign body) inflammatory reactions disfiguring and painful

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

28. 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. 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 Subsequent analyses show no such links

29. History of Breast Augmentation 2005: FDA allows silicone breast implants back on market (with registry) 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 A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation Today: fat transfer, newer generation silicone implants, saline implants, dermal fillers Today: fat transfer, newer generation silicone implants, saline implants, dermal fillers

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

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

32. Breast Implant Complications Five Yrs After Surgery Cosmetic implants – 12% Cosmetic implants – 12% After prophylactic mastectomy – 30% After prophylactic mastectomy – 30% After mastectomy for breast cancer – 34% After mastectomy for breast cancer – 34% Latest trend: microsurgical breast reconstruction using implants or autologous tissues Latest trend: microsurgical breast reconstruction using implants or autologous tissues

33. New Breasts for Graduating Seniors 11,326 procedures performed on 18-year olds in 2003 11,326 procedures performed on 18-year olds in 2003 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 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

34. Breast Augmentation for Females Under Age 18 4,108 procedures on women 18 and under in 2008 4,108 procedures on women 18 and under in 2008 US and EU: breast augmentation surgery allowed on those under age 18 only for medical reasons 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 Yet 50% of procedures done for purely cosmetic reasons

35. Headline from The Onion: Plastic Surgeon General Warns of Small Breasts Epidemic

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

37. Anabolic Steroid Abuse Supplement industry booming Supplement industry booming 3 million American men have swallowed or injected anabolic steroids since they became widely available in the 1960s 3 million American men have swallowed or injected anabolic steroids since they became widely available in the 1960s 2.8% of current high school males have used (50% increase over last 4 years); rates among girls may be even higher 2.8% of current high school males have used (50% increase over last 4 years); rates among girls may be even higher Use associated with violent behavior Use associated with violent behavior

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

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

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

41. 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) Most common cosmetic procedure in Asia = eyelid surgery, to create a crease above the eye (up to 60% of Korean women) Trisomy-21 surgery (covered in ethical issues slide show) Trisomy-21 surgery (covered in ethical issues slide show)

42. Reconstructive Surgery – The Latest Hand transplants Hand transplants Face transplants Face transplants 2005: first procedure on female dog-mauling victim (10 worldwide through late 2010, 2 associated deaths) 2005: first procedure on female dog-mauling victim (10 worldwide through late 2010, 2 associated deaths) 15-20 hour procedure (including 5 hours for harvest); involves multidisciplinary team 15-20 hour procedure (including 5 hours for harvest); involves multidisciplinary team Ethical issues Ethical issues Lifelong immunosuppression required Lifelong immunosuppression required

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

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

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

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

47. Cosmetic Surgery – The Fringes Genitalia redesign: foreskin restoration, mechanical and cosmetic phalloplasty, vaginal tightening/alteration of angle/dimensions, partial labial excisions, fat injection into labia Genitalia redesign: foreskin restoration, mechanical and cosmetic phalloplasty, vaginal tightening/alteration of angle/dimensions, partial labial excisions, fat injection into labia 4500 procedures in 2007 4500 procedures in 2007 ACOG: “safety and effectiveness have not been documented” ACOG: “safety and effectiveness have not been documented”

48. Cosmetic Surgery – The Fringes The Jade Lady Membrane Man-Made Hymen The Jade Lady Membrane Man-Made Hymen Marketed in China Marketed in China Blood-colored fluid released during sex Blood-colored fluid released during sex Labial dyes (“My New Pink Button”) Labial dyes (“My New Pink Button”) Furries: lovers of anthropomorphized animals Furries: lovers of anthropomorphized animals Surgical enhancements Surgical enhancements Conventions Conventions

49. Cosmetic Surgery – The Fringes Deliberate amputations of body parts Deliberate amputations of body parts Apotemnophilia – attraction to the idea of being an amputee (a paraphilia) Apotemnophilia – attraction to the idea of being an amputee (a paraphilia) Not to be confused with acrotomophiliacs – sexually attracted to amputees Not to be confused with acrotomophiliacs – sexually attracted to amputees Wings, chimeras, and stem-cell cosmesis Wings, chimeras, and stem-cell cosmesis

50. Cosmetic Surgery – The Fringes Sarah Burge (born 1959) holds world plastic surgery record: Sarah Burge (born 1959) holds world plastic surgery record: Over 100 procedures Over 100 procedures Cost = $850,000 Cost = $850,000 Celebrity plastic surgery: Celebrity plastic surgery: Michael Jackson, Pamela Lee, Meg Ryan, Cher (?), many others Michael Jackson, Pamela Lee, Meg Ryan, Cher (?), many others

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

52. Pets Neuticles (artificial pet testicles) Neuticles (artificial pet testicles) “To boost your pet’s self-image” “To boost your pet’s self-image” Over 250,000 sold through mid 2008 Over 250,000 sold through mid 2008 No FDA-approved artificial testes for humans, so cancer victims buy and have plastic surgeon install No FDA-approved artificial testes for humans, so cancer victims buy and have plastic surgeon install

53. Pets We value our pets, but… We value our pets, but… In 2008, almost 1200 people purchased stem cell surgery for their dogs In 2008, almost 1200 people purchased stem cell surgery for their dogs Pet cloning Pet cloning Pet jewelry Pet jewelry Over $3 billion pet pharmaceutical market Over $3 billion pet pharmaceutical market

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

55. Conclusions Beauty has different definitions in different times and in different cultures 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 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 More education needed at all levels

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

57. References Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at 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 http://www.medscape.com/viewarticle/529442 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 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 http://www.medscape.com/viewarticle/542448

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