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  • 1. Cosmetic Surgery:Cosmetic Surgery: Past, Present and FuturePast, Present and Future Martin T Donohoe, MD, FACPMartin T Donohoe, MD, FACP
  • 2. Cosmetic Surgery is a Branch ofCosmetic Surgery is a Branch of Plastic SurgeryPlastic Surgery  Plastic surgeons repair congenital malformationsPlastic surgeons repair congenital malformations (e.g., cleft lip and palate), disfiguring wounds,(e.g., cleft lip and palate), disfiguring wounds, animal bites, burn injuries, and performanimal bites, burn injuries, and perform reconstructions after surgeries for chronicreconstructions after surgeries for chronic and/or malignant conditionsand/or malignant conditions  Cosmetic surgery is largely elective and designedCosmetic surgery is largely elective and designed to augment “normal” appearanceto augment “normal” appearance
  • 3. Plastic Surgery CharitiesPlastic Surgery Charities  Operation Smile - correcting congenitalOperation Smile - correcting congenital defects in patients in the developing worlddefects in patients in the developing world  Face-to-Face: The National DomesticFace-to-Face: The National Domestic Violence Project (sponsored by the Am AcadViolence Project (sponsored by the Am Acad of Facial Plast and Reconstr Surgeons) – forof Facial Plast and Reconstr Surgeons) – for domestic violence victimsdomestic violence victims
  • 4. History of Reconstructive and CosmeticHistory of Reconstructive and Cosmetic SurgerySurgery  600 BC: Hindu surgeon reconstructs nose using a piece600 BC: Hindu surgeon reconstructs nose using a piece of cheekof cheek  By 1000 AD: rhinoplasty commonBy 1000 AD: rhinoplasty common  Due to common practice of cutting off noses and upper lipsDue to common practice of cutting off noses and upper lips of enemiesof enemies  1616thth Century: Gaspare Tagliacozzi (“the father of plasticCentury: Gaspare Tagliacozzi (“the father of plastic surgery”) reconstructs noses slashed off during duels bysurgery”) reconstructs noses slashed off during duels by transferring flaps of upper arm skintransferring flaps of upper arm skin  Also used to reconstruct “saddle nose” deformity ofAlso used to reconstruct “saddle nose” deformity of congenital syphiliscongenital syphilis
  • 5. History of Reconstructive and CosmeticHistory of Reconstructive and Cosmetic SurgerySurgery  1798: Term plastic surgery (from the Greek1798: Term plastic surgery (from the Greek "plastikos," fit for molding), coined by Pierre"plastikos," fit for molding), coined by Pierre DesaultDesault  19th century: developments in anesthesia and19th century: developments in anesthesia and antisepsis make plastic surgery safer, techniquesantisepsis make plastic surgery safer, techniques improveimprove  Skills developed during the World Wars I and IISkills developed during the World Wars I and II applied to victims of birth defects andapplied to victims of birth defects and automobile and industrial accidentsautomobile and industrial accidents
  • 6. History of Reconstructive and CosmeticHistory of Reconstructive and Cosmetic SurgerySurgery  Eugenics movement, post-WWIIEugenics movement, post-WWII prosperity, rise of movies/TV all increaseprosperity, rise of movies/TV all increase popularity of cosmetic surgerypopularity of cosmetic surgery  1923: first modern rhinoplasty1923: first modern rhinoplasty  1931: first public face lift1931: first public face lift
  • 7. History of Reconstructive andHistory of Reconstructive and Cosmetic SurgeryCosmetic Surgery  1950s: first hair transplants1950s: first hair transplants  1990s onward: more procedures carried1990s onward: more procedures carried out in doctors’ offices and free-standingout in doctors’ offices and free-standing surgical centerssurgical centers  2000s: Aesthetic medicine, medi-spas, luxury2000s: Aesthetic medicine, medi-spas, luxury clinicsclinics
  • 8. Motivations for Cosmetic SurgeryMotivations for Cosmetic Surgery  External: avoidance of ethnic prejudice; fear of ageExternal: avoidance of ethnic prejudice; fear of age discrimination; coercion by spouse/parent/bossdiscrimination; coercion by spouse/parent/boss  Internal: desire to diminish unpleasant feelingsInternal: desire to diminish unpleasant feelings like depression, shame, or social anxiety; to alter alike depression, shame, or social anxiety; to alter a specific feature they dislike; desire for a morespecific feature they dislike; desire for a more youthful, healthy look that signals fertilityyouthful, healthy look that signals fertility (women); interest in developing a strong, powerful(women); interest in developing a strong, powerful look that may facilitate career advancementlook that may facilitate career advancement
  • 9. Arguments for Cosmetic SurgeryArguments for Cosmetic Surgery  Aging as a physical illnessAging as a physical illness  Aging as a mental illnessAging as a mental illness  Substitution of happiness for health as theSubstitution of happiness for health as the goal of medical treatmentgoal of medical treatment  A business service provided to those whoA business service provided to those who desire it, can pay, and accept the risksdesire it, can pay, and accept the risks involvedinvolved
  • 10. Representations of Cosmetic Surgery inRepresentations of Cosmetic Surgery in Women’s MagazinesWomen’s Magazines  2008 study2008 study  Only 48% of articles in magazines like CosmoOnly 48% of articles in magazines like Cosmo and O, The Oprah Magazine discuss the impactand O, The Oprah Magazine discuss the impact of cosmetic surgery on emotional healthof cosmetic surgery on emotional health  Most articles link cosmetic surgery withMost articles link cosmetic surgery with enhanced emotional well-being, regardless of theenhanced emotional well-being, regardless of the patient’s pre-existing emotional healthpatient’s pre-existing emotional health
  • 11. Cosmetic SurgeryCosmetic Surgery  91% of patients women91% of patients women  84% white84% white  2/3 report family incomes2/3 report family incomes < $50,000< $50,000  More popular on West CoastMore popular on West Coast
  • 12. Cosmetic SurgeryCosmetic Surgery  34% of patients have multiple34% of patients have multiple procedures done at the same timeprocedures done at the same time  ““Drastic plastic”Drastic plastic”  40% of patients are repeat patients40% of patients are repeat patients
  • 13. Cosmetic SurgeryCosmetic Surgery  Complications rare but possibleComplications rare but possible  E.g., infections, bleeding, hyponatremia,E.g., infections, bleeding, hyponatremia, allergic reactions, anestheticallergic reactions, anesthetic complicationscomplications  Revision rates as high as 10%Revision rates as high as 10%  E.g., face lift lasts 10 yrsE.g., face lift lasts 10 yrs
  • 14. Cosmetic SurgeryCosmetic Surgery 2008 prices – Do not include anesthesia, OR facilities, other costs2008 prices – Do not include anesthesia, OR facilities, other costs  10.3 million procedures ($11.8 billion):10.3 million procedures ($11.8 billion):  2.5 million botox procedures2.5 million botox procedures  1.3 million hyaluronic acid fillers1.3 million hyaluronic acid fillers  592,000 chemical peels592,000 chemical peels  897,000 microdermabrasions897,000 microdermabrasions  906,000 laser hair removals906,000 laser hair removals  590,000 vein sclerotherapies (strippings)590,000 vein sclerotherapies (strippings)
  • 15. Cosmetic SurgeryCosmetic Surgery 2008 prices – Do not include anesthesia, OR facilities, other costs2008 prices – Do not include anesthesia, OR facilities, other costs  11.7 million procedures:11.7 million procedures:  341,000 liposuctions: $2,874341,000 liposuctions: $2,874  152,000 rhinoplasties: $4,369152,000 rhinoplasties: $4,369  356,000 breast augmentations: $3,600-$3,900356,000 breast augmentations: $3,600-$3,900  195,000 blepharoplasties (eyelid195,000 blepharoplasties (eyelid reconstructions): $2,921reconstructions): $2,921  147,000 abdominoplasties (“tummy tucks”):147,000 abdominoplasties (“tummy tucks”): $5,470$5,470  140,000 breast reductions: $5,630140,000 breast reductions: $5,630
  • 16. Cosmetic Surgery:Cosmetic Surgery: Other ProceduresOther Procedures  Face liftFace lift  Chemical peelChemical peel  Forehead liftForehead lift  Upper arm liftUpper arm lift  Buttock liftButtock lift  Thigh liftThigh lift  LiposuctionLiposuction
  • 17. Most popular procedures for menMost popular procedures for men (2008 stats)(2008 stats)  Liposuction: 31,453Liposuction: 31,453  Rhinoplasty: 30,174Rhinoplasty: 30,174  Eyelid surgery: 28,678Eyelid surgery: 28,678  Breast reduction: 19,124Breast reduction: 19,124  Hair transplantation: 18,062Hair transplantation: 18,062
  • 18. Other popular procedures for menOther popular procedures for men  Scalp reduction (for male pattern baldness)Scalp reduction (for male pattern baldness)  Cheek implantsCheek implants  Ear reshapingEar reshaping  Pectoral implantsPectoral implants  Chin augmentation (implants)Chin augmentation (implants)  Calf implantsCalf implants
  • 19. Most popular procedures for womenMost popular procedures for women (2008 stats)(2008 stats)  Breast augmentation: 355,671Breast augmentation: 355,671  Liposuction: 309,692Liposuction: 309,692  Blepharoplasty: 166,426Blepharoplasty: 166,426  Abdominoplasty: 143,005Abdominoplasty: 143,005  Breast Reduction: 139,926Breast Reduction: 139,926
  • 20. History of Breast AugmentationHistory of Breast Augmentation  With a few exceptions, large breasts inWith a few exceptions, large breasts in vogue since antiquityvogue since antiquity  Brassieres and corsets used to enhanceBrassieres and corsets used to enhance sizesize  1919thth Century: surgical breast enlargementsCentury: surgical breast enlargements attempted using ivory, glass, metal, rubber,attempted using ivory, glass, metal, rubber, and paraffinand paraffin
  • 21. History of Breast AugmentationHistory of Breast Augmentation  1895: Czerny performs first reported successful human1895: Czerny performs first reported successful human mammary reconstructionmammary reconstruction  actress who had undergone removal of a fibroadenomaactress who had undergone removal of a fibroadenoma  transplanted lipoma from her hiptransplanted lipoma from her hip  1903: Charles Miller inserts "braided silk, bits of silk1903: Charles Miller inserts "braided silk, bits of silk floss, particles of celluloid, vegetable ivory, and severalfloss, particles of celluloid, vegetable ivory, and several other foreign materials”other foreign materials”  granulomatous (foreign body) inflammatory reactionsgranulomatous (foreign body) inflammatory reactions disfiguring and painfuldisfiguring and painful
  • 22. History of Breast AugmentationHistory of Breast Augmentation  1903-1950s: petroleum jelly, beeswax,1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins used.shellac, and epoxy resins used.  Early 1950s: liquid silicon injections usedEarly 1950s: liquid silicon injections used  1962: first US woman to receive1962: first US woman to receive encapsulated silicon breast implantsencapsulated silicon breast implants
  • 23. History of Breast AugmentationHistory of Breast Augmentation  1992: FDA bans silicone breast implants except1992: FDA bans silicone breast implants except in strictly controlled trials for breast cancerin strictly controlled trials for breast cancer reconstructive surgery due to reports linking thereconstructive surgery due to reports linking the implants with a variety of connective tissueimplants with a variety of connective tissue diseases and neurological disorders.diseases and neurological disorders.  Subsequent analyses show no such linksSubsequent analyses show no such links
  • 24. History of Breast AugmentationHistory of Breast Augmentation  2005: FDA allows silicone breast implants back2005: FDA allows silicone breast implants back on market (with registry)on market (with registry)  A minimum of 15% of modern silicone implantsA minimum of 15% of modern silicone implants will rupture between the third and tenth yearwill rupture between the third and tenth year after implantationafter implantation  Today: newer generation silicone implants, salineToday: newer generation silicone implants, saline implants, dermal fillersimplants, dermal fillers
  • 25. History of Breast AugmentationHistory of Breast Augmentation  2007: Stem cells and fat derived from2007: Stem cells and fat derived from liposuction used to grow breast tissue in clinicalliposuction used to grow breast tissue in clinical trials in Europetrials in Europe  2008: Israeli surgeon develops “breast lift2008: Israeli surgeon develops “breast lift procedure” involving internal titanium bra withprocedure” involving internal titanium bra with silicone cupssilicone cups  2008: MyFreeImplants.com2008: MyFreeImplants.com  Facilitates communication and fundingFacilitates communication and funding
  • 26. Breast Implant ComplicationsBreast Implant Complications (most to least common)(most to least common)  Capsular contractureCapsular contracture  Implant ruptureImplant rupture  HematomaHematoma  Wound infectionWound infection  Breast implants decrease sensitivity of screeningBreast implants decrease sensitivity of screening mammography among asymptomatic women, butmammography among asymptomatic women, but do not increase false-positive rate nor affect tumordo not increase false-positive rate nor affect tumor prognostic characteristicsprognostic characteristics
  • 27. Breast Implant Complications Five YrsBreast Implant Complications Five Yrs After SurgeryAfter Surgery  Cosmetic implants – 12%Cosmetic implants – 12%  After prophylactic mastectomy – 30%After prophylactic mastectomy – 30%  After mastectomy for breast cancer –After mastectomy for breast cancer – 34%34%  Latest trend: microsurgical breastLatest trend: microsurgical breast reconstruction using implants orreconstruction using implants or autologous tissuesautologous tissues
  • 28. New Breasts for Graduating SeniorsNew Breasts for Graduating Seniors  11,326 procedures performed on 18-year olds in11,326 procedures performed on 18-year olds in 20032003  Phenomenon suggests poor parenting, throughPhenomenon suggests poor parenting, through the capitulation of financially well-endowedthe capitulation of financially well-endowed parents to the whims of their children, whoparents to the whims of their children, who likely have self-esteem problems and are not yetlikely have self-esteem problems and are not yet emotionally (nor perhaps even physically)emotionally (nor perhaps even physically) maturemature
  • 29. Breast Augmentation for FemalesBreast Augmentation for Females Under Age 18Under Age 18  4,108 procedures on women 18 and under4,108 procedures on women 18 and under in 2008in 2008  US and EU: breast augmentation surgeryUS and EU: breast augmentation surgery allowed on those under age 18 only forallowed on those under age 18 only for medical reasonsmedical reasons  Yet 50% of procedures done for purelyYet 50% of procedures done for purely cosmetic reasonscosmetic reasons
  • 30. Headline fromHeadline from The OnionThe Onion:: Plastic Surgeon General Warns of SmallPlastic Surgeon General Warns of Small Breasts EpidemicBreasts Epidemic
  • 31. The Adonis ComplexThe Adonis Complex  38% of men want bigger pectorals; 34% of38% of men want bigger pectorals; 34% of women want bigger breastswomen want bigger breasts  Each year, men spend over $2 billion onEach year, men spend over $2 billion on health club memberships and $2 billion forhealth club memberships and $2 billion for home exercise equipmenthome exercise equipment  Tommy John surgeryTommy John surgery  To enhance elbow strength and improveTo enhance elbow strength and improve pitching velocitypitching velocity
  • 32. Anabolic Steroid AbuseAnabolic Steroid Abuse  Supplement industry boomingSupplement industry booming  3 million American men have swallowed or3 million American men have swallowed or injected anabolic steroids since they becameinjected anabolic steroids since they became widely available in the 1960swidely available in the 1960s  2.8% of current high school males have used2.8% of current high school males have used (50% increase over last 4 years); rates among(50% increase over last 4 years); rates among girls may be even highergirls may be even higher  Use associated with violent behaviorUse associated with violent behavior
  • 33. Penile Size and Penile ReconstructivePenile Size and Penile Reconstructive SurgerySurgery  Ancient Greeks believed small penis wasAncient Greeks believed small penis was superiorsuperior  Later, phallic identity and phallocentrismLater, phallic identity and phallocentrism increasingly popular – “penis is central to man’sincreasingly popular – “penis is central to man’s identity, virility”identity, virility”  No correlation between shoe size and penileNo correlation between shoe size and penile lengthlength
  • 34. Penile Size and PenilePenile Size and Penile Reconstructive SurgeryReconstructive Surgery  1971: First penile augmentation surgery1971: First penile augmentation surgery  Girth enhancements with fat injections,Girth enhancements with fat injections, Alloderm (derived from human skin)Alloderm (derived from human skin)  Penile lengthening proceduresPenile lengthening procedures  Complications: scar, keloid, penile lumps, sexualComplications: scar, keloid, penile lumps, sexual dysfunction, further penile shorteningdysfunction, further penile shortening  Augmentation procedures not sanctioned byAugmentation procedures not sanctioned by American Urological AssociationAmerican Urological Association
  • 35. Cosmetic Surgery Odds and EndsCosmetic Surgery Odds and Ends  Most common cosmetic procedure in Asia =Most common cosmetic procedure in Asia = eyelid surgery, to create a crease above the eyeeyelid surgery, to create a crease above the eye (up to 60% of Korean women)(up to 60% of Korean women)  City in America with the most plastic surgeonsCity in America with the most plastic surgeons per capita = San Franciscoper capita = San Francisco  Country with the most cosmetic sugeryCountry with the most cosmetic sugery operations per capita = Braziloperations per capita = Brazil
  • 36. Reconstructive Surgery – The LatestReconstructive Surgery – The Latest  Hand transplantsHand transplants  Face transplantsFace transplants  2005: first procedure on female dog-mauling2005: first procedure on female dog-mauling victimvictim  15 hour procedure (including 5 hours for15 hour procedure (including 5 hours for harvest); involves multidisciplinary teamharvest); involves multidisciplinary team  Ethical issuesEthical issues  Lifelong immunosuppression requiredLifelong immunosuppression required
  • 37. Cosmetic NeurologyCosmetic Neurology  Interventions to enhance the cognitive andInterventions to enhance the cognitive and emotional brain functions of theemotional brain functions of the neurologically non-diseasedneurologically non-diseased  Currently being pursued by theCurrently being pursued by the pharmaceutical industry (via drugs topharmaceutical industry (via drugs to increase intelligence) and the military (viaincrease intelligence) and the military (via interventions to create more effectiveinterventions to create more effective soldiers)soldiers)
  • 38. Cosmetic Military NeurologyCosmetic Military Neurology  ““Go-go pills" (amphetamines) used by USGo-go pills" (amphetamines) used by US soldiers in WW IIsoldiers in WW II  Modafinil (wakefulness-promoting agent)Modafinil (wakefulness-promoting agent) improves pilot alertness and performance inimproves pilot alertness and performance in helicopter flight simulations.helicopter flight simulations.  Many military pilots today rely on caffeine andMany military pilots today rely on caffeine and other stimulants, including amphetamines, toother stimulants, including amphetamines, to complete missionscomplete missions
  • 39. Cosmetic NeurologyCosmetic Neurology  Raises concerns about:Raises concerns about: Distributive justiceDistributive justice Informed consentInformed consent In the military setting or inIn the military setting or in childrenchildren
  • 40. Cosmetic Surgery – The FringesCosmetic Surgery – The Fringes  The Jewel Eye: implantation of tinyThe Jewel Eye: implantation of tiny platinum jewels into conjunctiva (20platinum jewels into conjunctiva (20 minutes, $3900)minutes, $3900)  Am Acad Ophth warns not proven safeAm Acad Ophth warns not proven safe  Umbilicoplasty, lengthening/shorteningUmbilicoplasty, lengthening/shortening toes to improve “toe cleavage,” fracturingtoes to improve “toe cleavage,” fracturing and resetting jaw to alter smile, foreheadand resetting jaw to alter smile, forehead implantsimplants
  • 41. Cosmetic Surgery – The FringesCosmetic Surgery – The Fringes  Genitalia redesign: foreskin restoration,Genitalia redesign: foreskin restoration, mechanical and cosmetic phalloplasty,mechanical and cosmetic phalloplasty, vaginal tightening/alteration ofvaginal tightening/alteration of angle/dimensions, partial labial excisions,angle/dimensions, partial labial excisions, fat injection into labiafat injection into labia  4500 procedures in 20074500 procedures in 2007  ACOG: “safety and effectiveness have not beenACOG: “safety and effectiveness have not been documented”documented”
  • 42. Cosmetic Surgery – The FringesCosmetic Surgery – The Fringes  The Jade Lady Membrane Man-Made HymenThe Jade Lady Membrane Man-Made Hymen  Marketed in ChinaMarketed in China  Blood-colored fluid released during sexBlood-colored fluid released during sex  Furries: lovers of anthropomorphized animalsFurries: lovers of anthropomorphized animals  Surgical enhancementsSurgical enhancements  ConventionsConventions
  • 43. Cosmetic Surgery – The FringesCosmetic Surgery – The Fringes  Deliberate amputations of body partsDeliberate amputations of body parts  Apotemnophilia – attraction to the idea ofApotemnophilia – attraction to the idea of being an amputee (a paraphilia)being an amputee (a paraphilia)  Not to be confused with acrotomophiliacs –Not to be confused with acrotomophiliacs – sexually attracted to amputeessexually attracted to amputees  Wings, chimeras, and stem-cell cosmesisWings, chimeras, and stem-cell cosmesis
  • 44. Cosmetic Surgery – The FringesCosmetic Surgery – The Fringes  Sarah Burge (born 1959) holds world plasticSarah Burge (born 1959) holds world plastic surgery record:surgery record:  Over 100 proceduresOver 100 procedures  Cost = $850,000Cost = $850,000  Celebrity plastic surgery:Celebrity plastic surgery:  Michael Jackson, Pamela Lee, Meg Ryan, CherMichael Jackson, Pamela Lee, Meg Ryan, Cher (?), many others(?), many others
  • 45. Prime Time Cosmetic SurgeryPrime 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”
  • 46. PetsPets  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 2008Over 250,000 sold through mid 2008  No FDA-approved artificial testes forNo FDA-approved artificial testes for humans, so cancer victims buy and havehumans, so cancer victims buy and have plastic surgeon installplastic surgeon install
  • 47. PetsPets  We value our pets, but…We value our pets, but…  In 2008, almost 1200 people purchasedIn 2008, almost 1200 people purchased stem cell surgery for their dogsstem cell surgery for their dogs  Pet cloningPet cloning  Pet jewelryPet jewelry  Over $3 billion pet pharmaceuticalOver $3 billion pet pharmaceutical marketmarket
  • 48. ConclusionsConclusions  Body modification common today andBody modification common today and throughout historythroughout history  Risks involvedRisks involved  Obesity a major public health problemObesity a major public health problem  The body modification and weight lossThe body modification and weight loss industries marred by hucksterism, falseindustries marred by hucksterism, false claims and conflicts of interestclaims and conflicts of interest
  • 49. ConclusionsConclusions  Beauty has different definitions in differentBeauty has different definitions in different times and in different culturestimes and in different cultures  The health professions can play aThe health professions can play a constructive role in supporting safe andconstructive role in supporting safe and healthy behaviors and promoting realistichealthy behaviors and promoting realistic ideals of beautyideals of beauty  More education needed at all levelsMore education needed at all levels
  • 50. Covered in Other Slide ShowsCovered in Other Slide Shows  Ideals of beauty and body modificationIdeals of beauty and body modification  Female genital cuttingFemale genital cutting  Body weight and the obesity epidemicBody weight and the obesity epidemic  Ethical and policy issuesEthical and policy issues
  • 51. ReferencesReferences  Donohoe MT. Beauty and body modification.Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s HealthMedscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at2006;11(1): posted 4/19/06. Available at  http://www.medscape.com/viewarticle/529442http://www.medscape.com/viewarticle/529442  Donohoe MT. Cosmetic surgery past, present,Donohoe MT. Cosmetic surgery past, present, and future: scope, ethics and policy. Medscapeand future: scope, ethics and policy. Medscape Ob/Gyn and Women’s Health 2006;11(2):Ob/Gyn and Women’s Health 2006;11(2): posted 8/28/06. Available atposted 8/28/06. Available at http://www.medscape.com/viewarticle/542448http://www.medscape.com/viewarticle/542448
  • 52. Contact InformationContact Information Public Health and Social Justice WebsitePublic Health and Social Justice Website http://www.phsj.orghttp://www.phsj.org martindonohoe@phsj.orgmartindonohoe@phsj.org