‘Quackery was outlawed in medicine over a century ago, but it is in danger of returning in the cosmetic surgery industry.’
Of all the global beauty industry trends, the rise and acceptance of aesthetic surgery treatments – as well as interventions like Botox and dermal fillers – is the most remarkable. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) said it had noted a 437 per cent increase in the number of procedures over the previous decade, with annual spend reaching US$13.2 billion.
A couple of years later, the same organization reported that a tough economic climate had hardly affected the trend at all. Its survey showed that 51 per cent of all Americans, regardless of income, approved of cosmetic surgery. Gender-wise, 53 per cent of women and 49 per cent of men said they would consider a procedure; 67 per cent of Americans said they would not be embarrassed if their friends learned they’d been under the knife. Alarmingly, the youngest age group, 18- to 24-year-olds, were the most likely to consider aesthetic surgery for themselves, now or in the future.
In Europe the situation is similar, with the British Association of Aesthetic Plastic Surgeons noting annual increases of more than 5 per cent, to around 40,000 procedures a year. In France, a magazine called Perfect Beauty, devoted to cosmetic surgery and other medical makeover options, hit newsstands at the beginning of 2011. It is distributed through kiosks, cosmetic surgery clinics, beauty salons and luxury hotels, as well as the Eurostar and Thalys high-speed train services. Along with surgery, it covers anti-ageing products, dieting, skincare, fitness and spas. ‘Today, cosmetic surgery is no longer taboo or just the domain of celebrities,’ commented editor Brigitte Dubus.
In Italy, the venerable cosmetics brand Santa Maria Novella (or to give it its full name, Officina Profumo – Farmaceutica di Santa Maria Novella, founded in Florence in 1612) sells a Plastic Surgery Support skincare line. For example, the Face Recovery Kit contains ‘products to reduce the initial consequences and discomforts following cosmetic procedures like face lift and eyelid surgery’. It includes Face Calming Water to reduce puffiness, as well as Papaya Gel, owing to its ‘excellent antioxidant properties’, and an aloe cream that ‘acts on skin texture leaving it softer and smoother’. The kit also includes ‘balsa cream which helps improve scar appearance and quality’. It’s a brilliant marketing idea that says a lot about the brand’s target demographic, as well as its struggle to conquer the US market.
In other parts of the world, as we’ve seen in Chapter 12, aesthetic surgery is flourishing as young women struggle to conform to globalized ‘norms’ of beauty. The internet and the falling cost of international travel have also led to ‘cosmetic surgery tourism’, says the ASAPS. ‘Popular destinations include Argentina, Brazil, Costa Rica, Dominican Republic, Malaysia, Mexico, Philippines, Poland, South Africa, and Thailand. These destinations offer everything from “safari and surgery” to “tropical, scenic tour” vacation packages.’
Wendy Lewis, the author in 2007 of a book called Plastic Makes Perfect, has pointed to a shrinking tolerance for imperfections as ‘advancements in cosmetic treatments offer promises of beautification and age reversal’ (‘Aesthetic surgery update’, WGSN.com, 3 December 2008). Once again, her words raise the spectre of a two-tier society based on those who elect – or can afford – to pay for a procedure or not.
With aesthetic surgery becoming more mainstream, I wanted to find out how well the industry was regulated. How could customers be certain that a cosmetic surgeon was a respected professional and not a charlatan with a scalpel? I put the question to Nigel Mercer, president of the British Association of Aesthetic Plastic Surgeons (BAAPS).
‘On an international level the industry is largely self-regulating, with associations like our own setting standards,’ he replies. ‘We’re currently pressing for common European standards. Of course standards are not laws, and the legal situation varies broadly. France has strict laws; Belgium has no laws at all. In the UK we police our membership: we monitor what they’re doing, how they’re doing it and complication rates.’
Mercer admits that many aesthetic surgeons operate outside the regulatory framework. Others agree. An article in the British Medical Journal explains bluntly: ‘Any General Medical Council registered doctor can practise as a “cosmetic surgeon” in the United Kingdom’ (‘The hard sell in cosmetic advertising’, 16 March 2010).
Mercer says, ‘A combination of media coverage driving increased customer demand on the one hand and greed on the other has created a potentially disastrous situation.’
He advises those considering a procedure to liaise first with their doctor, who should be able to refer them to a named surgeon. (Occasionally general practitioners refuse to recommend cosmetic surgery, forcing the patient to short-circuit the process and go directly to a clinic. Mercer warns that, if patients go to a clinic, no matter how good, they will be operated on by the doctor who has the first slot available, not the best one for their problem.) Never rely on reports in the media or, especially, advertisements. In fact, the BAAPS has called for an outright ban on advertising – a situation that already exists in France.
A casual scan of the inside back packages of the British editions of Elle and Vogue reveals a rash of ads for breast reduction and enhancement, ‘fat removal’ and ‘body contouring’, somewhat lowering the tone but perfectly in context with publications that weave a fantasy of glamour and physical perfection.
Advertising by cosmetic surgeons in the UK is regulated by codes of practice established by bodies such the General Medical Council and the Advertising Standards Authority – the advertising industry’s own self-regulatory organization. As the British Medical Journal puts it: ‘UK and European law, professional rules, and government monitors… which oversee the advertising of prescription drugs, make few specific references to cosmetic surgery… Because cosmetic surgery clinics are not aimed at treating disease, their advertising is exempt, and regulation falls almost entirely with the advertising industry itself.’
Mercer says: ‘The GMC states that doctors cannot ‘advertise’ and that any entry, on a website or telephone directory, for example, must be factual only. The ASA states that any advert must be ‘legal, decent, honest and socially responsible’. But even in markets like France, where advertising is banned, online advertising is extremely hard to regulate. And online is where most advertising is done these days.’
Regulation of Botox injections and similar treatments is also lax in Europe. As you may know, Botox derives from botulinum toxin, one of the most powerful neurotoxins on the planet, which paralyses muscle nerve endings. In the 1970s scientists discovered that botulinum toxin type A could be used in small doses to treat crossed eyes and muscle spasms. Its smoothing effect on wrinkles was first documented in 1989. In 2002 the FDA announced regulatory approval of botulinum toxin type A – marketed under the name Botox Cosmetic – to treat frown lines. Widespread publicity about the use of the treatment by celebrities – with pictures of the smooth-browed stars accompanied by hypocritically disapproving headlines – attracted the attention of the public. In 2009 there were 5 million procedures in the United States alone.
In the UK, high street chemist Boots began offering Botox injections for £200 as early as 2002. It has since stepped back from this and other beauty treatments to return to its roots as a retailer. But the press coverage that accompanied the move reinforced the idea that Botox was almost as problemfree as an anti-ageing cream. In fact, the Botox Cosmetic website clearly states that it ‘may cause serious side effects that can be life threatening’. These include ‘problems swallowing, speaking, or breathing, due to weakening of associated muscles’ and a ‘spread of toxin effects’ resulting in ‘loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice (dysphonia), trouble saying words clearly (dysarthria), loss of bladder control, trouble breathing, trouble swallowing’ (www.botoxcosmetic.com).
Frankly, it sounds as though ingesting gold might be safer.
Tales of botched interventions involving the injection of fillers surface regularly. Nigel Mercer has written scathingly about regulation in the medical journal Clinical Risk (2009):
In the USA, there are only a handful of ﬁllers with FDA approval… whereas in the UK there are over 100 on the market. Why the difference? In the USA, the products undergo testing as a ‘drug’, but in the UK they are tested as a ‘device’ and so only have to pass ‘CE’ mark [it stands for Conformité Européenne or European Conformity] requirements, which relate to standards of production, not of efficacy. Drug testing is lengthy and expensive but CE marking is not.
Mercer calls on the European Community to adopt FDA-like testing. He adds: ‘Permanent and semi-permanent ﬁllers all come with a greater incidence of complications, which may not be correctable… Quackery was outlawed in medicine over a century ago, but it is in danger of returning in the cosmetic surgery industry.’
There is little doubt that the fashion press is largely behind the normalization of aesthetic surgery. Opening a copy of a magazine recently, I happened on an article about ‘an anti-aging oracle’ who had started out as a cardiologist before she was encouraged by a friend to give cosmetic dermatology ‘a go’. She added that she ‘just taught myself, really’. The whole thing looked to me like a huge flashing warning light, but the doctor’s customers clearly have confidence in her, so much so that she now has a second house in the country and an impressive wardrobe of designer clothing.
Nigel Mercer confirms that aesthetic surgery has become more acceptable. ‘People are more open in talking about it, particularly in the affluent section of society.’ As for the types of procedures that are being undertaken, they have evolved very little over the past few years: nasal surgery, breast reduction, liposuction and tummy tucks are all high on the list. An increased use of Caesarean sections has led to a demand from women who wish to correct scarring.
‘Facelifts are in decline,’ Mercer adds. ‘Botox has almost replaced brow lifting.’ He’s also noticed a slight increase in male patients, who opt for eye pouch removal, liposuction and the removal of pectoral fat. When I ask him about procedures worldwide, he answers, ‘It’s a globalized market. There’s pretty much an international standard of beauty.’
What’s the Holy Grail of cosmetic surgery? I imagine that it’s gaining height, but apparently this is quite easily achievable – if painful and expensive. The treatment is growing in popularity in China, where the tall are seen as socially advantaged. Orthopaedic surgeons saw through the tibia and the fibula below the knee, without touching the bone marrow. Heavy metal braces are screwed into the patient’s legs. Every day for four months, these are expanded to slowly stretch the leg. The bones regenerate to fill the gap. The tendons and arteries magically stretch too. Four months of this torture gets you two to three inches.
‘Actually, it’s fine lines around the mouth.’ says Mercer. What? ‘The Holy Grail of aesthetic surgery is improving the lines around the mouth,’ he repeats. ‘It’s because they’re so tiny. Lasers and chemical peel don’t work very well. That’s something I’d like to see improved upon.’
The phenomenon is quite common among smokers – another good reason to give up, because, even if you survive your habit, cosmetic surgery may not be able to fix your looks.