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cmf file 52 (2013) - cosmetic surgery

Society appears to agree with the Ben Sherman advert, 'Looking good isn't important, it's everything'. A person's value is often seen as being dependent on looks, ability, income, and image. (1) If uncertain what 'looking good' is about, we look at the faces and bodies that fill the screens and magazines. These show that young, slim and beautiful is the order of the day for women, while a lithe, wellmuscled and toned Adonis is the ideal male. (2) For those struggling to achieve the perfect face and body, adverts for breast augmentation, Botox, hair transplants and buttock implants indicate 'cosmetic surgery is here to help'.

Cosmetic surgery is big business

The saying goes that no one ever lost money by over estimating women's vanity. The same could probably be said of men. In 2011, the UK cosmetics product industry was valued at £8.3 billion. (3) Cosmetic interventions are also a booming business, worth £2.3 billion in 2010, with an estimated worth of £3.6 billion by 2015. (4) Non-surgical interventions, for example dermal fillers, Botox and lasers, 'which can have major and irreversible adverse impacts on health and wellbeing', (5) account for 90% of procedures. (6)

Is there a problem?

According to the UK paper Metro, 30% of people feel most judged by body shape, 22% by dress sense and 21% by clothing brands. (7) The comic Francesca Martinez's five step advice on how to appear normal in today's society includes 'be dissatisfied with your body'. (8) Eating disorders are an ongoing problem, impacting on individuals and occupational groups, for example modelling, horse racing and now Formula One. (9) Maybe this helps us understand the rather chilling 2012 data from the Girl Guide Association about how unhappy girls are with their appearance. (10) It may also shed some insights into steroid abuse and 'bigorexia' – muscle dysmorphia – in men.

While many may seek cosmetic surgery as a technological way of achieving wellbeing, for others it is about addressing unhappiness, and creating and maintaining appearance. For others still, it is about the retention of youth. If, in addition, adverts for cosmetic surgery increase dissatisfaction with appearance, (11) it follows how this, along with idealised views of what is normal and a consumer culture, can all combine to prey on vulnerable people.

Slippery terminology

Terms like plastic surgery, cosmetic surgery, and aesthetic surgery are often used interchangeably.

Plastic surgery, however, typically describes therapeutic procedures ranging from those used to cope with life threatening emergencies to the removal of skin cancers in a way that minimises disfigurement. It is also used to describe restorative surgery, for example after mastectomy.

Cosmetic surgery is defined in varied ways. (12) The British Association of Aesthetic Plastic Surgeons (13) (BAAPS) uses the word aesthetic to describe cosmetic procedures done by plastic surgeons, whereas the Royal College of Surgeons (14) uses the terms cosmetic practice and cosmetic surgery, these being most commonly used and understood by patients.

Perhaps the most helpful definition is found in Good Medical Practice in Cosmetic Surgery / Procedures: (15)

Cosmetic Surgery comprises operations or other procedures that revise or change the appearance, colour, texture, structure or position of bodily features to achieve what patients perceive to be more desirable.

The aim of any cosmetic surgical intervention is important to identify. It may be therapeutic, restorative or enhancing. A therapy is a 'treatment intended to relieve or heal a disorder', (16) for example the removal of a facial skin cancer. Restoration is about returning something to its original condition, (17) for example using certain techniques to remove a cancer but retain appearance. Enhancement is about further improvement, (18) becoming better than well. In cosmetic surgery, therapy and restoration effectively enable the patient to remain within or move toward the norm of the population of which they are a part. Restoration does not, therefore, include anti-aging procedures, which are about moving towards the norm of a different – often younger – population, which can be seen as enhancement.

This File assumes a holistic bio-psychosocio- spiritual view of the person. It will not cover surgical procedures indirectly aiming to retain or alter appearance, for example, gastric banding to aid weight loss or termination of pregnancy to prevent alteration of body shape.

What is normal?

Concern about appearance is not new. Make up, clothing, footwear, tattooing and many other permanent and non-permanent interventions have been used for millennia to change and 'enhance' appearance. Sushruta (600 BC), one of the earliest recorded surgeons, known by many as the 'Father of plastic surgery', (19) is believed to have been the first person to describe rhinoplasty for cosmetic reasons. (20)

Yet many seeking cosmetic surgery are not seeking enhancement, but instead wish to appear more 'normal'. In any population, there will be those at the extremes of the normal distribution curve, whether in height, nose size or breast size. It is not unusual for plastic surgeons to meet patients with physical features at these extremes of normal, who feel self-conscious about their appearance. Whereas technology to address this concern used to be limited, the improvements which now enable restoration of normal function with less associated risk in other clinical areas, for example knee and hip replacements, can also enable those at the extremes of the normal distribution curve in appearance become 'more normal'.

Holistic health and wellbeing

While papers may tell of a 'Cosmetic patient's suicide after surgery “hell”', (21) many GPs and plastic surgeons can relate other stories of patients adversely impacted in social, physical and psychological ways by an aspect of their appearance. For some this can result in mood disorders and suicidal ideation, for others it can result in social pain or isolation, being subject to bullying and ridicule. While breast augmentation has been associated with an increased suicide risk, (22) lack of access to surgery can also have a similar impact. Kerrie Jewel, (23) who felt suicidal as a result of her 40HH breast size, had been asking unsuccessfully for a NHS breast reduction for 25 years: 'I don't want to look like a top model. I only want to be like normal people and not get teased.' In a similar way, the development of breast tissue in men can have adverse social and psychological impact, (24) as can prominent ears in children. (25)

The broader context

All of these stories are set in a broader context. While many UK plastic surgeons and GPs performed cosmetic procedures for many years on the NHS, from the removal of an unsightly mole to more major operations, most healthcare commissioners no longer approve referrals for cosmetic surgery. As a result, much of the booming industry in aesthetic surgery resides in the domain of private health care where an increasing number of NHS practitioners, both in primary and secondary care, are now providing private cosmetic procedures, tacitly affirming that such access is needed.

However, the private cosmetic sector is poorly regulated and comprehensive outcome data is hard to find. Not all procedures are provided by registered doctors who are bound by their codes of practice and whose performance is reviewed annually in appraisal. Procedures are also provided by many other, often unregistered, practitioners from varied backgrounds. It appears to some that much cosmetic surgery is more financially, than therapeutically, motivated, aiming to maximise profit in a consumer market. Yet when things do go wrong in the UK it is often the NHS that has to deal with adverse outcomes and pick up the costs. (26)

In the context of this paper, the words of the cosmetic surgeon Atiyeh et al help crystallise the dilemma:

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the healthcare system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? (27)

Cosmetic surgery: is it safe?

The regulation and safety of cosmetic surgery appears to be a big concern. On the face of it, a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), highlighted several patient safety concerns. (28) They also noted that while a number of patients were likely to have unrealistic expectations of cosmetic surgery and deep-seated problems, in only 4% of sites was it normal practice for a patient to see a Clinical Psychologist. (29)

The Expert Group on the Regulation of Cosmetic Surgery: Report to the Chief Medical Officer, (30) noting unacceptable methods of advertising, made 20 recommendations and concluded that, 'Although there is no one authoritative source of evidence to show that significant harm is caused to patients by cosmetic surgery, evidence from numerous bodies, as related in this report, suggests that there are grounds for concern.'

The 2013 Department of Health review suggested that 'a person having a non-surgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush'. (31) Bruce Keogh, in the final part of the foreword to this report, urges 'the Government, regulators, provider organisations and professionals ... to make sure that individuals' health and safety is prioritised ahead of commercial interest'. (32)

Professional values and codes of practice

Most healthcare professionals are bound by codes of practice. Such codes go back millennia, from the Code of Hammurabi and the Hippocratic Oath to key documents relating to cosmetic surgery which include the Independent Health Advisory Service Good Medical Practice in Cosmetic Procedures (33) and Professional Standards for Cosmetic Practice. (34) The latter document, published in 2013, summarised cosmetic practice guidance for three professional groups: nurses, dentists and surgeons:

Practitioners should adhere to the process of patient care outlined in this document, which highlights the importance of preparing the patient before the procedure, ensuring that [the] patient has a full understanding of the risks involved in the procedure, consideration of the need for a psychological assessment and the pre- and post-operative requirements of the procedure.

Noting the increasing number of requests for genital surgery in under-18s, it advises that high levels of anxiety, if appearances are within normal limits, should trigger psychological referral.


    Imagine the following requests by a competent 35-year-old female:
  • Breast augmentation for non-existent breasts
  • Female circumcision (35)
  • Labial reduction
  • Vulval rejuvenation
  • Removal of a benign prominent facial lesion
    Imagine the following requests by a competent 35-year-old male:
  • Hair transplant
  • Removal of breast tissues
  • Rhinoplasty
  • Rejuvenating eye lid surgery
    Imagine the following requests by parents for their children:
  • Surgery for an 8-year-old with prominent ears
  • Ear piercing for an 8-year-old
  • Circumcision for a female child
  • Circumcision for a male child
  • Removal of a prominent facial lesion
  • Orthodontic treatment for cosmetic reasons
  • 16-year-old with 36C breast size wishing breast augmentation
  • 16-year-old with 36HH breast size wishing breast reduction

Cosmetic surgery: an ethical issue

Cosmetic surgery is a complex ethical area (See Table 1). With the spectrum of requests, how is it possible to decide what is ethically justifiable?

Papers have sought to address this issue, (36) (37) but perhaps one of the most helpful publications is the Nuffield Council on Bioethics' Forward Look Background Paper produced by Donna Dickenson. (38) She highlights that what from one perspective can be seen as enhancing freedom of choice to be able to alter one's body as one pleases, can, from another perspective, be seen as 'loading new pressure on women and girls (who constitute over 90% of patients) to conform to increasingly stringent and abnormal expectations of what the female body should look like'. (39)

Implicit in this are feminist arguments against cosmetic surgery. Quoting from an NSPCC qualitative study on sexting, Dickenson gives one girl's comment on the message sent by the prevalence of pornography: 'Your body should be like hers for him'. (40) The ethical areas she then explores are consent, choice and patient autonomy, the duties of a doctor and the goal of medicine. She also quotes Urban Wiesing, crystallising the key question about cosmetic surgery from the doctor's perspective: 'It should not be asked whether a patient should have an aesthetic operation or not, but whether physicians should perform it.' (41)

Accepting that consent, choice and patient autonomy are key elements of medical practice, (42) (43) (44) and that medical practice seeks to minimise harm, the ethical question remains: on what basis can it be decided whether an aesthetic procedure is ethically justifiable, and should be offered or expected as a therapeutic option? I would like to suggest that weighing the three different parts in the following approach can generally help guide both patient and clinician, whatever their worldview.

Part 1: Where does the 'concern' lie on the normal distribution curve? Those with an appearance further from the norm would be deemed more suitable than those closer to the norm.

Part 2: What is the impact of the 'concern' on the health and wellbeing of the individual: physical, social, psychological and spiritual? Those more severely affected, following detailed assessment of the impact and failure to adequately improve wellbeing using other methods, for example psychological interventions, would be deemed more in need of a surgical intervention than those with minimal impact on wellbeing.

Part 3: How safe and effective is the procedure? The safer and more effective a procedure, the more likely it is to be ethically justified.

Using this approach, ethical justification for a therapeutic or restorative surgical intervention for people at the extremes of the height distribution curve is less likely due to the risks and poor effectiveness of surgery. Ethical justification for surgical intervention would be more likely for someone with a 40HH breast size, who is experiencing unresolvable social, psychological and physical pain. Ethical justification is less likely for offering rejuvenating or genital surgery for someone near the norm for their age group.

While this framework will aid clinical decision-making and inform patient expectation in the area of cosmetic surgery, it does not deal with the heart of the problem alluded to earlier – the distorted view of beauty, and the concern that much cosmetic surgery is unregulated, financially motivated, and preys on vulnerable people.

Beauty in the Bible

The saying goes 'Beauty is in the eye of the beholder'. Christians gaze on the beauty of the Lord (45) – and many would say that their most powerful experience of beauty is in God himself and in his nature. Most would consider that God 'delights in those who fear him, who put their hope in his unfailing love'. (46)

The Bible has many references to beauty. There are beautiful women: Abigail, (47) Bathsheba, (48) Tamar, (49) Abishag, (50) Esther. (51) There are beautiful places (52) (53) and actions. (54) God is seen to have 'made everything beautiful in its time.' (55) The Bible says that when God made Adam and Eve and completed his work of creation, it was 'very good'. (56) The Bible also tells of future times when 'The LORD their God will save his people on that day as a shepherd saves his flock. They will sparkle in his land like jewels in a crown. How attractive and beautiful they will be.' (57) The God of the Bible is seen to have created a beautiful world and created humans as part of that beautiful world, with the capacity to enjoy that beauty in what is seen, heard and experienced – for example in art, in music, and in other people. Christians are encouraged to take time to appreciate and make the best of what God has given them, whether in caring for gardens, homes, or in clothing. However, the writer of the book of Proverbs reminds the reader that 'Charm is deceptive, and beauty is fleeting; but a woman who fears the LORD is to be praised'. (58) The prophet Isaiah, writing about Jesus some 700 years before his birth, indicated that Jesus 'had no beauty or majesty to attract us to him, nothing in his appearance that we should desire him'. (59)

For Christians, beauty is not skin deep. It is about the whole person: heart, soul, mind and strength. It is witnessed to in the life and character of the Christian, described in Paul's letter to the Galatians as the fruit of the Spirit: 'Love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness and self-control.' (60)

A perfect world

Christians believe that in creation, God made a perfect world without sin, sickness and death, but through sin that perfect world became tainted. In Romans the apostle Paul explains that, 'The wages of sin is death'. (61) He continues, 'but the gift of God is eternal life through Jesus Christ our Lord'. Christians therefore believe that through the death of Jesus on the cross, the wages of sin have been paid. Through the resurrection of Jesus the tainted and fallen world is in the process of being restored, with the future promise of a new heaven and earth, with no more death, crying, tears or pain – where all things will be made new. (62)

Thus, while Christians believe God is at work in the world, and in the lives of Christians, transforming and restoring, enabling them to become more like Jesus, sickness, ageing, death and decay are still part of our lived experience. Thus Christians seeking to follow Jesus' footsteps strive to bring healing and release, and to promote holistic wellbeing (63) – life in all its fullness. (64)

The image of God

The emphasis of the Bible is that all human beings are made in the image of God. It is not about how people look but who they are in God – created and loved, with the hope of being transformed into the likeness of Christ. 'Knowing who we are and who we are intended to be helps us to resist the cultural pressures to find our deepest identity in the images and ideals of perfection that we see all around us.' (65)

Christians, considering their own approach to cosmetic surgery, may find themselves agreeing with Richard Poupard, who warns that 'we should be discerning regarding our motivations for pursuing cosmetic plastic surgery... we should be careful if our motivations for surgery are principally to increase our self-esteem.' (66) They may also find it useful to reflect on the motivation underpinning the desire or need for cosmetic surgery. Is the motivation to promote Christ-likeness? Is it to enable the best use of the gifts they have been given? Or is it about seeking identity or security in our own image?

This does not mean that Christians are opposed to cosmetic surgery. Indeed, as in the ethical framework described earlier, the Christian seeking to promote healing, health and wellbeing would probably be happy with most therapeutic and restorative interventions. They may find themselves advocating for those denied much-needed cosmetic surgery. They may also work to encourage the development of national and international standards in this whole area, looking also to see how similar approaches can be applied to other interventions, for example orthodontics.

For most, the world's concept of beauty is unattainable. Even the most highly paid models have their 'imperfections' airbrushed out. Yet 1 Peter 3:3 tells us that in God's eyes, 'Your beauty should not come from outward adornment, such as elaborate hairstyles and the wearing of gold jewellery or fine clothes. Rather, it should be that of your inner self, the unfading beauty of a gentle and quiet spirit, which is of great worth in God's sight.' While man may look at outward appearance, God looks at the heart.(67)

Rhona Knight is an academic GP in Leicestershire.

Unless otherwise stated, Scripture quotations taken from The Holy Bible, New International Version Anglicised Copyright © 1979, 1984, 2011 Biblica. Used by permission of Hodder & Stoughton Publishers, an Hachette UK company. All rights reserved. “NIV” is a registered trademark of Biblica. UK trademark number 1448790.

  1. Orbach S. Bodies. London: Profile Books, 2010
  2. Pope HG, Phillips KA, Olivardia R. The Adonis complex: how to identify, treat and prevent body obsession in men and boys. New York: Touchstone, 2002
  3. Cosmetics, Toiletry and Perfume Association. Key Facts about the Cosmetics Industry.
  4. Department of Health. Review of the Regulation of Cosmetic Interventions: Final Report. April 2013.
  5. Ibid:5
  6. Ibid.
  7. Metro, 7 October 2013:12
  8. Francesca Martinez's five-step guide to being 'normal'. Time Out
  9. Formula one: a new era of eating disorders. The Week 12 October 2013
  10. Girlguiding UK. Girls' attitudes survey 2012.
  11. Fatah F. Should all advertising of cosmetic surgery be banned? Yes. BMJ 2012;345.
  12. The Royal College of Surgeons of England. Professional Standards for Cosmetic Practice. 2013:7.
  14. The Royal College of Surgeons of England. Professional Standards for Cosmetic Practice. 2013:6.
  15. Independent Healthcare Advisory Services. Good Medical Practice in Cosmetic Surgery / Procedures. May 2006. This document supplements the GMC's Good Medical Practice and the Royal College of Surgeon's Good Surgical Practice.
  19. Bhattacharya S. Sushrutha - our proud heritage. Indian J Plast Surg 2009;42:223–225 1.
  20. Saraf S. Sushruta: rhinoplasty in 600 BC. The Internet Journal of Plastic Surgery 2006;3.
  21. Metro, 26 September 2013:29
  22. Sarwer DB, Brown GK, Evans DL. Cosmetic Breast Augmentation and Suicide. Am J Psychiatry 2007;164:1006-1013
  23. The Northern Echo, 7 September 2011
  24. 'Moob' operations double in five years as men turn to surgery to get rid of male breasts. Daily Mail, 7 January 2013
  26. NHS. PIP breast implants - latest from the NHS. 18 June 2012
  27. Atiyeh BS, Rubeiz MT, Hayek SN. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg 2008;32:829-39; discussion 840-1.
  28. NCEPOD. On the face of it. A review of the organisational structures surrounding the practice of cosmetic surgery. September 2010:4
  29. Ibid:7
  30. Expert Group on the Regulation of Cosmetic Surgery. Report to the Chief Medical Officer. Department of Health, January 2005:20
  31. Department of Health. April 2013:5
  32. Ibid:6
  33. Independent Healthcare Advisory Services. Op Cit
  34. The Royal College of Surgeons of England. Op Cit
  35. African Doctor: 'Is female circumcision so awful?' Jezebel, 30 November 2007
  36. Mousavi SR. The Ethics of Aesthetic Surgery. J Cutan Aesthet Surg 2012;3(1):38-40 1.
  37. Atiyeh et al. Op Cit
  38. Dickenson D. Aesthetic/Cosmetic Procedures Background Paper. May 2013
  39. Dickenson D. Op Cit:5
  40. Ringrosse J, Gill R, Livingstone S and Harvey L. A qualitative study of children, young people and 'sexting'. London: NSPCC, 2012:40
  41. Wiesing U. Ethical aspects of aesthetic medicine. in Prendergast PM and Shiffman MA (eds.) Aesthetic Medicine. Berlin: Springer, 2011:7-11.
  42. GMC. Consent: patients and doctors making decisions together (guidance for doctors). GMC, 2008
  43. GMC. 0-18 years: guidance for all doctors. GMC, 2007
  44. Barratt H. Autonomy - who chooses? CMF File 29, 2005
  45. Psalm 27:4
  46. Psalm 147:11
  47. 1 Samuel 25:3
  48. 2 Samuel 11:2
  49. 2 Samuel 13:1
  50. 1 Kings 1:3
  51. Esther 2:2
  52. Jeremiah 3:19
  53. Jeremiah 6:2
  54. Matthew 26:10
  55. Ecclesiastes 3:11
  56. Genesis 1:31
  57. Zechariah 9:16-17a
  58. Proverbs 31:30
  59. Isaiah 53:2b
  60. Galatians 5:22-23
  61. Romans 6:23
  62. Revelation 21:5
  63. Luke 4:16-19
  64. John 10:10
  65. Winter R. Perfecting Ourselves to Death. Downers Grove: InterVarsity Press, 2005:161
  66. Poupard RJ. Self-Esteem from a Scalpel: The Ethics of Plastic Surgery. Christian Research Journal, 2010;33(4)
  67. 1 Samuel 16:7
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