Tuesday, April 26, 2016
In the aggressive world of cosmetic surgery, patients can't afford to be naïve
The lovely young woman on my medical rounds has a gaping hole on her forehead. The hole is deep and there is pus brimming from the side. The edges look macerated and discoloured and the stench emanating from it is noticeable.
She looks like the victim of a vicious accident until we discover that this is the result of a cosmetic procedure gone wrong. She is flustered and angry, but mainly worried about the possibility of permanent disfigurement.
The plastic surgeon duly arrives, his response one of unmitigated dismay: “Oh God.”
Over the next week, the woman receives powerful antibiotics and one round of surgical debridement. The surgeon advises that the repair process will take several months.
When she knows us a little better she produces consecutive images capturing the unfolding catastrophe. The final picture is from Instagram before intervention. Her skin is smooth and young and her features look nice, but all she notices is the blemish of a mole.
“See that? I couldn’t bear it, but now I am positively ugly.” Then she bursts into tears.
We console her as best we can but there is no escaping the fact that in the quest to fix a small perceived defect she has attracted a lot more trouble than she bargained for. She seems nonplussed when the plastic surgeon questions her about the qualifications of her provider. “He was a doctor,” she says defensively. “What else did I need to know?”
This woman may sound naïve but qualified plastic surgeons say that she is typical of uninformed patients who belatedly realise the consequences of their decision to have “routine” cosmetic surgery.
Cosmetic surgery clinics have long operated with impunity but they have recently been in the spotlight with reports of widespread shoddy procedures including unsafe anaesthetic practices and inadequate infrastructure to monitor serious complications.
Beauty clinics that once offered safe services now perform a ubiquitous trade in laser procedures. “Getting a Brazilian does not involve nearly the same level of risk as laser resurfacing,” says a dermatologist, who sees examples of interventions gone wrong.
But unregulated cosmetic clinics are thriving, offering everything from Botox, laser and fillers to breast and nose jobs, tummy tucks and facelifts. Slick websites promise the world: quick and painless makeovers that will restore patients (mostly women) to their pre-baby self or sculpt the confident, trim and taut body they have always dreamt of having.
The word “cosmetic” is affixed to doctor, physician, surgeon, plastic surgeon and dermatologist. Of these, only the latter two have undergone years of specialist training and accreditation by a professional college. While clinics claim that other cosmetic providers may have a basic medical degree, their training in performing complex cosmetic procedures is variable and unscrutinised.
According to plastic surgeons who end up picking up the pieces after cosmetic surgery gone wrong, many providers know that patients don’t have the sophistication to question the difference. They describe removing botched breast and nose implants, treating disfiguring scars and resuscitating patients who suffer large fluid shifts after aggressive liposuction. Many of them have taken place on a “luxury” overseas holiday that combined tourism and surgery at a fraction of the price. The corrective procedures are painful, time-consuming and place an extra burden on the public healthcare system.
But “cosmetic” does not mean “unimportant”, as one dermatologist rightly says. It’s naïve to think that appearance doesn’t matter. It matters in every walk of life. Even the ancient Egyptians, free of the influences of social media, regarded beauty as a sign of holiness, going to considerable lengths to procure Kohl and malachite for their eyes and red ochre for cheeks.
A man wants the red veins on his nose removed to remove the impression of being an alcoholic. A woman feels that the permanent frown on her forehead makes her look angry to her colleagues and is threatening her job security. A young man says people can’t look beyond the large birth malformation on his face. Modern medicine has the tools to help, and patients ought to benefit from them, but they also deserve an honest discussion of the evidence underlying treatment.
When a woman tells me she settled on a tummy tuck after a single phone call, I wonder how uninformed buyers can be so easily convinced of the merits of expensive and major surgery. Visiting various websites, I am struck by the glossy pictures selling the attractive proposition that a tummy tuck is perfect for the woman who wants to look more feminine, regain her self-esteem and nicer contours – for someone who doesn’t mind the children but hates the resulting abdominal baggage, for the woman who dreads the beach and who is at risk of sinking into depression because her waist is larger than her hip.
There is an outwardly sympathetic but sinister implication that sometimes, no amount of healthy living can make a woman as beautiful as a round of surgery. The mention of complications is notably sparse and that of cost virtually non-existent. You could be forgiven for thinking that although the benefits are self-evident and compelling, the risks are a side issue and the costs immaterial.
In a 2015 study published in the journal Plastic and Reconstructive Surgery, American researchers reported on the outcomes of 25,000 abdominoplasties (tummy tucks) – 95% of patients were women, with an average age of 42. Two-thirds combined the procedure with other cosmetic surgery. Tummy tucks can be undertaken alone or as part of the “Mummy Makeover Package”, combining breast, abdominal and vaginal work. Less serious problems managed in the clinic were not included in the study but the rate of major complications was high at 4%, rising to an alarming 10.4% for combined procedures. The commonest complications were bleeding, infection, venous thrombosis, and lung injury, all potentially life-threatening.
When I call a popular cosmetic clinic on a Friday afternoon and ask to speak to a patient advisor, demand is high and the wait is long. I introduce myself as a mother enquiring about cosmetic surgery for the first time and am immediately asked which one of the extensive menu of procedures I want. An abdominoplasty, I venture, and am rewarded with the knowledge that it’s “incredibly popular.”
“I’d like to know who this procedure is right for,” I ask.
“It’s right for anyone who wants it’.
I am astounded by this claim, and from a nurse too.
Her advice contradicts professional guidelines that advise surgery in cases of massive weight loss (that leaves redundant skin behind), documented serious infection or skin necrosis due to overhanging fat or functional limitation with walking or hygiene, and only when non-surgical management has not worked.
After hearing a slick promotion about the tummy tuck that will iron out more than the abdominal sags, I ask about side effects and costs and am told this requires a discussion with the doctor. I concede this as reasonable but can’t help noticing that the anticipated benefits have already been aggressively impressed upon me without the same doctor’s input.
“Do women decide so quickly?” I enquire, considering I am none the wiser about the provider’s qualifications, cost or complications.
“Most of our women have already decided and they walk out of here with a date.”
Research into the preferences of first-time cosmetic surgery recipients finds that viewers of plastic surgery reality television are more likely to be influenced by the shows, believe themselves to be better informed, but have more unrealistic expectations of surgery.
Experts say that cosmetic surgery is a sign of our times and here to stay, which is why qualified plastic surgeons and dermatologists, who might previously have avoided the field, want a hand in the game. They say that while most patients are satisfied, cosmetic surgery providers are obliged to screen out those with depression, psychosis, body dysmorphic disorder and minimal deformity who need other forms of help instead of surgery they can ill-afford. But many openly admit that the multimillion dollar cost of running a modern cosmetic clinic causes ethical obligations that clash with the financial imperative.
“When you have bought a six-figure laser machine and are spending tens of thousands in maintenance fees, there is a perverse incentive to suggest a procedure instead of reassuring a woman that her nose looks just fine,” a clinic owner tells me. If patients are to be adequately protected, the cosmetic industry will need to be regulated rather than customers relying on a voluntary code of conduct.
In today’s aggressive world of cosmetic surgery, the patient’s role can’t be ignored. The patient can’t afford to be naïve and trust the most polished advertising. Before committing to cosmetic surgery, there is a personal obligation to reflect a little on what it will actually accomplish.
Disappointingly, research shows that when it comes to almost every form of healthcare, with every pill we swallow and procedure we subject to, we consistently overestimate the benefits and underestimate the harm.
Combine this with an unchecked industry, and the potential for tears is as boundless as our longing to look good.