There are widespread misconceptions about plastic surgery. Perhaps the most prevalent is that it’s all just a bunch of vain rich people and aging movie divas who are getting “some work” done. But in reality, across the world, the most common plastic surgery procedure is not a tummy-tuck, it’s tumor removal for skin lesions such as skin cancers. And cosmetic reconstruction due to accidents, deformities, and burns are also quite common procedures. These are usually life-saving, or life-improving, operations but it’s still the lipos and the nose jobs, the brow lifts and the boob jobs that get all the press–and they’ve gotten a lot of press in recent years.

It’s difficult to turn on the TV, flip through a magazine–or simply listen to people in line at the grocery store–without coming away thinking that the whole world is obsessed with how they look. Television programs like Extreme Makeover have turned plastic surgery from a private procedure into a public spectacle and, in the case of The Swan, a game show. There are websites, like hotornot.com, where people submit their photos so that complete strangers can judge how ‘hot’ they are. HBO has turned plastic surgery into a television series, Nip/Tuck, which according to creator Ryan Murphy is a “heavy drama about what people hate about themselves and why they hate themselves.”

And it’s not only adults who are taking a long hard look in the mirror (and “hating themselves” one assumes). According to The New York Times, the number of cosmetic surgeries performed on people aged 18 and under reached 74,233 in the year 2003. Both girls and boys as young as six are getting plastic surgery in order to flatten their stomachs. The newspaper, China Daily, recently reported that a six-year-old child had asked a physician for double eyelids, and a Chinese mother insisted that a doctor plant two dimples in her three-year-old daughter to cultivate her sense of being a “model.” What is going on? Is everybody really as ugly as they believe they are, or is it that the media’s decided plastic surgery is this year’s hot trend, like pilates?

One of the biggest misconceptions about plastic surgery is that it’s so new. While it first moved into the public consciousness in the 1950s, as an overall part of President Truman’s national health care plan, it has actually been a part of our lives as far back as 3400 BC; a time before even the word (from the Greek plastikos meaning “to mold” or “give form”) for the procedure was coined. And it was in India, sometime between the sixth century B.C. and the sixth century A.D. that the bible of plastic surgery, Susruta Samhita, was written. Over the centuries the practice of plastic surgery grew and evolved, it thrived, it fell into disuse, it was entirely forgotten, it was revived, it was condemned by the Catholic Church as sorcery and then, eventually, it became recognized as an integral and distinguished practice of the medical community.

But why the general public’s recent fascination with it? Plastic surgery has always been the province of the rich and famous. It was something the public whispered about and clucked their tongues over–it wasn’t something they actually ever did. But that was before plastic surgery came out of the closet; before Geraldo Rivera had the fat removed from his buttocks and injected between his eyebrows–on national television in 1992. Since that time “having something done” has inched its way out of the shadows and into the spotlight, boasting a roster of celebrity role models (willing or not) like Cher, Priscilla Presley, Liz Hurley, Paul Newman, Jane Fonda, Dolly Parton, Patricia Heaton, Elle MacPherson, Roseanne, Joan Rivers, Carol Burnett, Pamela Anderson, Carnie Wilson, Michelle Pfeiffer, Mary Tyler Moore and Lauren Hutton. A recent article in People magazine quotes celebrities such as Julia Roberts and Jennifer Aniston as saying that while they haven’t had any, they wouldn’t think twice about having some surgery in the future. It’s so unlike the old days, when a Hollywood star had to make up an elaborate story about “visiting health farms” in order to explain away their rejuvenated new looks–although some, like Michael Jackson, may not come clean about just how many times they’ve had something done. (According to Jackson, he’s had just two operations on his nose.)

Plastic surgery has also become more cost-affordable. It is now inexpensive enough for the average person to have some procedure done. (The typical price of a nose job is around $5,000). With the social stigma now removed, and the cost-prohibitive aspect of it diminished, more and more people are not only electing to have a nip or a tuck performed–they don’t care who knows about it. A national survey of 1,000 adults was conducted last year by the American Society for Aesthetic Plastic Surgery (ASAPS). The results showed that 54 percent of respondents approved of cosmetic surgery. 24 percent (30 percent of them women and 18 percent of them men) said that they would consider it for themselves. And three-quarters of both men and women said if that if they had cosmetic surgery, they wouldn’t be embarrassed if others knew. Meanwhile, in Los Angeles, Botox parties are becoming as common as dinner parties in some circles.

While plastic surgery has become more affordable in the US, it is even less expensive abroad. Companies like Surgeon and Safari, a South African-based company that promotes medical tourism, combines plastic surgery with an African safari. (A little rhino hunting with your rhinoplasty, maybe?) In the words of Colleen Hiltbrunner, a woman who underwent the Surgeon and Safari experience for herself, “The opportunity to see the animals in their natural habitat. To go where man originated, and at the same time, get the plastic surgery I need at a bargain rate is just fantastic.” As tempting as it may be to see lions and tigers in the wild–and have major surgery “at a bargain rate” to boot–the ASAPS stresses that plastic surgery is not without its risks, however minor, and that it’s especially difficult to check the credentials of foreign doctors.

Which brings us to the difference between a cosmetic/plastic surgeon and a Board Certified plastic surgeon. Surprisingly, just about any doctor can offer cosmetic surgery, whether they are a gynecologist, a pediatrician–or even your dentist. In California there’s a bill making its way through state senate that could make it legal for some oral surgeons to perform facial plastic surgeries, including facelifts and nose jobs. Dubbed the “Nip, Tuck and Crown Bill” it is understandably causing concern in the plastic surgery community. Thomas Hiser, President of the California Association of Oral and Maxillofacial Surgeons (OMS), wants qualified oral surgeons to be allowed to perform “elective cosmetic surgeries” in the areas around the neck and face (OMS already performs reconstructive plastic surgeries in emergency rooms). Board Certified plastic surgeon, Dr. Leonard Glass, is naturally against the bill. “(Oral surgeons) are doing facial injuries. That’s a far cry from someone who is looking fine as they are, but want to look a little bit better. …They think it’s an opportunity to make a bunch of money by doing cosmetic surgery.” Dr. Hiser counters by saying, “It’s a turf war, okay? The cosmetic procedures are procedures that are usually not covered by insurance, it’s discretionary dollars by the patient, and it’s a lucrative field.”

The difference between having your dentist versus a Board Certified doctor perform your facelift is vast. Being Board Certified means that the doctor has gone through very specific, and extensive, training in a specialized field and has passed a difficult examination by a board of experts in that field. Board Certified plastic surgeons consider this an issue of public safety and suggest that going to anyone but a Board Certified plastic surgeon is a huge mistake, asking, “Would you want your plastic surgery performed by someone who has never had any formal plastic surgery training?” Sometimes the difference between the two is more serious than having a botched nose job, it could mean the difference between life and death.

Dr. Michael McGuire, a leading California plastic surgeon, is quoted in a recent article in Mirabella magazine as saying that the risks of surgery are “usually superficial, meaning they don’t involve major organs or blood vessels, and they’re typically done on relatively young, healthy people. Right there, you’ve eliminated a lot of the complexities involved with almost all other kinds of surgeries. Most surgeons won’t do plastic surgeries on patients who have health problems.” That’s true, but while the risks of surgery (when performed by a qualified doctor) are few (around 1% of all patients who have plastic surgery performed do experience some kind of problem), when you consider that more than 8.7 million procedures were performed in 2003 alone then that means that there were at least 87,000 problems. So why do people have plastic surgery? Especially considering that a great number (not all) of procedures are elective surgery and therefore not usually covered by health insurance?

From making oneself look and feel younger, to improving mental and physical health, the reasons why people elect more and more to go under the knife these days are as varied as the procedures themselves. In the movie, The First Wives Club, Goldie Hawn plays a woman named Elise who gets nipped and tucked and lifted in order to show up an adulterous husband who left her for a younger woman. “It’s the 90’s,” Elise says “plastic surgery is like good grooming.” (In a sad twist, Olivia Goldsmith, the author of the First Wives Club, died of complications from anesthesia during plastic surgery.) Ironically, it’s adultery that lead to the popularity of plastic surgery in the first place. It was in sixth century India that surgeons first developed the basics of an operation known as “the attached-flap method” which was used to repair the damage inflicted on people found guilty of adultery, the cutting off of the nose. As the Susruta Samhita explains:

“The physician takes the leaf of a plant the size of the destroyed parts. He places it on the patient’s cheek and cuts out of this cheek a piece of skin of the same size (but in such a manner that the skin at one end remains attached to the cheek). Then he wraps the piece of skin from the cheek carefully around it, and sews it at the edges. Then he places two thin pipes in the nose where the nostrils should go, to facilitate breathing and prevent the sewn skin from collapsing. Then he strews powder of Sapan wood, Licorice-root and Barberry on it and covers with cotton. As soon as the skin has grown together with the nose, he cuts through the connection with the cheek.”

Not exactly the way they’d do it in Beverly Hills, but as crude as the operation was it did help pave the way for what transpired in early October 2004. That’s when a team of surgeons successfully performed the very first reconstruction of an entire face on a burn patient. The surgical team used a tissue expander in the back to create a single piece of thick skin, with its own unique blood supply, and transferred it to the face. The skin flap was large enough to cover the face completely, with extra tissue to create a nose, which otherwise would require a separate surgery. According to Dr. Thomas Ray Stevenson, president of the Plastic Surgery Educational Foundation: “Through this combination of surgical techniques, a burn patient (now) has only one operation rather than multiple procedures, reducing pain and recovery time.” That’s a very long way from tummy-tucks, nose jobs, brow lifts and boob jobs, but the procedure received virtually no play in the press. Certainly not as much attention as the media gave to the recent debate over whether or not Lindsay Lohan has had breast implants or not. (For the record, she says “not.”)

While no one yet claims to have discovered a fountain of eternal youth there is evidence that new techniques, and ways of looking at aging, are making growing old gracefully an option and not just a philosophy. One of the most promising areas of research revolves around fat. Atlanta’s Dr. Pradeep K. Sinha of the Atlanta Institute for Facial Aesthetic Surgery and Aesthetic Solution Center, is one of the only doctors in the Southeast performing a procedure that involves extracting living fat cells from one area of the body and then injecting them into contours of the face. This procedure, which is called fat transfer, is achieved under light sedation in only about 45 minutes. Unlike Botox, which is a temporary fix and paralyzes certain nerves, the transferred fat cells are actually able to attach to capillaries in the new location and grow, giving the face a more youthful appearance.

Another physician, Dr. Robert Ersek, a 66-year-old plastic surgeon from Texas, is also infatuated with fat. He regularly ships his own liposuctioned fat to a California company for processing and long-term storage. It turns out the type of cell–a kind of stem cell–being stored for Ersek is medically promising. “Fat,” say members of the (unfortunately named) International Fat Applied Technology Society (IFATS), “is a little-discussed source of stem cells, those versatile biological building blocks that can morph into a variety of tissues.” IFATS claims that fat-derived stem cells might someday provide replacement tissue for treating such conditions as Parkinson’s, heart attacks, heart failure and bone defects. While the research is still in its preliminary stages, Dr. J. Peter Rubin, assistant professor of plastic and reconstructive surgery at the University of Pittsburgh School of Medicine, says that there is promising evidence that fat-derived cells can “morph into bone, cartilage, skeletal muscle, blood vessel tissue, heart muscle and nerve cells” and might someday even be used to make more fat, for uses like breast reconstruction after surgery. Dr. Curt Civin, a stem cell expert at Johns Hopkins University in Baltimore, has called the fat-derived cells “intriguing” but says that the jury is still out.

We are in a new age of accessibility to plastic surgery, which is both exciting and frightening. Techniques that are commonplace would have been laughable as science fiction as little as ten years ago. And the future holds many more surprises in store, including fetal cell research, virtual reality, and robot doctors. Many physicians today believe that unraveling the mystery as to why fetal wounds heal without scars will revolutionize medicine. Many others envision a near-future scenario where remote surgery using a computer-aided robot will be used to custom-design and fit breast and facial implants. Through morphing computer software patients will be able to visualize what they’ll look like after surgery, and virtual reality will allow them to sense what they will feel like after the operation. It’s not a long ways off, but it is a long long way from the days when Gasparo Tagliacozzi, professor of surgery at Bologna in 1597, used to perform primitive nose jobs by grafting skin from the upper-arm and allowing one end to remain attached to the arm so it could be nourished by the body’s blood.

As we know, plastic surgery itself has had a bit of a makeover in the last few years, transforming from a shameful procedure to hide away, or deny altogether, into one that’s not only openly discussed on national TV but is considered as ho-hum as a haircut. Some procedures you can now do on your lunch break. Surgical techniques have improved, health risks have diminished, and costs have been reduced for many operations. That’s good, but it’s also been trivialized in many respects; turned into gruesome game shows like The Swan where former ugly ducklings undergo radical surgery in order to compete for prizes and love, and exotic vacations where you can stalk wild elephants while having an eye lift. Our obsession with looks reached new high in lows recently when speculation ran amok that Danny, the Pekinese crowned 2003 champion at the famed Crufts dog show in England, might have had a facelift. (Turns out he didn’t.)

Love it or hate it, we have become nip/tuck nation. Even though plastic surgery has gone through enormous changes since the Greek physician, Claudius Galenus of Pergamum, performed regular reconstruction’s of the nose, ears and mouth in 166 AD, it has always led to mankind’s pursuit of improving their appearance. But perhaps another Greek, Socrates, best understood our obsession with our looks when he wrote “Beauty is a short-lived tyranny.”

(c) 2010 Jim Yoakum

All rights reserved

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