Corporate Promotion of Cosmetic Surgery and Enhancements

Celebrities who undergo plastic surgery without question have a compelling influence on the general population, particularly those under the age of 40. One has to look no further than the checkout aisle in the grocery store to see how celebrity visibility is thrust upon us. From these consumer magazines to numerous television shows, anyone with a Hollywood connection is tracked and speculated upon about their cosmetic surgery, even if they have never had it. The media’s desire to push these cosmetic surgery tales of the stars fuels the public’s obsession with discovering the secrets to what keeps the beautiful and famous looking so.

While the star’s experiences may fascinate, they do little to actually educate. It is easy to confuse entertainment with reality because it is simply more interesting. Take the recent case of 23 year-old Heidi Mondag who had numerous cosmetic procedures done to satisfy her narcissistic and career agendas. While she may have had a lot of procedures, they were all quite small in scope. Most of her procedures were really ‘nip and tucks’ and not major overalls. After all, how many physical problems could a young person really have particularly given her appearance beforehand?  But this is not how the media interpreted her surgery. Rather it was made to sound like it was a great undertaking and required supernormal surgical skills to complete.

These ‘tweakments’ are largely what is fueling the increasing visibility of plastic surgery. Botox, injectable fillers, lasers and minor skin lifts of the face have created a whole new set of treatment options that did not exist just a decade ago. While a 23 year-old partaking of this cosmetic menu does border on the overly self-indulgent, those in their late 30s and 40s have a more significant purpose. Fending back the early signs of aging is proving to be a more effective strategy than awaiting the day when major plastic surgery is needed. While my mother may have waited until retirement to wage the battle against the effects of time, today’s middle agers understandably what to look better and more rested now.

What is unique about these minimal procedures is that most of them are fueled and promoted by the cosmetic device and pharmaceutical industry. Plastic surgeons have taken a back seat to the promotions and marketing that billion-dollar-in-sales companies can do. The once retail approach to cosmetic and beauty products has expanded to include drugs and surgery. Targeting consumers through popular magazine and internet strategies, rebate coupons for Botox and eyelash stimulants are widely available as well as even franchise surgery for facelifts. Breast implant sizer kits are mailed to prospective patient’s homes with incentives for other procedures packed inside. Plastic surgeons collectively spend an insignificant fraction on marketing compared to that of the corporate world. This wave of industry’s promotion for profit and media attention for sales is why most people today know something about cosmetic enhancement and why it is now mainstream.

But like all entrepreneurial endeavors, making a profit and driving sales does produce some good byproducts that have wide benefit. Like the old commercial slogan from decades ago, there is ‘better living through modern chemistry’.

Dr. Barry Eppley

When The Unexpected Happens After Plastic Surgery

Of the very large number of cosmetic surgery procedures that are performed each year in the United States, a certain number will undergo subsequent revision. While this is a concept explained to patients by their plastic surgeon beforehand, it is understandable that it falls on deaf ears for the most part. The euphoria of the upcoming outcome blocks any realistic consideration that anything but the best will happen. The decision to undergo cosmetic surgery is both emotional and optimistic.

Why does surgery not always turn out to be exactly as desired? While there can be numerous reasons, including the wrong operation for the problem or that the operation was not done well, but the most common reasons for these undesired outcomes are less obvious. How the body responds to the trauma of surgery and the not always predictable events of wound healing account for much of the need for revisional surgery. The occurrence of complications in cosmetic plastic surgery is uniquely different from that of most other types of surgeries. Unlike common surgical problems, such as infection or bleeding, the healing of a cosmetic surgery site may be perfect but the aesthetics of the healed site may still not be what was desired. Cosmetic surgery results are judged by a higher standard, they must both heal and look good as well. Even the avoidance of common wound healing problems is not enough in cosmetic surgery.

While the real number of the incidence or need for revision in cosmetic surgery will never be known, estimates are thrown around of around 15% on a national average. This estimated number will be quite different depending upon the type of procedure being performed. For example, any form of breast surgery carries a higher revisional risk than that of a facelift. Any operation that relies on an implantable device to achieve the outcome will always have more potential problems than those operations that don’t. While revisional surgery in most cases is minor and nothing in comparison to the original operation, potential patients need to appreciate that the need for secondary surgery in cosmetic procedures is not rare.

When postoperative complications occur and revisional surgery is needed, there is unhappiness on the part of both patient and plastic surgeon. The cosmetic patient is understandablely unhappy as they never really believe it would happen to them no matter how it was disclosed or what forms they signed. Such surgical problems happen to other people, no one thinks or hopes that it will happen to them. Other people make up statistics but not themselves. Patient naivety in this regard has been promoted, inadvertently, by cosmetic surgeon’s themselves through countless promotional efforts. Advertising ‘lunchtime facelifts’, ‘weekend recovery’, and other seemingly too good to be true procedures has only added to dumbing down that fact that it is real surgery with associated risks.

Like the patient, plastic surgeons are equally not pleased about the need for revisional surgery. There are many reasons for such a response by the surgeon from facing a patient’s disappointment, a perceived failure of their own skills and expertise, and how this result reflects on their own reputation and image. Sometimes, a difference in opinion may develop between the patient and surgeon as to the need and advisability of revisional surgery. In these circumstances, patients often seek out other surgeons to undergo their revisional surgery, getting a fresh perspective on their adverse outcome. When needed, however, surgical revisions should be done in the proper setting and under the appropriate circumstances. Certain minor revisions can be reasonably performed under local anesthesia in the office. This approach is simple and avoids the use of the operating room. Many times, however, this office approach to revisional surgery is overused in an effort to save the patient further expense. As a result, the desired outcome may still be suboptimal. In many cases of revisional surgery, the patient and surgeon needs to be willing to accept the additional arrangement and expense of an operating room to put themselves in a position where the procedure can be carried out properly.

The potential need for revisional surgery after a cosmetic procedure is a statistical reality. Revisional cosmetic surgery has associated physical, emotional, and economic consequences. It will often test the depth of the relationship and preoperative dialogue between plastic surgeon and patient.

Dr. Barry Eppley

But It's Not Surgery

The greatest trend in plastic surgery in the past decade has been, ironically,  the explosion of procedures that don’t involve actual surgery. Comprised largely of injectable therapies, such as Botox and fillers, and laser and light treatments, making the face look rested, supple and youthful  has become as easy as a quick visit to the doctor’s office. By sheers numbers, non-surgical facial enhancement far exceeds the actual number of cosmetic surgeries performed per year.

Such ‘beauty treatments’ have been very successful for concerns of facial aging but the same approach has not seen the same successes for body concerns. The search for an effective non-surgical method for the reduction and removal of fat remains as elusive as finding the magic pill or diet for weight loss. Much has been promised, but little has been delivered so far.

The allure of ‘non-surgical’ is always a compelling one and any device or product that offers it always attracts a large amount of public interest. But within that appeal lies the often ignored fact that non-surgical treatments are not equivalent to surgery. They produce results that are far less and should be of thought as a delaying tactic or a complement to what surgery can do, not a substitute.

Non-surgical facial methods should never be equated to what actual surgery can do. You can reduce a few wrinkles, plump up some thin tissues, and get your skin to look fresher. And, to be sure, those are great changes for many people, but many patients often expect or believe much more will occur. This is unfortunately not helped by the sometimes very ‘broad’ promotional claims of product manufacturers and doctors alike. Unless properly advised, it is easy for one to undergo some form of office treatment, often not inexpensive, and be disappointed with the results. This is especially seen when it comes to a wide variety of ‘facelift-like’ methods. I have seen many such patients, all of whom in the search for something less, did indeed end up with less.

While seriously ‘injurious’ complications are rare with underperforming and overpromised cosmetic treatments, there is always the economic loss. Wasted money may prevent someone from contributing to and having a more significant procedure that would provide much better long-term benefit. The point being is that one must keep an eye on the concept of value when comparing non-surgical versus surgical cosmetic procedures.

One good illustration of this concept  is in the highly promoted ‘Liquid Facelift’ procedure. Plumping your face up with injectable fillers does create some more fullness in the face and it could  be called  a lift of some sort (it does nothing for the neck which is why most people seek a facelift).  But its effects last perhaps six months and costs several thousand dollars. Some form of a real facelift (and there are many variations) may cost two or three times more but the results are much more significant and could easily last a decade or more. Is either one wrong? No. Each person has their own objective and needs and either approach could be right for different people.  But from the concept of value, removing, lifting and tightening is actually more economical in the long-run than plumping and a little smoothing.

Most non-surgical office treatments have no recovery, a near instant result, and cost less …and do so at the ‘price’ of being less effective as well. Expectations are the key to any plastic surgery procedure and simple office treatments should be judged more for their contribution to value than their ease of doing them.  

Dr. Barry Eppley

Cosmetic Surgery in the Military – Necessary or Optional?


As an appreciation of what our military does around the world, our Patriot Program exists to help make plastic surgery more affordable to them. Having seen and talked to many of these military patients, I have become aware that elective plastic surgery is often done at Armed Services facilities. In addition, one of my plastic surgery techs spent nearly a decade in the military and he often speaks of the cosmetic surgeries that he knows where done or participated in.

According to a recent article in Stars and Stripes (passed along to me by one of my military patients…he thought I might be interested), the military says it does not pay for unnecessary plastic surgery. But an audit of patient records released in February by the Pentagon says this is not so. The audit found that military doctors were regularly performing breast augmentations, tummy tucks, liposuction and other cosmetic surgery without charging the patients as they are supposed to do.

Plastic surgeons exist in the military to perform reconstruction of many injuries that are sustained from war, accidents and disease. The very existence of plastic surgery as we know it today is the result of the experience gained in the first two World Wars in the first half of the last century. Because military plastic surgeons need to keep their skills up for when they get out (and to encourage them to enter the military in the first place), they are allowed to perform cosmetic plastic surgery for patients as long as they pay for it…just what people have to do in the civilian world. Such requirements have been in place for the military for some time. Troops have had to do so since 2005 and dependents and retirees have been required to pay since 1992.

However, it appears that some service members and their dependents are having cosmetic surgery on the military’s (your) dime according to the audit. Arguments can be made that they deserve it or it doesn’t really matter since most of the costs are already built-in anyway. The basic costs of the facilities and doctor’s and operating room staff salaries is an ongoing expense, it is really just a supply issue to perform the surgery.

One of the real interesting sides to this story, and one that we face every day in the civilian world with medical insurance, is what is the difference between medically necessary (reconstructive) and cosmetic plastic surgery. From the military’s standpoint, what should they be paying for and what should patients be paying for?  By definition, plastic surgery is reconstructive if it restores or repairs appearance or function from trauma, disease, or birth defects. Cosmetic plastic surgery is changing what is not deformed, injured, or diseased. That seems like a simple differentiation…but it often is not.   

In the Stars and Stripes article, for example, they discussed male breast reduction or gynecomastia surgery. This is a source of embarrassment for many young men but is often viewed as a cosmetic problem in the civilian world and is not often covered by medical insurance. But in the military, male breast enlargement can make wearing body armor difficult and that can make it medically necessary. Similar situations may exist for rhinoplasty (breathing problems), otoplasty (helmet wearing), and even tummy tucks. (hernia repair)

One of the side, but important, issues is being able to recruit or retain plastic surgeons in the military. Outside of being close to a war zone, plastic surgeons in the military may encounter few combat casualties and may not do enough reconstructive surgery to keep their skills and board-certification current. (in some ways, this is thankful) Cosmetic surgery techniques are an extension of those used in reconstruction. A midface lift, for example, is a cosmetic procedure developed from repairing cheek bone fractures and lower eyelid deformities. There are many connections between cosmetic and reconstructive plastic surgery and their differences in technique are often more gray than trying to determine the medically necessary basis of the procedure.

Of significance, the military report suggests that plastic surgeons are increasingly leaving the military because of their inability to keep up their cosmetic surgery skills due to the 2005 patient payment policy. That is unfortunate as plastic surgeons have  a lot to offer our military service members. Perhaps continuing to provide cosmetic surgery is a retention factor for both plastic surgeons and our military alike.

Dr. Barry Eppley

Botox and Breast Augmentation: Plastic Surgery's Commodities

While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.

Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.

Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer.  These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.

But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.

Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.      

Dr. Barry Eppley

Botox, Tanning and Health Care Reform

The recent surprise decision by Senator Evan Bayh to not seek re-election is likely a strong reflection of his desire to flee an unpopular ship as it is with his frustration with the ways of Washington. The recent questionable efforts to ramrod through a monster of major health care reform is certainly one factor that drove him closer to the edge of this decision. Perhaps Bayh knew that as the details of the health care bill began to see the light of day, great public disdain for all those that voted for it was sure to occur.

As a plastic surgeon, I was happy to see that the unsavory ‘Botax’(a 5% tax on all cosmetic procedures, surgery or otherwise) was cut from the final version of the Senate health care reform bill. The ‘Botax’ was eventually eliminated when it was quite rightly pointed out that it was not only a discriminatory tax on women but it was punishing those who sought self-improvement…the equivalent of taxing healthy behavior given the efforts of most patients to take good care of their investment in themselves.

As a replacement for taxing cosmetic surgery, the Senate desperately searched for ways to redistribute more of your money.  They turned their focus to… indoor tanning of all things. Known as the ‘Tan Plan’, a 10% federal tax on indoor tanning was quietly included in the revised bill. Optimistically, it is expected to generate close to 3 billion dollars to help pay for the uninsured. Tanning is a more palatable target because it is a debatedly unhealthy behavior that in the very least, doesn’t improve your skin’s condition from the experience.

While I don’t want to be an endorser of any behavior that exposes people to more ultraviolet radiation and thereby increases their risk of developing skin cancer, this new federal tax is just as reprehensible as the Botax and may even be more discriminatory.  Though the tanning industry and tanning advocates have put forth their concerns, I have yet to hear anyone mention the very biased nature of this tax. I am most definitely not a tanning expert,  but I am certain that the vast majority of the population that patronizes tanning salons are light skinned individuals seeking to darken their natural skin tone.  The number of non-Caucasian users of tanning salons must surely be very low, at best just a few percent of the total client base.  The Tan Plan is really a racially-biased tax, likely unintentionally but true nonetheless.

What the Botax and the Tax Plan demonstrate is that it is virtually impossible to pick and chose what type of human behavior you want to tax (penalize), and not raise a lot of concerns. If you really want to generate a lot of tax revenue and maybe even change societal health behaviors in the process, there should be a Fat Food Tax. Taxing food purchases with a certain percentage of fat content and the industry that makes them would make these other tax proposals as insignificant as the antioxidants in a soda.

Must we really be deluged with food choices that have such high fat or sugar contents? They taste great and we all love them, but most are a nutritional desert and have led us to be one of the most overweight countries per capita in the world. Obesity and all of the problems that it causes is a far greater health problem that cancer, AIDS and many other medical diseases combined. Such a food tax would, however, cause such a societal clamor that the mere mention of it makes one reach for that bag of Doritos. Taxing personal lifestyle behaviors is risky and will never be a politically popular way to try and fund some levels of health care reform.   

Dr. Barry Eppley

Cosmetic Tax Proposal in Health Care Reform – Taxing Women and the Health Conscious

There is sure to be much discussion about a provision in the U.S. Senate’s version of Health Care Reform which would impose a tax on elective cosmetic procedures. With a tax rate of 5%, the measure presumably will raise close to $6 billion of the projected $850 billion price tag of the healthcare bill (most analysts agree that this projected cost is fancifully low).

Given the name of “Botax” by many, the intent of it is to clearly tax those who can ‘afford’ to pay it…some call it a tax on the wealthy. But those who do so clearly have no idea who really makes up the cosmetic population. The Botax name is a clever variation of Botox® facial injections which have become the beacon procedure for non-surgical office procedures used for wrinkle reduction. In theory, the Botax could impact about 12 million cosmetic procedures and surgeries performed each year in the U.S..

As one would expect, all sides of the cosmetic surgery industry from physicians to patients are voicing opposition. Their argument is that such a tax unfairly targets the middle class and working women in particular. Statistics from the American Society of Plastic Surgeons (ASPS) show that only a minority of people who undergo any form of cosmetic surgery has a household income greater than $90,000 per year and the vast majority (greater than 80%) are women between the working ages of 18 to 65. Clearly this is not a tax on the wealthy and is a discriminatory tax that falls largely on women.

While the idea that it is a tax on the wealthy is fallacious, it is a tax on the healthy. Contrary to what many would guess, the vast majority of cosmetic procedures are done are health-conscious individuals. Most are already reasonable fit and are ‘appearance focused’.  The obese, smokers, diabetics and other ‘unhealthy’ patients make up just a fraction of those people ever undergoing cosmetic procedures or surgery. This proposed discriminatory tax is targeting those who do take care of themselves to help some who have made poor health choices along the way. It would make more sense to tax unhealthy food items, for example, that have incredibly high fat content…and it would bring a hundred fold increases in revenue to support health care reform.

This type of tax proposal is also troubling because it treads on choppy waters that health insurance companies have trouble deciphering.  What is the official or tax definition of a cosmetic procedure? IRS rules for tax deductions state that any procedure necessary to treat a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease is a medical procedure. Anything else is a cosmetic procedure. Some delineation is quite clear- Botox® used for wrinkles or for migraines for example. But what about a tummy tuck to treat the effects of pregnancy?   Are the effects of childbirth on a woman’s abdomen a cosmetic or reconstructive procedure? 

With so many differences between the House and Senate Health Reform bills, it is difficult to say what will eventually shake out. But this hidden tax will largely penalize health conscious women. It is a troubling signal of how far reaching your legislators will go to get more of your hard earned money. And once again the beneficiaries of your ‘generosity’ will likely be those that have sacrificed less.

 Dr. Barry Eppley

Assessing the Risks of Cosmetic Surgery

Some may have read the recent story of a 38 year-old ex-Miss Argentina who died from complications after undergoing plastic surgery on her buttocks. Solange Magnano, who won the crown in 1994, died of a pulmonary embolism three days after having buttock augmentation in Buenos Aires.

For many, this tragic story points to the inherent dangers of cosmetic surgery and that someone risked everything she had in life for a more firmer behind. On the one hand, there is some truth to that perception.  Surgery of any kind always involves some risk. The potential for deep vein thrombosis and pulmonary embolus has become a big prevention emphasis in any kind of surgery these days.

But the ex-Miss Argentina did not die from a vein-clot related pulmonary embolism.

Closer inspection of this story shows that she died from a lung embolus that resulted directly from what was injected into her. When I first read this story I thought this woman died from a fat embolus from having had buttock enlargement by  fat injections. It is rare but fat emboli have been reported to occur from liposuction and fat injections. But when pictures showed how thin she was, it became obvious that she had not enough fat to use. What was not printed was that a liquid filling material that contained tiny beads was used. Such a material is used here in the United States for facial injection purposes, but never anywhere else in the body. With many thousands of beads and clumps of beads injected, it would be very easy for some of them to get into the larger veins in the buttock…and be transported right upward through the heart into the lungs. Such a risk does not exist in the face where such materials were developed and intended for use.

What does this story tells us about the risks of cosmetic surgery? Does it indicate that cosmetic surgery is inherently dangerous? The answer is no…when done under the proper circumstances with good medical judgment. Almost everyone of these tragic stories that I have seen in my years of practice ends up showing some breach of the known standards of care. Whether it be how the surgery was performed, by whom, or in what type of setting and circumstance, violating established methods and standards of care can have catastrophic results.

Cosmetic surgery is real surgery…and there are no shortcuts. Sacrificing safety for what appears to be easy and quick has not usually proven to be a good trade-off.   

Was the death of the ex-Miss Argentina preventable? By not doing the surgery… for sure. But if the surgery had been done with proper methods and materials (or not done at all if there was not enough fat to be used), the risk of such an outcome would have been no higher than a similar fate occurring from an accident while driving to work everyday. Outside of the United States, there are few rules governing what ‘cosmetic doctors’ do.  In the United States the plethora of regulations and training requirements for plastic surgeons, while certainly contributing to costs, go a long way towards a much safer experience.

Dr. Barry Eppley