SCAR WARS

Aesthetic plastic surgery is booming in America.

Jonathan Sinclair Carey finds that many patients are quite

cut up about surgeons who can't be taken at face value

THIRTY years ago L. P. Hartley pub- lished a futurist novel, Facial Justice. He envisaged the greatest political attention being given to physical appearance, and the establishment of special surgical cen- tres established to alter faces and bodies to stipulated aesthetic levels, enforced by governmental inspectors. Hartley wrote, :Equality and Envy — the two Es — were in the moral sphere the positive and negative poles on which the New State rotated. The one attracted, the other repel- led.'

The central female character, Jael 97, is forced to report to the Ministry of Facial Jus- tice because of her facially overprivileged' attractiveness. Jael 97 Hartley used Jael 97's transmogrification to explore not only the 'face-saving busi- ness', as he called it, but also what the deprivation of individualism and privilege signify in his thinly disguised tale of the Post-war British welfare state. Much has Changed in the world since Facial Justice appeared three decades ago. But even 1— F. Hartley would not be quite prepared for the new state of aesthetic plastic surgery in America today as the spirit of capitalism invades its citizens' flesh, with Alpha-hood, rather than the two Es, being the scalpel's objective. Over two million Americans, 16 per cent male and a growing number of children, underwent elective aesthetic plastic surgery .last year, up from 590,550 in 1986. According to the statistics compiled by the American Society of Plastic and Recon- structive Surgery (ASPRS), over the past seven years there has been an increase of 34 per cent in the number of nose-jobs executed (at an estimated cost of $2,500 to $6,000), 40 per cent more eyelid surgeries ($2,500-$3,500), and 215 per cent more abdominoplasties ($4,000-$6,000), or what are more euphemistically referred to as `tummy tucks'. Substantial rises in patient numbers have come about in such peren- nial favourites as face-lifts ($4,500-$7,500), chemical peels ($2,000-$3,000), and lip enlargements ($2,000; and why not when last year nearly one billion dollars was spent by Americans on lipstick and lip gloss?). Chin and cheekbone implants ($1,000- $3,000) have become popular, as have hair replacements ($800-$1,500) and breast augmentations and reductions ($3,000- $8,000). There have also been noticeable rises in the incidence of penile prostheses to treat impotence (priceless, whatever the cost), collagen injections to reduce wrink- les ($150-$250 a visit), and breast recon- structions after mastectomies ($5,000- $15,000).

But aesthetic plastic surgery is no joke in the United States. It has become a serious multi-billion dollar industry. (Not surpri- singly, plastic surgery itself represents the fastest growing medical specialisation.) One plastic surgeon in California has spent over a million dollars on advertising. And the ads used by him, and by others, attempt to assure unsuspecting potential patients that cosmetic surgery is easy, safe, painless, and of great psychological im- portance. 'Improve on mother nature,' one caption reads: 'Feel good about yourself.' Other ads promote 'the liposuction diet' and promise, 'It doesn't hurt to look good again.' Slinky poses of vampish young models are standard, as are before and after poses to show selected results under careful lighting with optimal make- up and smiles. Yet probably the height of surgical hubris is the ad that features swimsuit-clad magazine centrefold Rebec- ca Ferratti posing with an expensive sports- car, saying, 'So next time you see me draped seductively over a Ferrari you'll know that the true caption ought to read "Body by Smithdeal".'

Qualified plastic surgeons like Dr Smith- deal are not the only ones getting in on the act of bespoke bodies. Legally, anyone medically qualified in the United States can perform brain or open heart surgery on you, or any procedure for that matter, provided that they have operating pri- vileges for that specified procedure in a hospital. Some hospitals have realised the immense revenue that can be generated from cosmetic surgery and have zealously encouraged physicians to expand their repertoires. Hospitals have built special aesthetic surgery centres resembling hotel suites rather than hospital rooms to pam- per 'guests', as one hospital calls them.

Aggressive marketing strategies have worked well across mainstream America promoting 'overall life-style enhancement' to the rich and hoi polloi. The Jewish Hospital in Louisville, Kentucky, has been highly successful with its campaign using slogans like, 'We've taken the wrinkles out of cosmetic surgery,' and, 'When your spirit is forever young, why shouldn't you look that way too?' Within two years of its birth in 1986, this centre realised a pretty profit of over $2.5 million in gross re- venues. Such advertising has also seemed to have reduced the age for requesting cosmetic surgery: 40 per cent of individuals who had face-lifts last year were between 35 and 50 years old. No wonder more and more physicians, throughout the country, and hospital administrators, see aesthetic plastic surgery as the wave of the future. Those who touch patient flesh do better than Midas. Incentives to operate may well be dictated, however, more by accoun- tants' principles than by the Hippocratic Oath.

The situation has become so serious that one conscientious plastic surgeon recently made the cutting remark, 'The field of elective aesthetic surgery now resembles the cheap carnival, complete with flashing coloured lights, gaudy trappings, and loud barkers.' But it is not just a cheap carnival. What has also emerged is a full-scale battle over operating turf, more recently referred to amongst members of the American medical profession as 'scar wars'. Given the financial incentives, some otorhino- laryngologists (ear, nose, and throat spe- cialists) routinely perform face-lifts and, increasingly, aesthetic procedures below the neck, which was once forbidden terri- tory for them. An occasional dermatologist may instal silicone breast implants. Some opthalmologists have become willing pupils in removing bags around the eyes. No longer can plastic surgeons lay claim to a monopoly of flesh manipulation.

During the uncivil warfare physicians have come to physical blows over who has the right to treat a patient, and physicians have filed malpractice suits against other physicians for impinging on their domain. Many bypass the issue of gaining hospital privileges — which would certainly limit their approved operations and generated incomes — by setting up their own private operating room facilities, where 95 per cent of cosmetic surgery is now done. Then only consciences and malpractice coverage (which few cosmetic surgeons actually carry) limit the range of possibilities to `Reshape Your Future', as one luring advertisement proclaims.

Many of these operators will ease your pain further by accepting credit cards or offering their own budgeting terms. For example, one surgeon in Virginia prides himself on making every procedure 'in- stantly affordable'. A breast-lift costs $5,000, which means only $80 per month with financing. (`Financing may vary de- pending on amount of down payment and length of payback period,' the fine print in the glossy brochure notes. 'Full details are available during consultation.') The final accounting for this surgical salvation may just reveal that Faust got off far cheaper with his own credit arrangements. For that matter, Faust didn't have to pay anything in advance: expected of all cosmetic pa- tients. If you're lucky, though, someone might give you a gift certificate for the aesthetic surgery of your choice, as the comedienne Joan Rivers, a walking hoard-

ing for aesthetic plastic surgery, did to close members of her staff at Christmas.

The knife, as well as credit, is also instantly available. That same slick plastic surgeon in Virginia, no doubt aware that almost 50 per cent of patients considering surgery do so for less than a year before having it, is notorious for cruising cocktail parties where he hands out his business card to targeted women (ideally about 40-45 years old, affluent, well-dressed, and recently divorced). After pointing out how easily, safely, and painlessly he could baptise them in his in-office surgical foun- tain of youth, he says sympathetically, 'My dear, I do emergency work. What about tomorrow?'' Many such tomorrows have made him a rich man today.

But surgery of any type is never com- pletely easy, safe, and painless. Easy? An estimated 30 deaths have been directly linked to mismanaged liposuction, not to mention botched operations where too much fat was removed, leading to serious consequences. One patient who brought a lawsuit against her physician almost didn't have a leg to stand on in court — literally She had an area six inches long and six inches wide running down the front of her thigh that was so deep she could place her hand in it. (She won the lawsuit. Inciden- tally, her physician probably learned lipo- suction in the first place at a weekend medical seminar, bought a $4,000 machine, and then began his surgical DIY.) Safe? A woman underwent a tummy- tuck and was so ineptly handled that subsequent infections led to her incurring severe heart damage. Painless? One New York City plastic surgeon, who became a multi-millionaire by the age of 32 through opening a chain of fast-flesh surgeries called Personal Best, had at least 212 malpractice claims pending against him. In one American plastic surgery malpractice claim, when an inadequately anaesthetised patient on the operating table called out in pain, her surgeon first ordered that a bandage be stuck in her mouth in case waiting patients heard her cries.

The American Medical Association (AMA) and other professional organisa- tions such as the ASPRS have been aware of misleading advertising and malpractice for some time, which according to the Wyeden Congregational and Committee costs the American public about $40 billion per year. Yet they have been helpless to do much, despite the lobbying efforts of the powerful AMA, the central organisation of the American medical profession with its 270,000 members and annual budget of $125 million. The 1975 ruling by the Federal Trade Commission (FTC) that allowed professionals such as lawyers and physicians to advertise for the first time — believing competition would lead to better care and lower prices — has been the cause of much of the trouble.

Plastic surgeons were among the first to take advantage of this change. Some of the ads became more Madison Avenue fantasy than fact in promised results, despite the admonition in the code of ethics of the American Society for Aesthetic Plastic Surgery (ASAPS) that no statements 'be intended or be likely to create false or unjustified expectations of favourable re- sults'. For • fear of incurring anti-trust charges, the AMA and other groups such as the ASPRS and ASAPS have been unwilling to intercede: the FTC has made it virtually impossible for the medical profes- sion to police its own to ensure ethical standards and quality care. Aware of this situation, some plastic surgeons and physi- cians have claimed membership of Impressive-sounding medical organisations unrecognised by the official American Board of Medical Specialties (ABMS), which sanctions only 23 medical boards, such as the American Board of Plastic Surgery.

This ABMS board-certification, granted only after rigorous written and clinical examinations, identifies the highest profes- sional attainment. Yet the unwary custom- er, seeing a framed certificate on the physician's wall testifying to his or her board-certification by the 'American Board of Facial Cosmetic Surgery', for example, would imagine it suggested espe- cial professional competence. In fact, it may well mean only that the physician has paid money for the privilege of receiving a framable certificate. Few members of the general public are sophisticated enough to recognise the credentials that matter, with sometimes disastrous results. Needless to say, the FTC's adamant belief in the overriding virtues of competition and advertising has proved erroneous, allowing the unregulated practitioners of elective aesthetic surgery to profit greatly by the experiment. Murderously so.

Finally, after an eight-month investiga- tion, a congressional subcommittee last Year held three formal hearings into cosmetic surgery and its abuses. The chair- man, Congressman Ron Wyden from Ore- gon, opined at the opening of the hearings that 'while some cosmetic surgeons have great skills, too many are hucksters who misrepresent their inadequate training to make a fast buck'. The testimony of experts, horrific accounts by dissatisfied and damaged patients, and physicians rep- resenting competing medical disciplines Vividly confirmed his statement. Many untrained doctors were practising new procedures on unsuspecting patients. Mis- leading advertising legitimised poor quality medical care. Unlicensed, uninspected out- patient surgical facilities jeopardised lives. Accounts of scar wars rendered members of the congressional subcommittee open- mouthed. The FTC's policies were put under close and critical scrutiny. It became obvious that far closer governmental su- pervision was needed to protect the mem- bers of the public all too willing to accept at face value the ads they see and the prom- ises made to them by unscrupulous practi- tioners, who one plastic surgeon forthright- ly referred to as 'moral lepers'.

But no legislation has been enacted yet, and it might take a long time. Despite the extensive adverse publicity — revealing warts, wrinkles, and scar wars involved with the practice of elective aesthetic surgery — the number of Americans seek- ing 'overall life-style enhancement' (Hart- ley's Alpha-hood) through cosmetic surgery increases daily — much to the continuing delight of its practitioners. In- deed, at the April annual meeting in Chicago of the American Society for Aes- thetic Plastic Surgery some 900 members attended workshops on such topics as laser • surgery, nipple reconstruction, removal of tattooes, constructing firmer breasts, and 'facial rejuvenation for active males (adv- anced)'. These surgical entrepreneurs could also attend afterno2n courses on 'Effective Internal Marketing of Aesthetic Plastic Surgery' and 'Effective Investment Strategies'. This last course proved so enriching, by the way, that it was held twice.

Reconstructive and plastic surgery has undeniably improved the quality of many lives. Many Britons recognise this point quite well, given that modern plastic surgery is very much a British contribution to medicine. The surgical work of Sir Archibald Maclndoe during the second world war at the Queen Victoria Hospital in East Grinstead helped to save and to improve many lives, especially those of badly burned soldiers. They became his willing 'guinea pigs', as he frankly admitted while he expanded the boundaries of plas- tic surgery through trial and error. This exclusive Guinea Pig Club, made up of his former patients and under the patronage of the Duke of Edinburgh, still flourishes.

For all the past important British con- tributions, the fact is that there are now more plastic surgeons in Los Angeles alone than in all of England. That is not to say that elective aesthetic plastic surgery is not performed by the 600 plastic surgeons in this country under stricter controls. The British Association of Aesthetic Plastic 'No matter how many Sock Shops close, you're always left with the odd one.' Surgeons has some 100 members dedicated to fostering the exchange of information about aesthetic surgical techniques. The European Academy of Facial Surgery, founded by otorhinolaryngologists and lo- cated in Harley Street, boasts some 350 members. Since the NHS does not readily cover many elective aesthetic surgical proc- edures, British patients desiring Alpha- or Beta-hood appearances will have to go private. Or go to America.

Yet, those seeking surgical improvement in the United States may be unwitting guinea pigs without the royal patronage. Many do not understand what they are getting themselves into. It may be that technical skills will advance, to enable the undoing of bad results from these scar wars. An overseas Guinea Pig Club might be established for the survivors of botched face-lifts, liposuctions, and whatever else done in the name of beauty. The answer might just be the establishment of an American League for Facial Disarmament.

Jonathan Sinclair Carey is director of the Institute of Ethics and Surgery in London.