Defining Cosmetic Surgery

An agreed definition of ‘cosmetic surgery’ would be helpful for the purposes of discourse on ethics, patient safety, healthcare policy and health economics. One of the problems with previous attempts at developing a definition is the narrow frame of reference and lack of engagement with the full spectrum of academics and stakeholders. This review brings together the sociological as well as the surgical literature on the topic of cosmetic surgery and examines societal, ethical and healthcare aspects. It outlines principles of constructing a definition and presents a provisional definition for further debate, namely: Cosmetic surgery is defined, for the purposes of a healthcare payer, as any invasive procedure where the primary intention is to achieve what the patient perceives to be a more desirable appearance and where the procedure involves changes to bodily features that have a normal appearance on presentation to the doctor. In contrast, surgery performed with the goal of achieving a normal appearance, where bodily features have an abnormal appearance on presentation due to congenital defects, developmental abnormalities, trauma, infections, tumours or disease does not fall under the definition of cosmetic surgery. It is a given that ‘normal appearance’ is a subjective notion. Determining whether patients have a normal or abnormal appearance on presentation will rely on the clinical assessment of the treating doctor.


Introduction
Cosmetic surgery is increasing around the world with a recent American Society of Plastic Surgeons Report suggesting an increase of cosmetic procedures of 132 per cent between the years AJOPS | ORIGINAL ARTICLE a 9 per cent increase in procedures in a 12 month period. 2 The rise and rise of cosmetic surgery makes it an important area to consider during any discourse on healthcare policy, health economics or safe surgical practice. One of the difficulties for such discussions is that the lines between beauty treatments, cosmetic surgery and surgery for medical need are ill-defined and lack even any set principles for their construction. Presumably, each of these items should be approached and responded to differently by policy makers and perhaps practitioners, yet there is limited clarity about which procedures, performed in what circumstances, and for whom, constitute 'cosmetic' procedures. This paper will explore the notion of what cosmetic surgery is, how it has been viewed in society and the advantages and disadvantages of establishing a definition.

The notion of cosmetic surgery
There are different views on what constitutes cosmetic surgery and the value of it on moral, medical, psychological and social grounds.
Frequent themes in the notion of cosmetic surgery seem to be that it is surgery that is 'not strictly necessary', that it is 'trivial' or 'glamorous'. Others see it as 'life affirming' or as a 'restoration' to which they have a right. What does seem to be a universal understanding is that it is to do with appearance. Some think that any procedure that alters appearance is cosmetic surgery, even when the primary goal of the surgery may be for physical symptoms and where the change  4 However, failure to find consensus seems common among such projects, perhaps due to a lack of common framework and the differing goals of participants.

Cosmetic surgery and society
There is a significant body of anthropological and sociological literature on cosmetic surgery which Plastic Surgeons are not normally exposed to, but which is interesting to consider in this context of an exploration of a definition. Parker, a sociologist who performed an in-depth qualitative study on cosmetic surgery interviewing both patients and surgeons, chronicles changing social attitudes to cosmetic surgery in her book Women, doctors and cosmetic surgery, noting that 'beauty surgery' was initially seen as 'quackery' and was a pejorative term in the late 1800s and early 1900s. 5 In his history of the cultural history of aesthetic surgery, Professor Sander Gilman likewise sets out the early history of cosmetic surgery and society's opinions of it, explaining the vacillating levels of respect given to the practice since its modern origins in the early 1800s. 6 Both note that a turning point in societal attitudes to appearance altering surgery was the develop-ment of the plastic surgical interventions which came with the two world wars and which were focussed on restoring the appearance of soldiers damaged by combat. Restoring these service men to a socially acceptable state brought a different societal perspective on the surgery of appearance and it was recognised as important and valuable work which was morally commendable.
Parker argues that up until the World War II, cosmetic or reconstructive surgery was generally undertaken so that people could 'pass' in societyto look 'normal' as opposed to looking beautiful or different to others. Gilman and Parker report that this phenomenon of surgery for 'passing' in society continued in the post-war period, especially in the USA, but this time took the form of Jewish or Italian Americans requesting rhinoplasties in order to look 'less ethnic' and therefore 'pass' in American society.
The professor of sociology, Anthony Elliott, in his review of the social aspects of cosmetic procedures argues that similar processes of 'passing' continue today, citing the more recent phenomenon of Asian patients requesting surgery to look more like Caucasians, to feel part of the 'society' promoted as ideal in the mass media. 7 The idea of using surgical transformation to fit in to a subset of society that is perceived to be more desirable is therefore a major theme in understanding the sociological perspective on cosmetic surgery.
Feminist studies in the early 1990s portrayed women undergoing surgery as the 'victims' of a patriarchal society brainwashed by an abundance of media portraying female beauty stereotypes. 8,9 However, other academic literature in this area accepts that this framework is over simplistic and that women are highly engaged and educated about their decisions for surgery, acting with 'agency' and even describing a sense of empowerment relating to such surgery. 10 A part of this latter conceptual framework describes women seeking surgery not to conform to some perfect beauty ideal but to reattain a body they feel fits better with their own self-image, that is, to restore some sort of balance between their own self-perception and bodily reality. Davis argues that a woman's choice to have surgery was a way of them taking back some control over their bodies. 10  liposuction is the best route to improved lives, careers and relationships'. 7 Parker interviewed women who had undergone cosmetic surgery and identified three particular groups, none of whom were seeking beautification or knowingly pandering to celebrity status-rather, all the women were focused on 'passing' within their social worlds. Firstly, some women had a part of their body that they regarded as an 'intruder' (for example, a large nose)-something they were born with, often were teased or ridiculed for at school and which impacted on their self-esteem, anxiety and feelings of self-worth. Secondly, women who had given birth to and breastfed their children talked about the need to get back to their 'normal', pre-children body size/shape, particularly with reference to tummy overhangs and so-called 'saggy' breasts. Again, women wanted to 'pass' in society, as opposed to look like a celebrity. Thirdly, women of older age within the workforces wanted to 'pass' or be accepted in reference to younger colleagues, fitting with Elliott's idea of 'ambient fear' in the workplace. 5 These women did not want to look younger or more 'beautiful', just to feel good about themselves and compete successfully in the workplace environment. All of these three typologies suggest the need for women to 'fit in', 'blend' or 'pass' within particular contexts, as opposed to stand out in something akin to a beauty pageant. Whilst all are 'cosmetic surgery', these women's accounts describe a psychological 'need', a feeling of necessity rather than choice. 5 The recent rise of cosmetic surgery for men to some extent destabilises the notion of cosmetic surgery as a purely masculine mechanism of oppression of women. However, it is identified that a 'gender-specific' relationship exists between cosmetic surgery and psychological variables. 12,14 The annual report of the American Society of Plastic Surgeons for 2016 found that 85 per cent of both surgical and 'minimally invasive' cosmetic procedures are performed on women. 1 Although the idea of cosmetic surgery as a purely gendered issue is perhaps lessening 15 there is increasing concern about the driving forces towards the homogenisation of bodies to some sort of abstract 'ideal'. This is manifested in surgery to 'reverse' aging, surgery to alter eyelids and noses in some racial groups and procedures to lessen the features AJOPS | ORIGINAL ARTICLE of genetic conditions such as Down syndrome. 16 The effects of the potential loss of visual diversity in society is an intangible and, as yet, unstudied field.
To some extent the unifying concept between all these types of surgery is the idea of trying to attain a 'better me', with the 'better' being some abstract idealised form. The 'better you' as a product you must buy, is a massive commercial enterprise, including not only the cosmetic surgery industry but also the fitness, health food and fashion industries. As such, it could be hypothesised that cosmetic surgery is just part of the package of consumer society. Although this 'product' is undoubtedly more risky and invasive than many of the other consumer products available, the guarantees and regulation of it are often less. The limited regulatory status of cosmetic surgery in some countries, including Australia, obfuscates many of the details regarding how, where, when, and on whom cosmetic surgery is performed. 7,17 The role of media in promoting images of being young, slim and Caucasian as the desirable society to belong to has been shown to be influential and often problematic, especially among teenagers and even primary school aged children. 18 A Swiss study exposing women to cosmetic surgery advertising found increased body dissatisfaction after exposure to advertising material when compared to a control group. 19 The level of dissatisfaction of women and girls with their bodies is at an all-time high with only 16 per cent of women and 27 per cent of men reporting that they like the way they look in the mirror and 46 per cent of men and 62 per cent of women reporting feeling ashamed of the way they looked. 20

Is cosmetic surgery effective?
The idea of effectiveness usually refers to treatment of a pathological condition. Where there is no pathological condition present it could be argued that it is an irrelevant metric in this group, and that other measures become more important.
Cano and colleagues identify that plastic surgeons must be more concerned with patient perception and quality of life measures because they are not operating with a view to reduce morbidity or mortality. 21 If 'satisfaction' is the goal, there are many reports of high levels of satisfaction following cosmetic surgery, although with caveats around those who are high risk for body dysmorphic disorder. 22 If improvement in psychological wellbeing is taken as the yardstick of success, rather than just satisfaction, a systematic review in 2006 found that evidence in this area was weak, 23 as did a review of facial instruments in 2009. 24 Part of the problem in this area has been a lack of well-validated instruments for use in outcomes measurement, 23 30 Parker's interviews with cosmetic surgeons in the US found that those surgeons regarded cosmetic surgery as being more effective than psychological therapy on the mental health of women, fitting in with the notion of cosmetic surgery as 'psychology with a scalpel'. 31 Parker argues that cosmetic surgeons are not necessarily trained in psychological therapy and ought to be working more with mental health teams. A longitudinal population study of young people in Norway, with more than 3000 initial participants, commencing in adolescence, which followed the cohort over a full 13 year period, compared the characteristics of those who underwent cosmetic surgery (n=71) with those who did not and found that although cosmetic surgery increased women's satisfaction with their breasts in breast augmentation, the mental health of patients was on average worse after surgery rather than better. In terms of factors that predicted whether a participant would undergo cosmetic surgery, they found that those with a history of a suicide attempt were more than three times more likely and those with depression and anxiety were twice as likely to undergo cosmetic surgery. Anxiety and depression increased in the years following surgery. 32 Although the numbers of cosmetic surgery patients were fairly small in the final analysis, these findings do seem to contradict the idea that cosmetic surgery is psychotherapeutic and reinforce the suggestion that access to mental health services for those requesting cosmetic surgery should be readily available.

Why would it be desirable or useful to have a definition of cosmetic surgery?
Developing discourse around the ethics of cosmetic surgery, the media and society requires a common understanding of terms and a definition of cosmetic surgery would surely be useful in such an arena.
From a health economic perspective, a definition would also be helpful. Health expenditure in Westernised countries is rising at a rate beyond what is affordable for governments. 33,34 In an era when complex health care technology is increasingly being used and where people live longer with chronic health conditions, the healthcare payers are looking to ensure that there is no unnecessary expenditure from the public purse. 35,36 Despite a lack of a definition for cosmetic surgery, most countries' governments seem to agree that it is not the role of the tax payer to fund cosmetic surgery.
The notable exception is Brazil, who espouse that 'even the poor have a right to beautiful'. 37 In the

Box 2. Australian health ministers' conference inter-jurisdictional cosmetic surgery working group definition
Cosmetic medical and surgical procedures are surgical operations and other procedures that revise or change the appearance, colour, texture, structure or position of normal bodily features with the sole intention of achieving what the patient perceives to be a more desirable appearance or boosting the patient's selfesteem.
BAPRAS has the following definition for those visiting its website: The term 'cosmetic surgery' refers to a range of surgical procedures that are carried out to alter and enhance a patient's physical appearance.

Desirable elements to a definition of cosmetic surgery
With the plastic surgical and sociological literature in mind, as well as the limitations of existing definitions of cosmetic surgery, the authors suggest that the following points are important in forming a useful definition for cosmetic surgery: • Meaning which is understood by the breadth of the community (which is why the term 'cosmetic' is used instead of 'aesthetic').
• Not trying to be everything to everybody. The key driver for this is health care policy. A definition focussed on mental health, for example, may be different. Trying to meet the requirements of all interested parties would not be possible, so the authors have focussed on a definition fit for the purpose of healthcare policy. This does not mean it cannot be used for research or other purposes as a secondary role.
• Not including extraneous concepts unnecessary to the core of what all agree is important to the essence of cosmetic surgery, which is the idea of appearance.
• Bringing in the idea of 'normal appearance at presentation' as a pre-requisite and recognising that not all surgery to alter appearance, or all surgery that results in an improved appearance, is cosmetic surgery.
• Recognising the key role that the assessing doctor (rather than the government or health care payer) has in assessing the normality of appearance at presentation, in the context of the medical history, and the familial, societal and cultural context as well as the physical examination.
The proposed definition in Box 3 is one that meets the criteria outlined above and may be a helpful preliminary version for healthcare policy and research purposes. There are limitations to this framework and to this study; for example, persons with gender identity disorders may have a 'normal' appearance but one that does not match their identified gender. The definition proposed would not work for such cases and as such requires further development. As this field is complex in itself, the authors were not able to cover it within the scope of this paper.

Box 3. Proposed definition of cosmetic surgery
Cosmetic surgery is defined, for the purposes of a healthcare payer, as any invasive procedure where the primary intention is to achieve what the patient perceives to be a more desirable appearance and where the procedure involves changes to bodily features that have a normal appearance on presentation to the doctor.
In contrast, surgery performed with the goal of achieving a normal appearance, where bodily features have an abnormal appearance on presentation due to congenital defects, developmental abnormalities, trauma, infections, tumours or disease does not fall under the definition of cosmetic surgery. It is a given that 'normal appearance' is a subjective notion. Determining whether patients have a normal or abnormal appearance on presentation will rely on the clinical assessment of the treating doctor.

Conclusion
Cosmetic surgery is a growing phenomenon within our society and it behoves specialist plastic surgeons to lead the way in facilitating public discourse on ethics, healthcare reform and regulation in this field. To do this we need to have a broader usual sphere and to develop a lexicon of common terms, concepts, and concerns. The definition presented here is neither perfect nor exhaustive, but may serve as a starting point for such critical discussion.