Laura J. Martin, MD
It may start with one body part. A woman goes in for a tummy tuck after having kids. The surgery is relatively painless and successful, so she figures, why not try another? Maybe a breast lift or a nose job. And what about those little lines that have started appearing around her eyes when she laughs and forehead when she frowns... well, those can be taken care of, too, she tells herself.
Cosmetic surgery is no longer just for the rich and famous. It has gradually seeped into the mainstream.
The number of cosmetic procedures performed in the U.S. has soared in the past decade, from 940,000 in 1997 to more than 1.6 million in 2010, according to the American Society of Aesthetic Plastic Surgery.
“Now it’s not framed as this kind of freakish thing only celebrities do," says Natalie Wilson, PhD, a professor in the women's studies program, literature and writing at California State University San Marcos. "It’s acceptable, expected, and you can get it on your lunch break.”
For some people, it goes too far. And it's not just the Hollywood crowd that's altering their bodies -- sometimes in extreme ways -- to reach their idea of perfection.
According to the American Society for Plastic Surgeons, business from “repeat” patients grew by 13% from 2009 to 2010.
It's relatively typical for people to come in and have two to three surgeries performed at once (like the so-called “mommy makeover,” consisting of a tummy tuck and breast lift), says Phil Haeck, MD, president of the American Society of Plastic Surgeons.
Though he says it’s not the norm, he says he has heard of surgeons spending 10 or more hours performing numerous elective surgeries at once.
Wilson, too, has heard many stories of someone going in for one procedure and leaving the office thinking they need four. She says practices such as “up selling,” offering credit plans and reducing prices for multiple procedures, are not uncommon.
“I have talked with people who go in for a nose job or tummy tuck and then start getting marked up” by the surgeons, Wilson says. “Not all surgeons do that, and some turn people away, but that is how they make their money -- by doing surgery.”
David Reath, MD, a plastic surgeon in Knoxville, Tenn., says he doesn’t see a lot of people wanting extreme surgery, but it does happen. And it’s not always easy to recognize when there might be an issue.
“Sometimes you start working with someone who is reasonable and the more you work with them, you begin to realize you will have to extricate yourself,” he says.
Part of the reason it is difficult to know how much is too much is because it varies from person to person, Reath says.
Some patients may be fine getting three procedures. For others, one may be too many. Knowing if there is a problem starts with figuring out why the patient wants the surgery.
Many of Wilson’s students are female. She says most of them think they are overweight if they are a size 8.
“When they talk about how they look, they think if they look better they will be happier,” she says. “I hear from students that if they look the right way or exercise more it will bring happiness -- not if they get a degree or a job.”
Appearances have long been important to people, but there has been a subtle change over the past decade, Wilson tells WebMD. People used to get plastic surgery when they started to age as a way to hold on to youth longer.
“It used to be that women were beautiful at a certain time and then not necessarily expected to be any longer,” she says. “Now we are expected to be beautiful from the cradle to the grave and not give up.”
This is due in part to the barrage of images we have on the Internet of perfect bodies and the desire to “put off the failure and aging of our bodies,” Wilson says.
She also sees an addictive aspect -- getting hooked on compliments and praise after undergoing a procedure. "It makes us feel better and want that high again,” Wilson says. “It’s almost like a drug. You do the first bit and it feels good, but you need to get more and more to get the same feeling again.”
Another reason people have plastic surgery is because they can’t accurately assess their own bodies, she says.
“Most people have disordered perceptions of their own bodies,” she says.
Though many of us may be more self-critical than necessary, it typically doesn’t disrupt our lives. But for about 2% of the population, it is a mental health condition known as body dysmorphic disorder (BDD).
People with body dysmorphic disorder obsess on a flaw that is minor or imagined. People with the disorder look normal, and are often considered beautiful, says Katharine Phillips, MD, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital and a professor of psychiatry at Brown University.
But they don't see themselves that way. Instead, they "obsess" about their perceived flaw, Phillips says. “It is very distressing and can sometimes make them housebound.”
Phillips says people with BDD may focus on one issue -- for instance, they may think their nose is too big or their ears stick out -- or they may think every part of their body is problematic. She says over the course of the illness, people typically are preoccupied with five to seven body parts.
People who are body dysmorphic sometimes have the same body part operated on multiple times. But because surgery doesn’t help the root of the problem -- which is their mental health condition -- it rarely is effective, Phillips says.
Phillips and her colleagues studied 200 patients with BDD who had cosmetic surgery or minimally invasive cosmetic procedures. Only 2% of them had even slight improvement in their BDD symptoms after their procedures. Even when their obsession eases, Phillips says they often switch their focus to another body part.
Her study also found that, of the 200 patients in the survey, only one-quarter were refused cosmetic treatment at some point by physicians. And surgeons were less likely to turn down surgical treatments than minimally invasive procedures.
Reath says he has turned patients away, but that there is a real “gray area” that surgeons have to wade through. When patients ask for something that a surgeon doesn’t necessarily agree with (like breasts that are too large) but that can be done safely, sometimes he will perform the procedure.
“If it is not my absolute preference, but it is not two standard deviations outside the norm, my job is to educate them on the risks and go from there,” he says.
Assuming someone is in reasonably good health, Reath says there aren’t a lot of major health risks involved in performing too much surgery. But there are a few problems that can occur.
Liposuction, for instance, can be done safely as long as you are only taking out a certain volume of fat. If it is an excessive amount, the risks go up. Doctors also have to be careful not to do too much of anything at one time.
“Surgeon fatigue is a consideration,” Reath says. “No one is as sharp in their eighth hour as they are in their first hour and that’s human.”
When someone has multiple surgeries, there can also be issues like scar tissue that forms during healing and tissue that dies. Breathing problems can occur after too many nose surgeries and people can have dry corneas, causing eye damage, from eye lifts.
Reath says determining what procedures can and can’t be done safely falls solely on the shoulders of the surgeons.
“You have to make sure it is a reasonable operation and the patient has appropriate motivation and they know what they are getting into,” he says.
The industry has some standards that address this to an extent. Haeck says the ASPS trains its members to recognize patients who may have body dysmorphic disorder. He says they often have multiple surgeries on the same body part. They will sometimes try to hide the other surgeries, or they will claim previous procedures have been botched and “heap a lot of praise” on the new surgeon, saying they will be the one to get it right.
“Any surgeon who has been through this once regrets operating on someone with body dysmorphic disorder,” he says.
If you're not sure whether your motivations and expectations are on track, check with your doctor before you undergo a procedure.
And if you find you're obsessing over parts of your body, consider shelving your cosmetic surgery plans until you've talked it over with a therapist. Taking the time to get clear about those issues may help you appreciate any "work" you eventually get done.
SOURCES:Natalie Wilson, PhD, professor, women's studies program, literature and writing, California State University San Marcos.Phil Haeck, MD, president, American Society of Plastic Surgeons.Katharine Phillips, MD, director, Body Dysmorphic Disorder Program at Rhode Island Hospital.David Reath, MD, plastic surgeon, Knoxville, Tenn.
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