Although plastic and reconstructive surgery can be traced back almost 3,000 years to Sushruta and his rhinoplastic surgeries in India, it is really only within the last 100 years that the field has become a formal specialty distinct from general surgery. There have been many developments in this time, from breast implants and Botox to plastic surgeon Joe Murray’s pioneering kidney transplants, hand and face transplants, Carl R. Hartrampf Jr.’s TRAM flap for breast reconstruction, and Rad Tanzer’s microtia reconstruction operations. Despite its size (there are fewer than 7,000 active plastic and reconstructive surgeons in the U.S.), the field has gained widespread attention through reality television shows like Dr. 90210, Extreme Makeover, I Want a Famous Face, and The Swan and dramas like Nip/Tuck.
This new prominence, coupled with the media focus on cosmetic and aesthetic surgery, has raised many interesting ethical questions, including surgeons’ complicity with perpetuating harmful or unattainable standards of appearance, a patient’s right to decide what happens to his or her own body, distribution of resources (allocation of health care funding and doctors’ time), and distributive justice—the potential for increased social stratification as the wealthy compound their advantages with enhanced appearance. The most highly visible of these conflicts is the debate over which procedures are therapy and which are mere “enhancement.” This dispute is colored by psychosocial concerns, such as whether the ramifications of appearance (which can affect a person’s self-confidence, social functioning, dating habits, social mobility, and academic and career success) constitute a legitimate medical condition. Answering that question requires differentiating between the delivery of needed therapy, on the one hand, and the commercialization of medicine or the medicalization of consumer dissatisfaction, on the other. This month’s issue of Virtual Mentortakes on all these questions and more.
The enhancement-versus-treatment debate appears in many of this month’s contributions. June K. Wu, MD, a pediatric plastic and craniofacial surgeon at Columbia, argues that helping a patient with a congenital deformity secure coverage for the aesthetic portion of reconstructive surgery is a part of the treatment and therefore within the scope of the physician’s responsibilities. The clinical pearl on evaluating and treating microtia was written by Mitchell A. Stotland, MD, MS, a pediatric plastic surgeon and director of the craniofacial anomalies program at Dartmouth (Rad Tanzer’s home institution).
Most contributors emphasize the importance of putting the patient’s best interests first. The case 1 commentary is by Paul J. Carniol, MD, associate professor at the University of Medicine and Dentistry of New Jersey and coeditor of Aesthetic Rejuvenation: Challenges and Solutions, A World Perspective, and Eric T. Carniol, an MD/MBA candidate at Boston University. They emphasize the importance of helping patients form realistic expectations and understand their own motivations for seeking surgery. Carniol and Carniol discuss the importance of timing body contouring procedures appropriately, taking into account the patient’s priorities other than aesthetics and self-esteem.
Joseph Rosen, MD, professor of plastic surgery at Dartmouth, and Dartmouth-Hitchcock resident Michael Van Vliet, MD, respond to a question about the ethics of filling an elderly woman’s request for breast implants. They make a case for putting patient autonomy (and, of course, physician nonmaleficence) above moral or aesthetic judgments about the suitability of a particular procedure for a particular patient.
Christian J. Vercler, MD, plastic surgery resident at the Harvard Combined Residency in Plastic Surgery, addresses the cutting-edge issue of facial transplantation. He explains how outcomes have highlighted the importance of selecting patients who are able to cope with the physical and psychological effects of the surgery and describes the components of an ideal informed consent process for facial transplantation.
In addition to serving the well-being of their patients, do plastic surgeons have a particular duty to society? Jordan Amadio, MD/MBA candidate at Harvard and former Harvard Law School Petrie-Flom Bioethics Center fellow, examines that question. Amadio looks at the tension between plastic surgeons’ positive effect on their patients (the alleviation of self-image-related suffering) and the potential for their work to perpetuate harmful notions of normal appearance, causing suffering to nonpatients who do not meet those standards. He questions what ethical responsibilities plastic surgeons have to society and whether they are obligated to advocate for the acceptance of diverse, natural appearances in both prospective patients and society as a whole.
The visibility of the field of plastic surgery has led to arguments about where the doctor’s fiduciary responsibility to patients conflicts with financial self-interest, advertising practices, and a consumer services model. A number of articles in this issue of VM explore cosmetic surgery as a commercial enterprise. Carniol and Carniol examine the practice of advertising package deals on cosmetic procedures and how these advertisements may be misleading. Deborah A. Sullivan, PhD, a sociology professor at Arizona State University and author of Cosmetic Surgery: The Cutting Edge of Commercial Medicine in America, gives some background on the history of marketing cosmetic surgery in the history of medicine section. She cautions physicians to beware the potential ethical challenges posed by commercializing aesthetic services, given the vulnerability of patients and the importance of maintaining the medical profession’s trusted reputation.
David Teplica, MD, MFA, plastic surgeon and clinical associate at the University of Chicago, illustrates how the union of art, science and technology serves and strengthens the practice of plastic surgery. In the art and medicine section, Teplica makes two arguments. First, using findings from monozygotic twins, he provides evidence that body size, but not shape, can be changed with environmental (diet and exercise) modification. Second, he shows how new photographic technology can be used to achieve standardized and more precise documentation of the results of plastic surgery.
Two other sections tackle issues related to plastic surgery in the legal arena. The health law section, by Kristin E. Schleiter, JD, LLM, senior research associate for the Council on Ethical and Judicial Affairs for the American Medical Association, describes the lucrative lawsuits brought against silicone breast implant manufacturers when such implants were a relatively new innovation; it took years to demonstrate the devices’ safety, during which time many lawsuits were prosecuted. And in the policy forum section, Lauren Sydney Flicker and Rachel Zuraw, both JD/MBE postdoctoral fellows at the University of Pennsylvania Center for Bioethics, explain that, though some U.S. lawmakers have advocated that cosmetic surgery, unlike other medical procedures, be subject to a “sin tax,” plastic surgery cannot practicably be classified as taxable.
Undoubtedly, in plastic surgery, as in all medical and surgical fields, one can find examples of both ethical and reprehensible practice. The ethical character of a specialty is determined by its practitioners. Robert Grant, MD, chief of the joint division of plastic surgery of New York-Presbyterian Hospital of Columbia University and Weill Cornell Medical Centers, and UMDNJ medical student Michael Sosin contribute an op-ed on the essential characteristics and traits of plastic and reconstructive surgeons and the importance of good mentors and role models in surgical training and professional development.
The public perception of plastic surgery may be lipo and boob jobs, but plastic and reconstructive surgery has the potential to do tremendous good, including fixing cleft lips and palates, performing nerve repairs in the upper extremity, and restoring a sense of womanhood through breast reconstruction after mastectomies. Organizations like Interplast and Operation Smile epitomize the humanitarian ideals of the field. Given the psychosocial ramifications of appearance and the effect of attractiveness on well-being and quality of life, it is important that plastic surgeons practice their craft and practice it ethically. This means selecting patients appropriately, providing a robust informed consent process, and managing expectations. It is possible for plastic surgery to be an ethical medical specialty that is beneficent, nonmaleficent, and just, so long as the patient’s best interests are the primary consideration.