ABSTRACT

Cosmetic surgery is one of the fastest growing and most lucrative of medical specialities (Haiken 1997, Sullivan 2001). This chapter considers the historical and social settings and trends that have evolved to provide such an extraordinarily fecund cultural climate in which the practice of cosmetic surgery most certainly thrives. The demand for cosmetic surgery, however, has arisen from within a particular set of social matrices emerging over many centuries. This chapter draws on the work of sociologists and social historians to identify these processes, and to argue that bodily appearance has persistently been used in systematic ways to organize and classify particular social groups. The earliest cosmetic surgery was instrumental in refashioning the features of physical appearance collectively deemed to be stigmatizing, but its more recent emergence as a major grooming industry has seen such surgery take on an increasingly significant role in determining the parameters of appearance, and the appearance of women in particular. Despite the evident growth in the cosmetic surgery industry, determining its actual size relies on estimation. Cosmetic surgery is sanctioned by institutional medicine, but functions largely outside its structures; consequently, it is difficult to establish the magnitude of the industry with any accuracy. This chapter begins by providing a brief overview of the recent growth in the cosmetic surgery industry, before considering the social and historical underpinnings of its formative development. It draws on the Cosmetic Surgery Report (CSR) undertaken by the Health Care Complaints Commission (HCCC) of New South Wales in 1999, and statistics provided by the American Society of Plastic Surgeons (ASPS 2008, 2010, 2011). The CSR (Walton 1999) examined the cosmetic surgery industry in the

most heavily populated Australian state of New South Wales (NSW). It found the way services were delivered to be far from ideal, leaving consumers vulnerable. The CSR defined cosmetic surgery as a surgical procedure undertaken to ‘reshape normal structures of the body, or to adorn the body, with the aim of improving the consumer’s appearance and self-esteem’ (1999:v). It observed that consumers themselves initiate treatments with a view to improving their appearance and promoting self-esteem. It also acknowledged that their judgments about their appearances were subjective. As found in

many global settings, the CSR noted considerable variation in the training of those who practise cosmetic surgery. In Australia the Fellows of the Royal Australasian College of Surgeons

(FRACS) require surgeons who practise in public and most private hospitals to undergo six years of specialized post-graduate training and successfully pass two exams. A basic medical degree completed in Australia, however, comprises two undergraduate degrees, a Bachelor in Medicine and a Bachelor of Surgery. Therefore any doctor who is registered as a medical practitioner can call him or herself a surgeon and practise cosmetic surgery (Walton 1999:34). Hence, a broad range of medical practitioners, including those specifically trained to practise reconstructive, plastic and cosmetic surgery, as well as dermatologists, ophthalmologists, ear, nose and throat specialists, and general practitioners, are among those who currently perform cosmetic surgery and cosmetic procedures. In addition, nurses, under the supervision of medical practitioners, perform cosmetic procedures such as injecting collagen, laser treatments, dermabrasion and facial peels. To a lesser degree dentists also carry out cosmetic procedures. Most significantly, the cosmetic surgery industry currently functions outside the regulated framework of organized medicine, therefore offering few safeguards to consumers (Walton 1999:v). Much cosmetic surgery is performed in private hospitals, day surgery units or doctors’ rooms. Recent developments in local anaesthesia, nerve blocks and sedation have reduced the need for general anaesthesia, resulting in an increasing number of cosmetic procedures, like laser skin resurfacing and liposuction, being performed in doctors’ rooms. The shift to doctors’ rooms is not unique to cosmetic surgery – the development of less invasive techniques has facilitated a more general trend which has seen surgical procedures once conducted only in clinical settings increasingly performed in doctors’ rooms (Walton 1999:29). The relocation from an institutional setting to private rooms frequently

reduces the costs to consumers, but it also diminishes the protections otherwise available to them. Consumers are further exposed to risk because the doctors performing cosmetic procedures are not answerable to a particular professional organization, nor are they required to undergo specific training. They do not need to demonstrate competency and, away from larger clinical settings, safety issues are no longer subjected to regulation or peer review. In addition, while Medicare may cover some cosmetic surgeries in Australia, consumers can also self-refer without prior consultation or referral by a GP. The relationship between patient and cosmetic surgeon is, therefore, potentially exclusive. This is of concern because the clients themselves may already be vulnerable. They may be dealing with doctors whose skills are questionable and who operate outside established structures, which leaves them exposed. One cosmetic surgeon I spoke to during the course of this study said he understood why his peers had such a poor reputation, given that many of those performing cosmetic surgery were ‘shysters’ and ‘not far removed from used car salesmen’.