Surgery for Sale: The Rhetoric of Cosmetic Surgery
Cosmetic surgery is different from other forms of surgery because patients are not suffering from a life-threatening condition, they must voluntarily undergo surgery, and they must pay the bill themselves (Pitts-Taylor 166). But even in the face of recession, cosmetic surgery remains a booming business in the United States. In 2009, the American Society of Aesthetic Plastic Surgeons (ASAPS) performed almost 1.5 million surgical procedures in the U.S. and Canada, and this number only accounts for procedures performed by board-certified surgeons, according to the American Society of Aesthetic Plastic Surgeons' Web site. Cosmetic surgery numbers have nearly quadrupled since the mid-eighties (Pitts-Taylor 3). Also interesting to note are the most popular types of plastic surgery. As of 2009, breast augmentation was most popular, liposuction was second, eyelid surgery third, nose jobs fourth, and tummy tucks fifth. Breast augmentation surpassed liposuction as America's most popular procedure in 2008, and surgeons performed triple the amount of breast augmentations in 2009 than in 1997, according to the ASAPS Web site. These statistics, combined with the fact that plastic surgery pervades the media, suggest that aesthetic plastic surgery is a cultural phenomenon in America.
These statistics raise a number of questions. How and why are so many people choosing surgery? How are plastic surgeons and patients communicating? What type of cultural backdrop does this exchange occur against? To better understand these questions, I will examine some of the language and rhetoric that surrounds plastic surgery. Specifically, I will examine doctor-to-patient exchange, non-doctor-to-patient exchange, and doctor-to-doctor exchange. I will then measure a surgeon's perspective against sociological studies. Because there is such a broad range of plastic surgery, I will focus specifically on breast augmentation for two reasons: it is the number one procedure performed, and the FDA has technical warnings for consumers about it. This enables comparison between doctors, patients, and a third source. This paper does not attempt to take a completely comprehensive look at the issue. Notably absent from the research are firsthand interviews with actual doctors and actual patients. I hope, however, that this document will build a foundation for someone seeking to perform interviews, providing them with a snapshot of the background against which this dialogue takes place.
Annemarie Mol posits that "no object, body, no disease, is singular" (Mol 6). She argues that any medical procedure is any number of different things when viewed from different standpoints. I extend her idea to include cosmetic surgery. Surgeons, patients, culture, and government all construct plastic surgery differently. Even if a comprehensive text about plastic surgery existed, it would still be impossible for someone considering plastic surgery to make a fully informed decision, because an individual's surgical outcome can never be completely predicted or guaranteed. Because of this, it is the shared responsibility of both doctor and patient to ensure patients undergo cosmetic surgery with realistic expectations.
One of the primary ways a patient might gather information about a plastic surgery procedure is the internet. Plastic surgery clinics understand this; therefore they have Web sites. I analyzed four specific Web sites: the American Society of Plastic Surgeons' (ASPS) Web site, the American Society of Aesthetic Plastic Surgeon's (ASAPS) Web site, Dr. Robert Schmid's Web site, and Southwest Plastic Surgery's Web site. The first two sites belong to two of the most prominent and influential boards in plastic surgery. The other two Web sites belong to plastic surgery clinics in west Texas. I will compare these Web sites using three major themes found on each Web site: Choose This Doctor, Do It for You, and Be Careful.
Choose This Doctor (or a Doctor Certified by This Board)
Every site featured a "choose this doctor" message prominently on its homepage. The ASPS placed a "Find an ASPS Member Surgeon" button in the center of their homepage, with a hyperlink to find an ASPS member surgeon right next to the button. The text at the top left of the page reads, "Choosing to have plastic surgery is an important decision. So is selecting a plastic surgeon," with "selecting a plastic surgeon" hyperlinked. According to Nielson Norman Group's eye tracking studies, the top left is statistically one of the first places people look at a Web site; it is considered a prime location to place important information ("Eyetracking Research"). Doctors must believe that some potential patients use the Internet as a starting point to search for surgeons. This demonstrates Mol's theories about the multiple ontology of medicine in practice - the decision to have surgery can start on the Internet. At the bottom of the page, the ASPS invites people to follow them on Facebook, Twitter, and YouTube. These media are used as public relations tools to announce conference times, symposiums, and breakthroughs in technology. Evidently, the ASPS believes choosing cosmetic surgery can be a social virtual decision. When a user "likes," "follows," or "subscribes" to the ASPS, a user declares interest publicly. Perhaps that user's friends will link to the ASPS page and choose ASPS doctors for themselves. To further emphasize the "choose this doctor" message, they include a video recording about the importance of choosing a board-certified surgeon after every animation of every surgical procedure (The site features 3D animations of many popular procedures). "As any licensed physician can perform cosmetic surgery, it's crucial to find one that is properly trained and certified. Choosing a physician who is a member of the American Society of Plastic Surgeons is the first step to ensure quality care and outcomes," says the female voice narrating the video. The ASPS clearly wants patients to choose ASPS surgeons.
The American Society of Aesthetic Plastic Surgeons' (ASAPS) homepage also features a "Find an ASAPS Plastic Surgeon" search box in the center of the site. It appears just below the banner at the top of the page, proclaiming their slogan "The Mark of Distinction in Cosmetic Plastic Surgery." In the "What to Know Before Choosing Surgery" section under "Consumer Resources," they announce that "Your ASAPS-member plastic surgeon is the best source of information as it relates to your particular surgery" (What to Know Before Choosing Surgery, par. 5) According to the ASAPS, an ASAPS-member surgeon is not just a good source of information, he or she is the best. And just like the ASPS Web site, invitations to connect to ASAPS' social media lie at the bottom of the page. The difference, however, is that the ASAPS connects to users' twitter and Facebook accounts and shares the link to the ASAPS' homepage. Again, the message is clear on the ASAPS Web site: choose ASAPS-certified surgeons. These pre-phases of plastic surgery are pure advertising, directed toward whoever is interested; come one, come all, ask questions, promote us. Selection comes later.
Moving from plastic surgery boards' Web sites to local clinics' Web sites, I examined doctorschmid.com, the Web site of Dr. Robert Schmid. I learned about Dr. Schmid by looking up plastic surgery under physicians in the Feist 2009 Lubbock/South Plains Yellow Book. The top left corner of Dr. Schmid's homepage declares that "choosing to undergo plastic surgery is a life changing decision and we're glad you would consider letting us help you make that decision." This statement is intentionally affable, and vague. Keywords such as "life-changing decision," "consider," and "help" aim to direct the patient from the Internet into Dr. Schmid's physical office for a consultation/evaluation. We see the fragmented nature of patient recruitment here. A short paragraph follows, and it concludes with, "Thanks for choosing Dr. Robert P. Schmid," as if people browsing the Web site have already chosen Dr. Schmid. Dr. Schmid's bio appears beneath the paragraph at the top. It boasts that Dr. Schmid is a Magna Cum Laude graduate of Texas Tech and an Honors graduate of the University of Texas Medical School. At the bottom of the webpage, it declares that Schmid is a member of both the ASPS and the ASAPS. It is not uncommon, and certainly seems business-savvy, for a surgeon to be a member of both boards. Schmid's Web site uses local appeal to build his reputation; his bio even mentions that he is one of former Texas governor Preston Smith's grandsons. The message is clear, though; choose Robert Schmid because he is local and talented.
The other Web site I found through the South Plains Yellow Book is plasticsurgerytx.com, Southwest Plastic Surgery Center's Web site. This site has a minimal amount of text on the homepage. Rather, it features pictures of the practice's three physicians standing side-by-side. Just beneath the Southwest Plastic Surgery marquee at the top it says "Bringing out the inner beauty." This slogan more blatantly implies "come to the clinic and the surgeons will figure out what to do next." The top left corner of the site features a thumbnail of a naked female chest next to an About Us link. The About Us link leads to surgeon's bios, detailing how experienced the surgeons are and how the practice has just celebrated its 29th anniversary. It concludes by saying that "Southwest Plastic Surgery Center...assures the highest level of patient care" (About Us, par.4). Choose Southwest Plastic Surgery because of the surgeons' experience and the age of the practice.
Each of the Web sites tries to persuade future patients that their board or their practice is the best. Plastic surgeons compete for business. This frames plastic surgery as a consumer commodity, a service offered. In fact, many surgeons view their practice that way. I elaborate on this idea further in the doctor-to-doctor exchange section.
Do It for You
Although less prominent than "choose this doctor," "do it for you" also appeared on all the Web sites I analyzed. The ASAPS Web site features drawn pictures of surgical procedures under the Consumer Resources link. They walk potential patients through the process of surgery, starting with the consultation, detailing the surgical experience, and explaining the risks and results of the surgery. They have this information for every type of surgery on the site. At the top of the page about breast augmentation, a paragraph concludes, "breast enhancement using breast implants can give a woman more proportional shape and may improve self esteem" (Breast Augmentation, par. 1).
Other examples of the "do it for you" message on this site include this passage on the eyelid surgery page: "You should do it for yourself, not to fulfill someone else's desires or to try to fit any sort of ideal image" (Beauty for Life, par. 5). The ASAPS again reiterates this message on the brow lift and nose surgery page: "A [brow lift/nose surgery] is a highly individualized procedure and you should do it for yourself" (Beauty for Life, par. 5) The Web site also features a video of a patient talking about her breast augmentation. She's a young, attractive blonde who declares, "Now all of a sudden that I've had the surgery, I'm happier," then implores people to "do it for you and only you; no one else" (Real People, Real Surgery, Breast Augmentation). This warning embodies a paradox of plastic surgery. Yes, doctors believe patients should have it, but patients must have it for the right reasons. Each side helps to construct a case for surgery. Mol discusses this when she notes "Illness is something being done to you, the patient. And something that, as a patient, you do" (Mol 20).
The American Society of Plastic Surgeon's site also features the "do it for you" message. In their web brochure about breast augmentation, they state, "Breast augmentation is a highly individualized procedure and you should do it for yourself, not to fulfill someone else's desires or to try to fit any sort of ideal image. Pictures of breast augmentation procedures performed by ASPS Member Surgeons may help you in the decision-making process" (Breast Augmentation Before and After, par. 7) They use the exact same wording as the ASAPS' site. Further, the ASPS offers patient stories on their site. One of the patients, Abigail Hardin, was nominated by the board as a "Patients of Courage Honoree." She has received several surgeries to correct her port wine birthmark on the side of her face, and recently published a children's book about a hippo with a birthmark. In her video, she states that plastic surgery is "not about changing completely how I look, it's actually having people look at me rather than a blemish or a birthmark or anything different." She continues on about how surgery was a part of "wanting to be your whole self" (Abigail Hardin: Patients of Courage Honoree). In her sociological study of women who elected to have cosmetic surgery, Kathy Davis finds this to be a common theme in her book Reshaping the Female Body; women do not undergo surgery to look beautiful, but rather to fit in with the norm (Davis 12).
Of the two clinics' sites I looked at, Southwest Plastic Surgery had the most prominent "do it for you" message. Just beneath the picture of the surgeons in the practice, it reads, "At Southwest Plastic Surgery Center, we know it's about inner beauty, it's about outer beauty, and it's about you." This message emphasizes the duality of one's internal and external appearance, and that the doctors are there to help align those two realities. Dr. Schmid's Web site is a bit lighter on the "Do It for You" message. The site never states it directly, but it is implied. "Breast augmentation can increase fullness and projection of your breasts, improve the balance of your figure, and enhance your self-image and self-confidence" (Procedures, par. 2). Dr. Schmid can help you with your self-esteem. Throughout all these sites, the message is clear: do it for you.
While these sites all encourage plastic surgery, they come with a caveat: be careful. Surgery is serious. The ASPS illustrates this point through the 3-D animations of cosmetic surgery procedures featured on their site (View the New You in 3-D). While the animations neatly do not feature any blood, they present surgery graphically, with pictures of medical tools and surgeon's fingers going in and out of a naked 3-D body with fat, muscles, nerves, and bones. A professional-sounding female voice narrates the procedure. Each procedure is divided into a series of steps. The last steps for every procedure are to be sure and select an ASPS-certified surgeon, and then to apply for financing. Placing financial details at the end implies that the cost of surgery is an afterthought. It also implies plastic surgeons themselves are not concerned with the financial details about surgery; billing is someone else's job. This connects with Mol's case study in The Body Multiple. Mol maintains that the clinic is not homogeneous. "It does not enact a single object" (Mol 51), as the surgeon's disinterest in billing demonstrates. After watching a graphic 3-D surgery animation, a big oval "apply now" button appears over "imagine the new you" in the middle of the screen. The female voice that narrated the surgery says "now you don't have to wait to receive the procedure you've always wanted! Apply now for a patient financing plan through Care Credit." Step one is making a surgical incision and step eleven is applying for financing. This seems to offset the seriousness of the surgical procedure just described,** but nevertheless, future patients have a clear idea of what the actual surgical process entails.
The ASAPS also warns future patients that surgery is a big deal, albeit with a little less flash than the ASPS. Under "Patient Safety Tips" they have an article entitled "Surgical Risks Overview." In this document, they enumerate on risks associated with general surgery, including scars, swelling, infection, bruising, and numbness (par. 3). They emphasize that patients typically need pain medication to help fall asleep for at least ten days after procedures. They also have an "Understanding Risks" section in their information about breast augmentation. They advise discussing the risks of breast augmentation with one's plastic surgeon as the best course of action. Following that, they say that breast implants are not lifetime devices, and warn of the dangers of encapsulation (implant hardening due to scar tissue forming around it), implant rupture, and difficulties with future mammograms (par. 2 &3).
Southwest Plastic Surgery Center and Dr. Schmid have the exact same information and warnings posted on their Web sites regarding augmentation mammoplasty (breast enlargement). These two clinics are only two blocks apart, so they undoubtedly know of each other. Additionally, Googling some of these passages in quotes reveals this information is a template: over 1,000 Web sites return in the results, each with the exact wording. The fragmented clinics single-source their warnings, thus presenting a glimpse of North American plastic surgery as a whole; the plastic surgery multiple. This information states that the major risks of breast augmentation include lack of implant permanence, encapsulation, infection, change in sensitivity of breast skin and nipples, and difficulties with future mammograms.
These sites offer consumers mixed messages. Decidedly, they try to get patients in for a consultation. This is evidenced in the prominent find-a-certified-surgeon boxes on the ASPS and the ASAPS Web sites, and the language used in the clinics' Web sites e.g. "contact us today to set up your first consultation visit and come in and meet our wonderful staff," from Dr. Schmid's Web site, and "ask your plastic surgeon for further information about the particular procedure and what you should expect," from Southwest Plastic Surgery Center's Web site.
While these sites warn patients about the dangers of augmentation mammoplasty, the information is often buried. The FDA serves as another information source about the dangers of breast augmentation. Because the FDA has no vested interest in selling implants, they spell out the dangers more forthrightly. In the "Breast Implant Questions and Answers" section on fda.gov, the FDA states that breast implants do not last forever, the surgery is irreversible, replacing implants is riskier than receiving them, and that breast implants may affect one's ability to breastfeed (par. 14). None of the other sites I looked at said anything about implants affecting breastfeeding ability or the risk of replacing implants. The FDA also recommends MRI scans every two years after receiving silicone implants, and they warn that the cost of these scans may ultimately surpass the initial cost of implants (par. 15). Disturbingly, none of the cosmetic surgeons' sites I examined warned patients about this, either.
To provide some contrast, and to transition to the next section, I will attempt to move away from surgeons' advice to patients and look at a doctor who has a more prominent presence in pop culture: Dr. Phil. Dr. Phil writes an article entitled "Should You Have Cosmetic Surgery?" on drphil.com where he lists questions people should ask prior to cosmetic surgery. He largely argues that an individual should not try to use plastic surgery to fix internal, personal issues. He also reiterates the "do it for you" theme, saying that "the only person who can give you what you want is you." According to Dr. Phil, good candidates for plastic surgery do it for themselves, consider their options carefully, are mostly happy with themselves, and take surgery seriously (Dr. Phil). Surgeons pen a similar theme in their periodicals: realistic expectations of plastic surgery and better informed consent lead to more positive patient outcomes (Rohrich 220; Tobin 157).
Now that we have overviewed some of the language doctor-to-patient Web sites use, we will look at how patients talk about surgery. To accomplish this, I looked at two chat forums, justbreastimplants.com and plasticsurgeryspot.com, to see if there were any discrepancies between how the surgeons' Web sites described surgery and how actual patients described surgery. One thing I noticed is a sharp us/them divide between patients and surgeons. "Surgeons have a skewed view of what is desirable. Not everyone wants to look like a porn star or have trout pout." Another post recommends seeing a psychiatrist before seeing a plastic surgeon, citing Michael Jackson as an example of a surgery junkie (www.plasticsurgeryspot.com).
On the other site, www.justbreastimplants.com/forum, patients discuss the pain of a breast implant procedure. One particular woman received a sub-muscular implant (the implant was placed below the pectoralis), and her pectoralis tore. She describes intense pain even a month after surgery: "Could not stand the pain any longer. It brought me to tears a few times. Sometimes it would just hurt so bad to breathe in deeply. I felt like I could not catch my breath." None of the patients remember the car ride home after the surgery, and they describe the pain much more vividly and colorfully than the surgeon's Web sites, which say "you will most likely be able to return to work within three to seven days of your procedure" (www.plasticsurgery.org). Patients also describe unforeseen inconveniences, such as not being able to drive even two weeks after the surgery. "My left breast is still so swollen that I cannot make turns!" These patients did not expect to encounter complications such as these. Important to note, too, that some people recovered very quickly and posted glowing reviews about their surgery on the Web site. Surgery and recovery time varies on an individual basis, and an individual's outcome for surgery is impossible to fully predict.
Patients receive messages about cosmetic surgery from sources besides the internet, such as television. In her book Surgery Junkies, Victoria Pitts-Taylor examines the effect of the popular reality TV show Extreme Makeover on cultural perceptions of plastic surgery. She cites a Henry Giroux article which calls television shows "popular pedagogies," because they circulate "not only information but also social meanings, norms, and values to their audiences." She notes that before this show, people were "unlikely" to undergo plastic surgery and then expose the results to a national audience. The show wove a narrative. It asked the audience to sympathize with people wanting extreme body transformation. An unattractive appearance was portrayed as causing agonizing life distress, with plastic surgery as the only cure (Pitts-Taylor 50).
The ASPS aligned itself with the show to increase business, although the subject divided the board sharply and a prestigious member resigned. The strategy worked, however, because 2004 saw a 32% increase in ASPS cosmetic procedures performed. By 2005, the show had massive ratings, but the ASPS distanced itself from it because the show portrayed extreme surgical procedures while minimizing the negative effects of surgery, such as pain. They also stressed that the show fostered unhealthy attitudes toward surgery. Dr. Rod Rohrich, president of the ASPS, issued the following statement: "The new wave of plastic surgery reality television is a serious cause for concern. Some patients on these shows have unrealistic and, frankly, unhealthy expectations about what plastic surgery can do for them." Rohrich explains further that plastic surgery only refines or improves someone's natural appearance and should not be viewed as a path to life transformation (Pitts-Taylor 64). This indicates that the "do it for you" message displayed on so many plastic surgen's websites comes with some caveats, e.g. realistic expectations. There is a definite divide between the plastic surgery portrayed on television and actual plastic surgery. Extreme Makeover ended in 2005, but it was the first widely-watched media outlet to normalize cosmetic surgery.
Of course, most people do not decide to have plastic surgery based on television alone. Sociologist Kathy Davis interviewed several women who underwent plastic surgery. In her book Reshaping the Female Body, she finds that each woman referred to a specific person, such as an acquaintance, friend or family member, who helped her make the decision (Davis 125). This person was female in all but one instance in Davis' research. The final decision required some form of outside encouragement from a person wholeheartedly in favor of plastic surgery. The women also did not choose surgery as an impulse decision. They deliberated for years, first dealing with the self-consciousness that came with the problem, then trying to wrestle with accepting the problem, failing, deliberating more, then finally appearing in a plastic surgeon's office for a consultation (Davis 139). These findings are supported on justbreastimplants.com, where many patients discuss how they waited for years to undergo breast augmentation. "For the next three years or so, I continued to go back and forth about the cost, the complications, etc., but on the other hand really wanting them" (http://www.justbreastimplants.com/forum/breast-augmentation-stories/56484-its-twins-very-long.html).
Deciding to undergo surgery is a process, and a patient receives information from a myriad of sources, including other patients, the internet, and television. Again, this document was not meant to be a complete guide to patient-to-patient rhetorical exchange. It aims to measure the climate in which the discussion takes place, considering a few of the sources that help create the temperature.
Different plastic surgeons perform different operations on different patients. I could not find a law against a plastic surgeon performing an operation on any willing patient. Beyond that, cosmetic surgeons disagree about contraindications to surgery. Rod Rohrich, president of the ASPS, spells out acronyms for surgeons to remember problematic patients versus ideal patients (Rohrich, Streaming Patient Selection 220). Rohrich warns surgeons to watch out for SIMON, or the Single, Insecure Male who is Overly expectant and Narcissistic. Surgeons welcome the female SYLVIA, on the other hand, the Secure, Young Listener who is Verbal, Intelligent, and Attractive. Rohrich states that a preoperative screening is mandatory in plastic surgery, and then cites a list from a book by R.M. Goldwyn. This list is titled "Don't operate if:"
- You don't like an individual patient.
- The patient asks you to do something you can't deliver.
- The patient asks you to do something that is outside your aesthetic sense of what the result should be.
- The patient is critical of previous surgeons or praises you excessively.
- The patient is rude to you or your staff.
- The patient lies to you or gives you a false history or information.
- The patient refuses to be examined, disrobe for examination, or be photographed.
- The patient is a perfectionist and wants a guarantee of result.
- The patient is paranoid, delusional, or depressed.
- The patient fails to communicate or is unable to understand what informed consent entails. (221)
Rohrich cites another list of high-risk patients, which include people in a hurry to have surgery, dirty and unkempt people, and the "surgiholic" patient with a history of procedures. Dr. Howard Tobin's list of potentially problematic patients is very similar to Rohrich's (Tobin 158). Tobin cautions against patients with obsessive-compulsive behavior, urgent demand for immediate surgery, extreme flattery, history of litigation, unclean appearance, and unreasonable or unrealistic expectations. Plastic surgeons have to be vigilant; because patients select surgeons and not vice versa, the surgeon must make sure the patient is sane enough to make important decisions. Early studies of plastic surgery and psychology (1940s and 50s) stated that most people seeking cosmetic surgery were psychologically disturbed. Later studies revealed that these early studies did not use standard measures of "psychological disturbance," and the numbers dropped significantly when studies used standard measures. However, this literature produced a societal stigma around cosmetic surgery that still lingers today (Sarwer, Wadden, Pertschuk, Whitaker 3). Society has changed, but surgeons still must screen for disorders, including Body Dysmorphic Disorder (BDD) (Pitts-Taylor 19). According to the Mayo Clinic, people suffering with BDD see a tiny or imagined deformity in their body and it causes them an immense amount of anxiety. Surgery cannot help someone with BDD, because the deformity is a psychological rather than a physical one (Mayo Clinic Staff, par. 1 & 2).
At its bottom line, plastic surgery is a business (see the Choose This Doctor section above). A business must protect itself, especially when it offers services that cannot be reversed or returned. A business must protect itself from lawsuits, from psychologically needy patients monopolizing the staff's time, and from a bad reputation (often caused by ethically irresponsible decisions). Plastic surgeons seek to operate on internally motivated patients instead of externally motivated patients. This raises contradictions with Davis' research where most patients refer to a specific person who helped them make the decision. Plastic surgery is not entirely internally nor externally motivated. As Mol discovered, "Reality is distributed" (Mol 96). Plastic surgery and aesthetic ideals are a dialoge between an individual and the environment around her or him. Doctors attempt to gauge whether or not patients are capable of healthy dialogue with themselves, the people around them, and their doctors. Internally motivated patients attempt to change factors within themselves, but externally motivated patients try to use surgery to change external factors in their lives. The classic example of the externally motivated patient is the woman who undergoes breast augmentation to save her marriage (Edgerton, Langman, Pruzinsky 596).
With the exception of one study, all the literature I reviewed advised surgeons against operating on patients with psychological problems. The study that did operate on problematic patients took place at Johns Hopkins University and the University of Virginia, with the cooperation of a mental health professional. The study found that if the patient and doctor communicate well enough, good surgical outcomes created good psychological outcomes 83% of the time, neutral outcomes 14% of the time, and negative outcomes 3% of the time (Edgerton, Langman, Pruzinsky 594).
But because most cosmetic surgeons do not operate in a university with a mental health professional, this data is not pragmatic for private practices. Private practices tend to adhere to Rohrich's list above, as evidenced in an article by Dr. Howard Tobin, who operates a clinic in Abilene, TX. His article, entitled "What Makes a Patient Unhappy" opens by declaring that plastic surgeons deal in want rather than need, and that patients rarely need the services he offers. He then uses that approach to ensure patients understand fully whether or not they actually want something. "I like to think that my primary goal is to make my patient feel better about himself or herself" (Tobin 159). Using that goal as a map, Tobin puts himself in the patient's place. The patient spends a lot of money and has no guarantee of results. Tobin also recognizes that patients forget much of what surgeons tell them in the consultation. This idea is also stated in other literature; Dr. Mark Gorney states that patients typically retain only 35% of what doctors tell them (Gorney 979), although neither article cites a source for this information. To counteract this, Tobin recommends supplementing the consultation with handouts. He admits that "There are some procedures we do over and over again. Even though there may be some differences with the patient, going through the same discussion can become tedious. Over the years, I have made PowerPoint presentations for the operations I do most frequently" (Tobin 160). That passage illuminates a large gap between patients and doctors in the consultation. For patients, the consultation is a very unusual event, but for the surgeon, it is part of the daily grind. The two come from vastly different places. For Tobin, accompanying the consultation with a handout becomes part of "risk management." For the patient, it is essential to her or his health and vitality.
Rohrich explains this further. He states that each patient has a different reason for each routine procedure he performs, and that patients look to him for answers to their problems. But even further, he posits that "patients seek to experience the intimate shared presence of another person, the surgeon. What do they really want from me? A part of my very self, given to them in the most intimate and personal of settings" (Rohrich, On the Receiving End 567). Rohrich reminds surgeons of how important their time is to their patients, and how just a few hours of a surgeon's time can influence the rest of a patient's life.
Another article details a list of all the signs to indicate a patient has BDD. Ideal patients should know exactly what they dislike about their appearance, and their physical concerns should be easily visible (Sarwer 196). But who determines if a patient's defects are easily visible? Does a doctor have that right? How does cosmetic surgery reframe the clinician's gaze, as detailed by Judy Segal in Health and the Rhetoric of Medicine (36)? Dr. Gorney writes that "[breast augmentation] is not an operation for any applicant whose motivation and emotional stability are not on par with her physical needs. The conscientious plastic surgeon strives to repair physical inadequacy or deformity, while at the same time repairing the patient's ‘body image' and thus, her quality of life" (Gorney 979). In addition to gauging a patient's emotional and mental health, the plastic surgeon also surveys his or her patients for aesthetic flaws. Tobin states that he prefers to use chin implants on rhinoplasty (nose job) patients who have a receding chin, saying that "All of us recognize the importance of total facial balance and harmony" (Tobin 159). Cosmetic surgery reframes the role of the clinician's gaze. Further research is needed to unpack that statement more.
Finally, I must admit one important limitation of my method of gauging doctor-to-doctor rhetoric: doctors publish publicly. They have polished and refined their language for presentation in these documents. Missing from this research is the language of the daily grind. Controversial personal opinions, swear words, and even casual conversations slip by undetected. Still, it stands in contrast to the printed words of surgeons' Web sites and the words of patients in chat forums.
Surgeon vs. Sociologist
Tobin's article provides a sharp juxtaposition to Kathy Davis' research in Reshaping the Female Body. Tobin builds his article around the premise that plastic surgery is built on want rather than need, and then takes a "patient satisfaction" approach to surgery. Through her interviews, Davis discovers that "cosmetic surgery is, first and foremost, about identity; about wanting to be ordinary rather than beautiful" (Davis 12). Unlike Tobin's analysis that plastic surgery is based solely on want (Tobin 157), these women present cosmetic surgery as "the final step in a trajectory of suffering - an attempt to alleviate a problem which had become unbearable" (Davis 74). Tobin sculpts his whole surgical philosophy around a patient wanting plastic surgery versus needing it. He describes something he calls "opportunistic surgery." Basically, it means having a backup plan in the operating room. If, for whatever reason, a surgery is not turning out as well as he would like, he switches the plan to whatever is safest for the patient. In life-saving surgery, this approach might not work, but in plastic surgery, there are often multiple ways to achieve a similar result (Tobin 162). Yet Davis finds that plastic surgery often divides patients' lives into before-and-after events:
The process of deciding to have plastic surgery has all the ingredients of a classic heroic tale: a pluck protagonist who valiantly conquers opposition and bravely overcomes all obstacles in her path, until she finally emerges, victorious and triumphant, with her goal accomplished. While the women I spoke with often described themselves prior to the decision as passively suffering victims of fate, taking the decision gives their life stories a dramatic turn. From the moment that they first contemplate doing something about their appearance, they position themselves as agents, underlining their own role in bringing the event from the realm of fantasy to reality. At long last, they are able to take the reins in hand. (132, 133)
For the women in Davis' studies, cosmetic surgery was a life-saving event. It may not have saved their biological life, but it saved their reality. Mol's thesis that disease is a plural entity manifests itself here, too: Tobin and Davis think of patients their own way, according to the contexts and models that work best in each of their situations.
Tobin also advises surgeons performing a consultation that a patient "can detect when you are simply going through the motions." He reminds surgeons to make eye contact, lean forward, and mirror the patient's actions, but not so much that "it looks phony" (158). Tobin says that "what you tell a patient before surgery is an explanation. What you tell them afterwards is an excuse" (159). Tobin's version of a consultation is much different from the women's consultations in Davis's book. Women explained to Davis that the actual process of a consultation is often humiliating (Davis 128). Coming to the doctor's office and persuading the doctor that one's breasts really are ugly and they really do need surgery while not coming across as mentally unstable is an embarrassing process. Perhaps this is one of the reasons patients have trouble remembering what the doctor said in consultation. This connects back to Mol's The Body Multiple. "[I]llness is something being done to you, the patient. And something that, as a patiend, you do" (Mol 20). During a consultation, both doctor and patient actively construct their roles, while assessing each other on multiple levels. The plastic surgery consultation is a complex rhetorical exchange.
Finally, Davis and Tobin both express a complete inability to determine why a patient walks in to a plastic surgery clinic. Sometimes a patient walks into Tobin's office with a large, unattractive nose, but wants eyelid surgery instead. Tobin says that individually reacting to patients' faces "could distress a patient by bringing up an issue that initially was of no concern" (Tobin 159). Davis declares "in the course of my field work, I watched fifty-five people enter the room for various kinds of cosmetic surgery. With one exception...I was never able to guess what the person had come in for" (Davis 70). When a patient walks in, plastic surgeons must be very careful how they advise him or her. Tobin describes suggesting a chin implant to a rhinoplasty patient: "No such luck! She was quite happy with her chin and only wanted the nose reduced...the result was less than ideal because of the receding chin. Nevertheless, she was happy." (Tobin 159) Pitts-Taylor recounts a similar encounter with a surgeon when she underwent rhinoplasty. The surgeon suggested chin implants to balance her profile. Pitts-Taylor found those types of suggestions to be offensive (Pitts-Taylor 169).
While routine for surgeons, a consultation can be embarrassing and stressful to a patient. It is important for a patient considering plastic surgery not to rely exclusively on information obtained in the consultation. Because of patient anxiety, stress, and other factors, patients often do not retain information. Some surgeons supply patients with a written record of the consultation, but patients should look at outside sources before committing to surgery, and doctors should encourage them to do so.
Cosmetic surgery is not a one-way street. Patients and surgeons experience the phenomenon from very different perspectives. Examining the communication processes between doctor and patient is important, because surgery takes place. I have taken a cursory look at some plastic surgery and clinics' Web sites to discover common themes between each one: Choose This Doctor, Do It for You, and Be Careful. I contrasted the warnings on these Web sites with the warnings administered by the FDA and Dr. Phil. Then I examined a few chat forums to see how the stories on the plastic surgeons' Web sites differed from the stories on the patients' Web sites. I examined some of the messages television broadcast about plastic surgery with Pitts-Taylor's analysis of Extreme Makeover, and I read Davis' account of how women decide to undergo cosmetic surgery. Then I compared different plastic surgeons' methods of evaluating patients, and some of the criteria for problematic patients surgeons commonly share. Finally, I compared the reality of a plastic surgeon with the reality of a sociologist to highlight the differences between their fields, and to highlight how a patient might get stuck in the middle. The point of comparing all these sources was to illustrate a fraction of the realities that construct cosmetic surgery. The issue exists from so many different angles that making a fully informed decision is impossible. Yet because the procedure can cause the patient much happiness or misery depending on the outcome, it is important for a patient to make a well-informed decision. A large part of this responsibility rests with the surgeon, but because the issue is so complicated, one party cannot be responsible for everything. Patients must research the issue and have a clear idea of what they want and a realistic expectation of the outcomes of the surgery, including its risks and disadvantages. Because plastic surgery cannot be reversed, both the surgeon and the patient must be absolutely clear about the operation before any surgery takes place.
**Since writing this paper in 2010, the ASPS has updated their videos to include a printout sheet of questions to ask the doctor before surgery. This gives the process more gravity by helping the patient understand the risks of surgery personally. Return to reading
Note: Not all of these links work anymore :'(
The American Society for Aesthetic Plastic Surgery. 2009. Web. 23 February 2010.
The American Society of Plastic Surgeons. 2010. Web. 24 February 2010.
Davis, Kathy. Reshaping the Female Body. New York: Routledge, Print.
Edgerton, Milton, Margaretha Langman, and Thomas Pruzinsky. "Plastic Surgery and Psychotherapy in the Treatment of 100 Psychologically Disturbed Patients." Plastic and Reconstructive Surgery. 88.4 (1991): 594-608. Print.
Gorney, Mark. "An Approach that Integrates Patient Education and Informed Consent in Breast Augmentation." Plastic and Reconstructive Surgery. 110.3 (2002): 979. Print.
Justbreastimplants.com/forum. 2010. Web. 27 April 2010
Mayo Clinic. "Body Dysmorphic Disorder." 2008. Mayo Foundation for Medical Education and Research. Web. 20 March 2010.
McGraw, Phil. "Should You Have Cosmetic Surgery?" 2009. Web. 04 April 2010.
Mol, Annemarie. The Body Multiple. London: Duke University Press, 2002. Print.
Nielson, Jacob and Kara Pernice. "Eyetracking Web Usability." 2010. Web. 16 February 2010.
Pitts-Taylor, Victoria. Surgery Junkies: Wellness and Pathology in Cosmetic Culture. Piscataway, NJ: Rutgers University Press, 2007. Print.
Plasticsurgeryspot.com. 2010. Web. 15 April 2010.
Robert Schmid. 2004. Web. 21 April 2010. http://www.doctorschmid.com
Rohrich, Rod. "On the Receiving End: The Patient's Perspective." Plastic and Reconstructive Surgery. 120.2 (2007): 567-568. Print.
Rohrich, Rod. "Streamlining Cosmetic Surgery Patient Selection - Just Say No!" Plastic and Reconstructive Surgery. 104.1 (1999): 220-221. Print.
Sarwer, David, Thomas Wadden, Michael Pertschuck, and Linton Whitaker. "The Psychology of Cosmetic Surgery: A Review and Reconceptualization." Clinical Psychology Review. 18.1 (1998): 1-22. Print.
Sarwer, David. "The "Obsessive" Cosmetic Surgery Patient: A Consideration of Body Image Dissatisfaction and Body Dysmorphic Disorder." Plastic Surgical Nursing. 17.4 (1997): 193-9; 209. Print.
Segal, Judy Z. Health and the Rhetoric of Medicine. Carbondale, IL: Southern Illinois University Press, 2005. Print.
Southwest Plastic Surgery Center. 2003. Web. 21 April 2010.
Tobin, Howard. "What Makes a Patient Unhappy." Facial Plastic Surgery Clinics of North America. (2008): 157-163. Print.
U.S. Food and Drug Administration. "Breast Implant Questions and Answers." 2009. Web. 15 March 2010.