Cosmetic surgery has become more commonplace. This is not only due to societal changes. The procedures have become safer, and there is an increasing need for medically indicated surgery.
In this issue of the Journal of the Norwegian Medical Association, Kvalem et al. publish a major cross-sectional study on cosmetic surgery among women between the ages of 18 and 60 (1). While the study gives an update on the use of cosmetic surgery, it also provides an opportunity to analyse the zeitgeist and the interaction between our health care services and perceived needs.
The researchers interviewed a sample of more than 3,000 women. Responses were compared to a similar survey from 2003, when 900 of 2,000 Norwegian women randomly selected from the National Population Register were asked whether they 'had ever had cosmetic surgery'. Comparisons were also made with the national survey on living conditions from 2008, when 5,000 women and men were asked whether they had undergone 'cosmetic surgery that they had paid for themselves' (2, 3). In the new study published by Kvalem et al., 17 % declared that they had undergone one or more cosmetic procedures, compared to 7–8 % in both 2003 and 2008.
The authors point to the emergence of social media as one of the most significant social changes to have taken place in the last two decades. They provide interesting and relevant reflections on the effect that social media has on consumer behaviour and on the desire for appearance-enhancement procedures. Other significant societal changes have also taken place. The western world is experiencing an obesity epidemic, and weight loss surgery has been introduced and improved. In recent years, the use of weight-reducing medications has exploded. Consequently, more people experience sequelae involving excess skin and accompanying physical problems and can therefore have medical indication for cosmetic surgery.
A considerable increase in cosmetic surgery has been observed, and this is probably an accurate picture
Surgery has become safer and less costly. In the 1970s and 80s, reduction mammaplasty involved hospitalisation for several days, and blood transfusion was needed in up to 25–30 % of cases (4). These days, the procedure is normally performed as outpatient surgery, and the rate of hematoma given in recent publications is very low (5).
A considerable increase in cosmetic surgery has been observed, and this is probably an accurate picture. Breast enlargements are rarely undertaken on medical grounds, and the frequency of the procedure may be a surrogate measure for the increase in cosmetic surgery. In the current survey, 4.5 % had undergone breast enlargement, which is more than twice the level recorded in 2003, which was 2 %.
In the last ten years, cosmetic injection treatments and so-called 'mini-invasive' procedures have emerged as popular options. These involve considerable tissue changes and an accompanying risk of adverse effects. These treatments have been subject to fewer regulations, and the medical competence of service providers varies. If this 'extreme end' of the cosmetic surgery market had been included in the survey, it is likely that the increase in appearance-enhancement procedures since 2003 would have been considerably more pronounced.
Compared to other countries, cosmetic surgery is well-regulated in Norway, thanks to the licencing regulations for performing cosmetic surgery procedures introduced in 2001, and the regulations on the marketing of cosmetic procedures introduced in 2005 (6). However, enforcement of these regulations has been minimal as regards the new and potent cosmetic treatments. In 2019, the Norwegian Association of Plastic Surgeons therefore highlighted a need to revise the regulations to ensure safe treatment of patients. In 2021, in an effort to reduce body-image pressures, the Norwegian Ministry of Health and Care Services put forward for consultation proposals for statutory and regulatory amendments (21/296). However, to date no such amendments have been introduced.
In 2021, the government temporarily removed the VAT exemption on cosmetic surgery as they sought to reduce body-image pressures. One side effect has been uncertainty as to when a procedure is defined as cosmetic. This has meant that patients with problems that are insufficiently severe to qualify for free treatment, now risk having to pay value added tax unnecessarily when they seek assistance from a private provider of plastic surgery.
Our skin is our most visible organ, but the correction of skin-related problems should not be equated to cosmetics
The authors define cosmetic surgery as 'surgical procedures that seek to change or improve a patient's physical appearance' but add that 'medically indicated plastic surgery can also have a cosmetic component'.
This illustrates the fact that the very nomenclature is problematic when we discuss cosmetic surgery. Based on the authors' definition, operation of non-symptomatic varicose veins would be cosmetic surgery, but in everyday speech most people would use the terms plastic surgery and cosmetic surgery synonymously about 'surgical procedures on skin, carried out by a plastic surgeon'. Our skin is our most visible organ, but the correction of skin-related problems should not be equated to cosmetics. Kvalem et al. did not ask whether the patients paid for their cosmetic procedure themselves, or if it had been carried out by a service provider in the public or private sector. Consequently, it is possible that some of the study's 'cosmetic procedures' involved skin problems corrected on medical grounds.
Excess skin after pregnancy or weight loss, or from aging, can cause problems with dressing, prevent physical activity and cause skin damage due to friction and moisture. Nevertheless, only considerable excess skin will qualify for free surgical correction. The threshold has risen with the increasing number of patients who have undergone bariatric surgery. When this group seeks surgical assistance from service providers in the private sector, they will probably answer 'yes' to whether they have had cosmetic surgery, even if this was required due to an objectively physical complaint.
'Altering normality' is a more functional definition of cosmetic surgery, while 'returning to normality' suggests medical rather than cosmetic grounds. Awareness-raising in respect of this categorisation is important for several fields of medicine. In Norway, plastic surgeons have drawn up ethical guidelines particularly for the performance of aesthetic plastic surgery, and we welcome the government's ongoing work to better regulate the market for 'altering normality' and ensuring patient safety.