What Is Aesthetic Surgery, Anyway?

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” “The question is,” said Alice, “whether you can make words mean so many different things.” “The question is,” said Humpty Dumpty, “which is to be master—that’s all.”1 Perhaps the definition of aesthetic surgery has always been somewhat subjective, but I believe that lately it has become more so. At one extreme are those who might argue that almost any operation accomplished in a manner that avoids disfigurement or distortion and minimizes visible signs of surgical intervention could be labeled “aesthetic.” According to this standard, a hysterectomy producing a well-placed, symmetrical, and minimally-distracting scar could be considered an example of aesthetic surgery. I imagine that virtually all readers of this journal would disagree! Although many types of surgery have an aesthetic component and can produce either a more or a less aesthetically-pleasing result, it seems obvious this does not necessarily qualify them as aesthetic surgery. I have always maintained that any operation on the female breast is an aesthetic procedure and, with the exception of breast reduction (which actually treats symptoms), all of our other efforts are aimed at restoring self-image, self-esteem, and confidence. We could even argue that any operation on the face and nose similarly falls under the category of aesthetic surgery. We always judge our results in breast, face, and nasal reconstruction as much, if not more, on the aesthetic quality than any functional restoration. The finer line, and undoubtedly the line most apt to be blurred, is the difference between aesthetic (cosmetic) and reconstructive plastic surgery. Today, it is not uncommon to see plastic surgeons title their papers and presentations with phrases such as “aesthetic breast reconstruction” or “aesthetic reconstruction of the nose” and to talk about “aesthetic reconstructive surgery” as an entity.2,3 Does this imply a growing tendency among plastic surgeons and related surgical specialists toward a lack of distinction between aesthetic and reconstructive surgery? Officially, there is a reasonably clear-cut distinction. According to the definition adopted by the American Medical Association (AMA) in 1989, “Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.” The AMA defines reconstructive surgery as surgery “performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”4 Of course, it is this last line that is particularly subject to interpretation. The American Society of Plastic Surgeons (ASPS) has accepted the AMA’s definition, which appears in the public section of its Web site.5 The American Society for Aesthetic Plastic Surgery (ASAPS) presumably holds the same or a similar official position, although I could find nothing specific on its Web site. Long before the AMA tried its hand at definitions, Italian surgeon Gaspare Tagliacozzi, in 1598, wrote concerning nasal reconstruction, “We restore, rebuild and make whole those parts . . . which nature has given but which fortune has taken away, not so much that it might delight the eye but it might buoy up the spirit and help the mind of the beset.”6 Although his words are most often quoted in the context of reconstructive surgery, Tagliacozzi’s remarks should also resonate with aesthetic surgeons, whose work is directed toward patient self-esteem. Interestingly, Tagliacozzi had many opportunities to practice his nasal reconstruction technique given the high incidence of saddle nose deformity, a disturbing social stigma in light of its association with the syphilis epidemic of that period.7 As Tagliacozzi’s insightful observation implies, the result of a reconstructive operation is judged not only by its restorative success, but also by its aesthetic quality. It has always been so, but certainly as reconstructive techniques have improved, the expectations for aesthetic outcomes have also risen. I believe that these rising expectations have contributed to blurring of the distinction between cosmetic and reconstructive surgery. Although there is absolutely no question that the ability to produce aesthetically superior results in reconstructive surgery is a tremendous achievement, it is nevertheless critical that we continue to differentiate between purely aesthetic surgery and the important aesthetic component of reconstructive surgery. One of the most compelling reasons for this distinction is a practical one. Our healthcare system recognizes the medical necessity of reconstructive surgery and therefore, in most cases, insurance is willing to pay for it. This is obviously critical to patient welfare. Take, for example, reduction mammaplasty: in an effort to reduce the subjectivity of defining a particular patient’s breast surgery as aesthetic or reconstructive, most insurance companies define the latter in terms of a required minimum amount of tissue removal—a highly imperfect approach, I might add, and one that is discouraged by ASPS in its advisory to third-party payers.4 Nevertheless, such policies are an attempt to more objectively define reconstructive versus aesthetic surgery. One of the gray areas with regard to the distinction between aesthetic and reconstructive surgery concerns the refinement of aesthetic outcomes following a reconstructive procedure. The applicability of insurance coverage may become a highly subjective call on the part of an insurer’s medical director, if the terms of the patient’s policy are unclear.8 I submit that the aesthetic component of a reconstructive procedure, whether the aesthetic refinement is accomplished in one or multiple stages, should not be considered “aesthetic” or “cosmetic” surgery. For ASAPS, the distinction between aesthetic and reconstructive surgery remains highly relevant. Without such a distinction, ASAPS would have no effective means to screen candidates for membership and no reason to exist as a separate organization. When surgeons apply for membership in ASAPS, they are required to submit documentation of aesthetic cases performed over the 12-month period preceding their application. The Society has established a minimum number of cases, below which an applicant will automatically be turned down for membership. The precise definition of aesthetic versus reconstructive becomes critical to the membership committee’s fair evaluation of each candidate. Although there are many excellent reconstructive surgeons who present beautiful work, if they do not present a sufficient number of purely aesthetic cases, they will not be accepted into ASAPS membership. How else could ASAPS support its mission and fairly represent itself to the profession and the public as a society of individuals with requisite experience specifically in aesthetic procedures? I believe that beyond the practical issues that I have already mentioned, there are additional reasons to maintain the “purity” of aesthetic and reconstructive surgery as distinct entities, while always acknowledging that one discipline informs and influences the other in important ways. The public is awed and inspired by the “miracles” performed daily by reconstructive plastic surgeons. The public is also willing to accept that in many cases, the results of reconstructive operations simply cannot be “perfect” and that reconstructive surgery, quite often, is “major” surgery. Cosmetic surgery, on the other hand, has become part of mainstream America. Apprehension concerning cosmetic surgery has been significantly reduced through careful and conscientious patient education. Expectations about the results of cosmetic surgery run high, despite all attempts to encourage realism, but in the majority of cases, results at least approximate expectations. In short, Americans as well as consumers in many other countries have increasingly come to regard cosmetic surgery as something desirable, safe, and accessible. Reconstructive surgery, on the other hand, is “necessary” surgery with the attendant risks this implies. For these perceptions to remain distinct is not, in my opinion, undesirable. I don’t profess to know exactly what Humpty Dumpty was getting at in the quote with which I opened this editorial, but here is my point: surgeons should certainly apply aesthetic standards to all of our work, but if we apply the label “aesthetic surgery” too broadly, we invite others to do the same. Perhaps most importantly, we ultimately obscure the very essence of our discipline and, quite possibly, lose our mastery over it. The author has no disclosures with respect to the contents of this editorial.