Who can have aesthetic surgery

This question, on the face of it (pun intended), is deceptively simple to answer: those suitable physically and emotionally who desire it and usually those who can afford it. The last determinant is least discussed by plastic surgeons at meetings, in journals, or even among themselves. Aside from our general reluctance to talk openly about personal income, perhaps we are embarrassed by the disproportionate amount of money we receive for those operations, as compared with our reimbursement for reconstructive procedures. At a symposium in the 1970s, Mario Gonzalez Ulloa (1913–1995) of Mexico City, who had contributed significantly to the development of aesthetic surgery and its popularization, stated the problem as well as the dilemma bluntly and bravely: ‘‘How can we make aesthetic surgery available to all who want it and deserve it and qualify for it medically without killing ourselves?’’ Although this quotation is approximate, its message is accurate, as is the phrase ‘‘without killing ourselves,’’ which I recorded because it was vintage Mario. He was referring more to underpayment than to overwork. Actually, even those who believe that medical– surgical care should be available to everyone because they consider it a basic right do not include aesthetic procedures, operative or ancillary. Rare is the plastic surgeon who wants third-party coverage for cosmetic surgery. Although those responsible for teaching programs make great efforts to have a clinic in which residents, with supervision, can treat patients at reduced rates and at no charge, this is not their custom in their offices with their private patients. If we all did it, Mario Gonzalez Ulloa s prediction would be right: we would be ‘‘killing ourselves,’’ at least fiscally. Certainly, the public would not mind, but most plastic surgeons would not choose monetary suicide. Plastic surgeons today no longer need to debate the benefits of aesthetic surgery with patients or colleagues in other fields as did our teachers. The recognition that aesthetic and reconstructive surgeries both are important does not mean that both are identical. Whereas the surgery of appearance (nonrestorative, nonreconstructive) improves the quality of life, it seldom saves life. It is not as necessary to physical survival as it is to psychological betterment. If we honestly believed that aesthetic and reconstructive surgeries were the same in essence and in purpose, we would not bemoan its coverage by insurance. In fact, we would seek such coverage as we have for reconstructive surgery in cases of congenital anomalies and after cancer or trauma. The fact and the acknowledgment that optimal reconstructive surgery has an aesthetic component do not make both equivalent to us, to the public, or to the patient. One need not be a Nostradamus or a Nobelist in economics to predict that with more people wanting aesthetic surgery as well as more plastic surgeons and others willing to perform it, commercial competition ultimately will lead to patients paying less, but likely not nothing. Furthermore, prospective patients who may be unable financially to have, for example, a surgical face-lift may turn to procedures involving less cost, less risk, and shorter recovery even if they must undergo additional or repeated treatment. Such procedures include botulinum and collagen injections, instillation of fat and fillers, laser treatment, and microdermabrasion. Because the alternatives or Present address: 54 Willow Crescent, Brookline, MA 02445, USA