Ethics in Aesthetic Surgery: Rituals and Realities

The pursuit of beauty, antiaging, and aesthetic surgery is a lifestyle choice. The patient is generally well and desires the improvement of his/her appearance to enhance self-esteem. There is a plethora of devices and procedures available, hence it becomes difficult for patients to decide which is the most suitable for them. Rampant commercialization, pressure through social media, and inadequate information by physicians and health care workers make it a herculean task for the patient to understand what is true and what is not. To make things easier, the concept of “informed consent” was introduced to give patients complete information on the procedure, results expected, timelines to recovery, and likely complications. “Consent” should be comprehensive and not be a piece of paper for the patient to sign on the dotted line.

This brings to the fore the dilemma of the physician: How much to inform to educate the patient and how much to withhold to avoid frightening the patient. Already the physician is burdened by the “googlization” of medicine. The consultation is often centered on answering numerous queries that the patient has collected by Google search, which may or may not be scientific.

A fine balance is required, depending on the individual understanding capacity of the patient. In the section on ethics, Kapoor[1] emphasizes that informed consent should not be a ritual even in a busy practice or in resource-poor settings. The current doctor-patient relationship has moved away from a holier-than-thou attitude to one of patient autonomy, where the patient is an equal partner in decision-making. He has discussed the practical aspects of informed consent, which must be taken care of particularly to avoid medicolegal problems.

The symposium in this issue is based on volumetric expansion of an aging face with fillers. There has been a paradigm shift from two-dimensional (2-D) rejuvenation to three-dimensional (3-D) rejuvenation of the face. Salti and Rausso[2] present the dual plane technique, which is based on the surgical anatomy of the aging face with deep bone and fat volume loss as well as superficial subcutaneous fat loss. They have treated 147 patients over 5 years with this technique and believe that this procedure leads to optimal utilization of filler with increased longevity. Felipe and Redondo[3] report their technique of a liquid face lift in 86 patients using dilute hyaluronic acid filler, which results in a natural, soft look. Fillers used to rejuvenate the hands are reported by Gubanova and Starovatova,[4] and the lips by Luthra.[5]

With increasing globalization, ethnic variations in the perception of beauty in males and females should be taken into consideration. An innovative technique reported by Shetty[6] for rejuvenating the face, uses the concept of outer circle versus inner circle. All these techniques show that there is a lot of scope in filler rejuvenation, elevating it into an art combined with science.

Dysmorphophobia is an underrecognized and underreported condition in aesthetics. Often there is a fine dividing line between the desire and the obsession. Aesthetic surgeons need to be sensitized to recognize this condition and manage it effectively or refer these patients appropriately rather than unethically continue performing multiple procedures. There is sparse information and knowledge on how to detect these disorders by dermatologists and plastic surgeons, and most patients never reach the psychiatrist. The section on “Bridging the Gap” discusses this issue from the psychiatrist's point of view.[7] In order to practice ethically, the physician must refer patients seeking repeated procedures for minor so-called defects to the psychiatrist for appropriate treatment. Such patients do not have realistic goals and are likely to be always unhappy, regardless of the surgical outcome.

A question rightly asked by Atiyeh et al.[8] is: Is cosmetic or aesthetic surgery a business guided by profits or a surgical intervention to benefit patients? Is it a money-making, frivolous specialty or is it an integral part of the health care system? The ethical practice of medicine is being tested severely as never before. Is it right to sell antiaging services and procedures as if the body is like a machine that needs continuous upgrades and modifications? Like the beauty industry, are we trying to sell our services and taking advantage of the vulnerability of patients to promote these procedures? Should we as physicians pander to their whims and fancies or explain the realities and limits and learn to say no? Are we giving informed consent rightly and explaining the associated morbidity, or are we presenting a rosy risk-free picture to lure the patient? The risk of malpractice claims is highest in cosmetic surgery. They are mostly not due to technical faults but to failure to communicate realities and improper selection of the patient or the procedure.

On the other hand, cosmetic surgery does provide new aesthetic treatment options for patients and can relieve psychosocial stress by enhancing body image. It also offers expanded practice opportunities for dermatologists and plastic surgeons. A fine balance needs to be maintained to avoid a bad reputation to the specialties and to benefit patients. In conclusion, ethical practice in cosmetic and aesthetic surgery must not be a meaningless ritual for profit but in reality, work in the best interests of the patients.