It is the Cooperation, Stupid!

INTRODUCTION

There has been an ongoing debate in several countries on who is not qualified to learn and practice cosmetic and aesthetic procedures. Many professional societies representing a diverse group of specialists often claim competence in a particular cosmetic or aesthetic procedure and project it as their exclusive domain and try to restrict other specialists from other streams to learn it, do it and master it. This is a seemingly never-ending debate, and the professional societies often have biased views due to conflicting interests. The regulatory bodies have been unable to decide on such issues, as aesthetic medicine and surgery is a relatively new field which at present is poorly defined, high in demand and not an independent speciality with a dedicated postgraduate course.

CONCEPTUALISATION OF BEAUTY, AESTHETIC SOCIALISM AND INTER-DISCIPLINARY COOPERATION

Aesthetic medicine and surgery is gaining rapid significance as the society at large has given up the myth of inner beauty since the 1980s and allowed open and uninhibited discussions on physical beauty. There is a biological and evolutionary basis of beauty. Beautiful creatures are healthier than less attractive creatures.[1] The biological anthropologist Karl Grammer found that symmetrical scorpion flies attract more mates than asymmetrical ones.[1] In humans, more attractive women produce more offspring over a lifetime than less attractive women. It has been observed that even young infants look more frequently at beautiful faces and beautiful children are less likely to get punishment in school.[1] Appreciation of beauty is one of the conserved traits in the animal kingdom [Figure 1a].

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Figure 1

(a) The attraction towards beauty is a common trait across species. The author was attracted towards the beauty of these flowers, so was the insect. (b) The aesthetics is a common speciality across many branches of medicine. Dermatologic Aesthetic Surgery International League Congresses are so successful because they engage different specialists on a single platform to create a high-standard scientific programme. The picture shows some of the Indian colleagues during a social event of the Dermatologic Aesthetic Surgery International League Congress - 2016 in Dubai

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Quantum physicist David Deutsch introduced the concept of objective beauty.[2] He emphasised that beauty exists outside cultural fads or sexual selection and it is as objective as the laws of Mathematics and Physics. People from South Africa and Austria judged the same Japanese women as beautiful suggesting that beauty is defined on similar lines across cultures. Populations as diverse as the members of Hazda tribe of Africa, who are not exposed to the external world and Europeans, judged the more average faces of Hazda tribe as attractive suggesting that the cross-cultural similarity of beautiful traits is not due to the effect of Western media and ideals.[3]

Beauty is all about averageness. Faces possessing characters common in a population are considered more beautiful. Extreme (non-average) genotypes are more likely to possess genes that are detrimental to an individual than those with more average genotypes. Thus attraction to averageness (close resemblance to the majority of other faces within a population) is also explained by theory that beauty is associated with biological fitness.[4] The most intriguing example is the colour of skin. In Asian societies, there is a great demand and huge market for the so-called ‘fairness creams’ which reflect the strong desire of people to turn the dark colour of their skin fairer or close to the global averages. On the other hand, many light skin-coloured populations in the West try to tan their skin by exposing to sun or ultraviolet rays to make their skin darker (closer to the global averages) even at the risk of exaggerated photoageing and skin cancers at a later age.

Though the basis of beauty is explained by biology, it is unfair that people are judged by their appearances only. Research has shown that attractive people are judged as being more trustworthy as compared to the not-so-attractive ones.[5] Beautiful people are inherently at an advantageous position due to their attractive traits.

The author (SG) introduces the concept of aesthetic socialism; according to this, those who are not so beautiful or those who have lost their beauty because of disease, trauma or ageing should have an opportunity to achieve or regain attractiveness by enhancing or restoring their beauty by modifying dimensions, proportions and complexion to bring them closer to the population averages so that they can enjoy social privileges which a naturally beautiful person enjoys. Aesthetic medicine and surgery can help achieving this by interdisciplinary cooperation and interaction to devise strategies to enhance or restore beauty.

Karl Grammar has done extensive work on the anthropological, biological and evolutionary basis of beauty. He identified eight pillars of beauty (the author has added two more i.e. the body shape and physical fitness).[1] Table 1 suggests how inter-disciplinary cooperation is necessary to achieve the aesthetic socialism.

Table 1 The pillars of beauty and how experts from different specialities can work together to enhance or restore beauty when it is lost or missing and achieve the goal of ‘aesthetic socialism’ by giving everyone a chance to look beautiful and thus enjoy sociocultural advantages

FREE MARKET AND AESTHETICS INDUSTRY

Many corporate houses are entering in the healthcare sector. Modern medicine, as a whole, and aesthetic medicine and surgery, in particular, is rapidly becoming a part of the profit-making industry. When we adopt the models of market for medicine, we are exposed to both the strengths and pitfalls of the market. We are living in a globalised world which allows open competition in the market; those who provide quality services and products will survive. Minimally invasive aesthetic medicine and surgery is among high-demand, high-profit and low-risk ventures and attracts a large number of specialists from different specialities. This upwards trend of inter-specialty aesthetic care is likely to continue for several more years until it slows down due to saturation of the market. For example, the number of cosmetic procedures in the United States has increased from 10 million procedures in the year 2005 to close to 16 million procedures in 2014, this amounts to an enormous growth of 60%.[6] The American Society of Plastic Surgeons Report indicates 759% increase in the use of Botulinum toxin Type A, 274% increase in soft-tissue fillers, 14% increase in chemical peel and 52% increase in laser hair removal between 2000 and 2015 in the United States.[7] This includes a period of economic recession which affected other industries but did not affect the growth of cosmetic procedures. Hassan Ghaladari jokingly said in his lecture during the Dermatologic Aesthetic Surgery International League (DASIL) Congress in 2016 at Dubai that ‘people may die hungry but they don’t want to die ugly’. Thus, the insecurities of specialists regarding the loss of market to another specialty to another specialty are excessive and unnecessary. There will be enough demand for cosmetic procedures for all in the foreseeable future. Rather professional societies should focus on strengthening the training opportunities for their members to improve the quality of aesthetic services and place them in a comfortable position in the aesthetic industry.

The training opportunities to interested specialists will continue to grow to meet the increasing demand of cosmetic procedures. As the open market principles are applicable to aesthetics, different specialties and specialists would seek and attempt to legitimise their claim on this field. On the other hand, beauticians and unqualified workers will also try to put forward their claim on quasi-medical cosmetic procedures in an attempt to capture the market. This may become a challenge in countries where regulatory bodies are not so effective. In such countries, they will capture a significant share of the minimally invasive aesthetics market as services provided by them will be economical as compared to qualified physicians.

LESSONS FROM THE DERMATOLOGIC AESTHETIC SURGERY INTERNATIONAL LEAGUE

The DASIL has set high standards of scientific content in their annual congresses. It is an excellent platform where experts and specialists of various specialties who have common interests in aesthetic and dermatologic surgery come together to exchange knowledge and interact [Figure 1b]. Just have a look at their membership categories below; it does not discriminate between specialties:

• Fellow member: A physician or surgeon, either allopathic or osteopathic, in good standing within the individual's country and is certified or credentialed by the country's or regional accrediting agency

• Associate member: A physician or surgeon, either allopathic or osteopathic, in good standing within the individual's country and who is eligible to be credentialed by the country or geographical accrediting agency

• Fellow-in-training: An individual currently engaged in post-residency or postgraduate study: graduate of an allopathic or osteopathic school who is studying in specialty-focused training

• Affiliate: A non-graduate of either an allopathic or osteopathic medical school who is actively engaged in the study and training of either dermatologic or aesthetic surgery or is employed supporting this practice environment

• Retired: A person who is no longer in active practice or employment, who has reached a predefined age but still wants involvement with the DASIL.

For a professional society to grow and expand, it has to breach the narrow boundaries of nationality, specialty, gender, age, etc., The Association of Cutaneous Surgeons (I) (ACS[I]) can take the lead from the DASIL. Some suggested steps which ACS(I) can take for its members are as follows:

• Take initiatives to include cosmetic, aesthetic and dermatologic minimally invasive procedures in postgraduate training curriculum of dermatology

• Form an alliance with different specialities to ensure holistic advancement in the field of cosmetic and aesthetic surgeries in India. This will ensure exchange of knowledge and will facilitate learning of ACS(I) members from the best of the experts

• Increase learning opportunities for its members through multidisciplinary conferences, workshops, hands-on training courses and fellowships. ACS(I) Academy is already working on this. However, in the second phase, ACS(I) should involve experts from other specialties and use modern techniques in imparting training and providing fellowships to its members [Figure 2]. This will be mutually beneficial.

• Let us stop worrying about the loss of patient population to another specialty. There are 10,000 dermatologists in India for a population of 1.3 billion, out of whom, only less than a quarter practice cosmetic and aesthetic surgeries. This means, on an average, one cosmetic dermatologist is catering to the aesthetic needs a population of about 500,000 people. The demand and supply deficit will continue to remain high.

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Figure 2

Milind Naik, an oculoplastic surgeon from Hyderabad, India, had organised a three-dimensional video workshop for the Association of Cutaneous Surgeons (I) members, mostly dermatologists, during the Association of Cutaneous Surgeons (I) North Zone workshop on November 13, 2016, in New Delhi. Interdisciplinary interaction and exchange of knowledge along with the use of modern technologies for training and teaching are the need of the hour

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IT IS THE COOPERATION, STUPID!

About 1½ centuries ago, Charles Darwin introduced his famous theory of evolution. According to his theory, struggle and violence are not just part of animal or human nature but also the principal ‘forces’ behind evolutionary advancement.[8] Darwin theorised that the fittest ones survive in the struggle for existence. However, subsequently, with further advancement of science, we came to the realisation that cooperative interaction among organisms and their environment is a far more important factor in evolutionary advancement than competitive struggle. The cooperation among the members of hunter-gatherer Homo sapiens gave them an evolutionary edge and thus supremacy over other species.

The significance of cooperation cannot be overemphasised in the modern world. The countries such as the United States which have opened their door to scientists and technocrats from all over the world have achieved more prosperity and technological advancement.

As an association, we should follow the same model if we wish to evolve in the current socio-cultural-economic scenario with the rapidly increasing demand of cosmetic and aesthetic procedures [Figure 2]. In the introduction, the author said aesthetic and cosmetic surgery is no one's domain, he ends this viewpoint by saying aesthetic and cosmetic surgery should be everyone's domain (i.e. everyone, in allied specialities who is trained in aesthetics), till such time it is an independent specialty with a dedicated post-graduate course. Let us cooperate with others and evolve!