To what extent is plastic surgery ‘ethical'? Selma Roth Saudi Gazette Most people want to look young and beautiful, but how far would you go to get the perfect look? Statistics from all over the world suggest we are increasingly willing to go under the knife to achieve our ideal self, as cosmetic surgery — despite worldwide recessions — has been on the rise. One study from 2011 showed that in the Kingdom, a total of 46,962 surgical procedures in addition to 70,254 non-surgical procedures had been performed, ranking the country at 22 worldwide. The study, conducted by The International Society of Aesthetic Plastic Surgery, showed that lipoplasty — a cosmetic surgery operation that removes fat from different sites on the human body – was the most popular surgical procedure of 2011 both in the Kingdom and worldwide. Remarkably, the study showed a major divide between Europe and North America, where breast augmentations were more popular, and South America and Asia, where lipoplasty topped the list. Among the non-surgical procedures, botulinum toxin type A — more commonly known as Botox — remained the most popular. However, undergoing a surgery is not without dangers. Saudi Gazette spoke to Dr. Pierre Nicolau, a consultant plastic surgeon at the Plastic Surgery and Burns Unit of the University Hospital Saint Louis in Paris, France, about the dangers of skin fillers, the reasons people decide to have aesthetic surgery, how cosmetic surgery trends are changing, as well as the ethical questions that may arise. The hidden risks of skin fillers The recent scandal of faulty PIP implants, which were made from industrial grade silicone as opposed to medical grade material and had double the rupture rate of other implants, did not visibly affect women's willingness to go under the knife: Breast augmentation surgeries spiked in the last two years. When it comes to minimally-invasive procedures, however, most people are not even aware of the difficulties that may arise. Astonished by the lack of scientific publications and studies on the biological effect of fillers, Nicolau, who also owns a private practice in Spain, started to investigate this in the early 2000s. “Up to now,” he says, “there are none or very seldom and on very limited subjects. It seems that many manufacturers probably prefer not.” The reason is not surprising. According to the plastic surgeon, who presented more than 170 communications and publications and is an expert on skin fillers, 100 percent of the people who gets injected with some type of skin fillers get an inflammation. “But this is not known. Or anyway, it is known because it is published, but it's not said because it doesn't show. This inflammation is a biological reaction at the cellular level. You have to take a biopsy, look under the microscope and you will see the signs of this so-called inflammation,” he says. At first the problems are not noticeable, but after a few years the skin becomes “extremely fibrotic, stiff and thicker, and it's not a natural, thin, moving skin,” says the skin filler expert with over 25 years of experience. “Can we decide that the only concern we have is the visible part? If that is the case forget about it: It's excellent. But if we consider that the invisible part is also very important then we have to think about that.” And for many patients the invisible part is indeed very important. They feel a hard lump in their skin, and they hate it. According to Nicolau, some of them are really unhappy with it. Recent studies focus on stem cells, in particular multipotent stem cells, which can produce cells of multiple differentiated cell types. These could be used to stimulate the skin to create more collagen. “It's a completely different concept,” Nicolau says about a new type of filler that uses this technique, calling it the future of skin fillers. The human body as a screen “I'm a plastic surgeon, and I make no difference between someone who comes for a surgery for a hare lip or after burns or an accident or a tumor, and someone who comes for a crooked nose or because of the aging of the skin. Why? Because these people suffer, and I have no ruler to measure the suffering,” he says when asked his opinion about cosmetic surgery. But shouldn't we accept ourselves — and our loved ones — the way we are, including crooked nose or wrinkled skin? Nicolau gives the example of a child who got burned in early infancy and grew up with terrible scars. Once this person reached the adult age, he only wanted light corrections even though he was almost disfigured. He did not mind, because he had always seen himself like that. On the other hand, he knows a case of someone with a small scar on his face and who did not go out at all because of that. “How do you measure? Would you say that one is abnormal and the other is not?” the surgeon wonders. That is not to say that plastic surgery is acceptable in all cases. To clarify, Nicolau compares the human body to a screen, on which you can project a film or hide behind. Similarly, people use their body to either project what they want to look like and present themselves in life, or to hide behind and say, ‘If I were like this or that I would be…' Cosmetic surgery and aesthetic treatments, says Nicolau, are there to help people improve their lives, to correct deformity, to help them to be themselves and live in harmony with themselves — not to completely change their life. Someone who approaches the cosmetic surgeon with a photograph, saying, ‘I want to look like that,' will have to find himself another doctor, because Nicolau refuses to do that kind of makeovers. “I am able to do that but I will not because it will be a failure,” he says, adding it is part of his work to be able to say yes or no, although “we have to be very careful. I am not a psychiatrist. I'm not a psychoanalyst.” His nearly 40 years of practice has given him the ability to segregate his own reactions and his patients'. “I see a lot of complications that arise from patients who did not want the operation or wanted it for the wrong reason. It can be a perfect success, technically speaking, and a total failure for the person.” However, he adds, “if the patient lies to me – and they lie a lot – it is their responsibility.” A demanding market Nicolau's own practice is located in the small town of Figueras, near the border with France. He is also a consultant at the University Hospital Saint Louis in Paris. However, he travels a lot and is familiar with cosmetic trends and practices all over the world. The Saudi market, he says, differs significantly from the European and American markets. “I found out that here, the ladies are extremely demanding. And they consider that if you say no, it's not because you're reasonable; it's because you're not good. Because if you're good you can achieve anything that is wanted, including the impossible.” He continues: “In terms of cosmetics, they all want very round faces and round cheeks. All of them.” This is a major difference with Western trends, where women like high, well-marked cheekbones and certainly not a round baby face. “So here they ask for a lot of volume. And this is why a lot of doctors use fat transfer, because you need very large volumes, and that could be extremely expensive using the fillers which come in syringes of 1 mililiter.” Thus, cosmetic surgeons here take fat from the body, prepare it as a graft, and inject it in as living cells. According to Nicolau, this is a good technique, but as not all the cells survive the procedure sometimes has to be done several times. The trend among Saudis to perform cosmetic surgeries abroad is also not very surprising, says Nicolau, as it costs less money in Europe than in the Kingdom. This is partly the result of more competition in Europe, but the financial crisis also made prices lower. Changing trends But not only can we discern different trends in every part of the world, time has seen changes in the cosmetic treatments that are carried out. Nicolau says the most important change is the diminution of the heavy, surgical procedures. He gives the example of the classical facelift. When Nicolau started with plastic surgery, the discussion was about the age of the first facelift: Should it be done before or after the age of 50, and how many facelifts can be done? At that time, facelifts only lasted for about five years, and after two or three facelifts people would look very tight. Once the technique changed and facelifts began to last for 10 to 12 years, cosmetic surgeons started doing facelifts at a much younger age. Most changes are a result of new knowledge. “We know much more about the physiology of aging,” comments Nicolau, admitting there are still things unclear up to now. “We know that with the fillers, for instance, we can compensate for bone loss, we can compensate for fat sliding; we can compensate with Botox for muscular retraction.” Scientists used to think that wrinkles were a result of relaxed muscles, but they later found it was the opposite: they tighten and contract. They also discovered that there is no much sagging of the face, but all underneath. In other words, it is not our skin that gets looser as we age; the change is from within, through loss of bone and fat. Ethical questions The scientific discoveries and techniques to remain young and healthy are incredible, but, again, you may wonder if we should not simply accept the fact that we get older and our bodies less attractive – in today's standards, that is. Nicolau also says that youth is “a social characteristic of nowadays. People do not want to die. They want to be eternal. They want to live up to 200 years. People go to cosmetic treatments like they go to the church, to the mosque, for the very same reasons: fear of dying.” He, however, does not think he is part of this stream that says young is not only beautiful, but also right. For people who feel miserable about their life and the way they look, aesthetic surgery may be their last hope, and “we cannot take hope away from them. Hope is extremely important in life.” As he said before, Nicolau thinks it is up to the patients to decide. That is not to say that doctors do not need to have ethics. Although he thinks doctors should not be considered as part of the cosmetic industry, they do have a responsibility in it. They need to be aware of the dangers, for instance, and be obliged to tell their patients about any possible complications, including the most exceptional ones. The paradox, nowadays, is that people want to look young and healthy, but at the same time many live a life that is destroying them: they smoke, expose their skin to the sun, eat bad, sleep little. “Of course we tell them. I refuse to operate patients who smoke now. Maybe because I can afford it, or maybe because I don't need money. Maybe because I changed my mind about money. Now, my children are grown up. I don't need it,” says Nicolau. The French surgeon lives by two advices he got from a British consultant plastic surgeon when he worked with him in 1979 in the United Kingdom. “He told me two things. The first one: If you want to be a good cosmetic surgeon, you should not need money. Second thing he said: When a patient comes to your office and walks into your room, always ask yourself, ‘is this patient going to do something for me, or am I going to do something for him?'” That sentence is engraved in Nicolau's mind. “It's a question of ethics. Every time I teach or give conferences, this is what I try to spread around. I don't try to convince them; I just show them how they can make their own decisions. Just like with my patients. My patients make that decision. My patients come to me very often and say, ‘Ok doctor, what's your advice?' ‘I don't know, here's the mirror.'”
