Recent figures from the USA and UK illustrate that, not only is the popularity of cosmetic surgery at an unprecedented high, but there has been a shift in the procedures requested by patients, and in the patients themselves. Many more men are now seeking cosmetic surgery, with face and neck lifts, male liposuction and gynaecomastia reduction being the most common procedures performed. “Mommy Makeover” surgery, which aims to restore a mother’s body to a pre-pregnancy physique through procedures such as breast augmentation, breast lift and abdominoplasty, has become increasingly popular in the USA, and this demand is likely to spread to the UK.

Perhaps the biggest influence is social media. Its extensive use by millennials – individuals aged 18-35 – is thought to contribute to a rapidly changing attitude towards aesthetic plastic surgery. They represent a generation that consider such surgical procedures acceptable, to the degree that they are often viewed as part of the norm in the pursuit of beauty. This is reflected in figures which show that millennials are considerably more likely to seek cosmetic and minimally invasive procedures than older generations, and also to have it at a younger age. Surveys in the USA have shown that a very high proportion of millennial women say that they are unhappy with at least one aspect of their bodies, and according to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2015, millennials made up nearly 27% of surgical procedures and nearly 16% of non-surgical procedures.

The President of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has summarised the anxieties about the younger demographic seeking cosmetic procedures: “The teen and young adult years are a highly impressionable time and the more consumers are inundated with celebrity images via social media, the more they want to replicate the enhanced, retouched images that are passed off as reality”.

Millennials are exposed to what is perceived as physical perfection by the celebrity culture and media. Though the reach of this influence is certainly not limited to a particular generation, it is the associated general desensitisation to cosmetic surgery and negative psychological impacts of social media that are driving people to seek plastic surgery, often with unrealistic expectations. A 2015 survey by AAFRPRS quantified the impact of social media and celebrity culture when it stated that 82% of surgeons cited celebrities as a “major influence” in their patients’ choice to undergo a cosmetic procedure.  This comes as public figures speak more openly about their relationship with plastic surgery, while the media plays into the insecurities of the public by continually focusing on the desirable features of high profile individuals.

Social media also affects how surgeons manage patients pre-operatively. Patients may have exaggerated concerns about perceived abnormalities, and it is the responsibility of surgeons to ensure that patients view their perceived problems in a proper perspective and manage expectations, especially if the desired features match those of a particular celebrity. Some individuals have unrealistic expectations stemming from an underlying condition that requires psychiatric care rather than surgical attention, and distinguishing this is very important. For instance, body dysmorphic disorder is when a patient believes that their appearance is abnormal when it is not so. As this is a psychological condition, it cannot be treated by cosmetic surgery, and an operation may in fact make the condition worse as the mental health of the patient has not been addressed.

The impact of social media extends beyond post-operative care as the work of surgeons is also affected. Interestingly, there is now a mobile app which specifically targets the younger demographic interested in plastic surgery by offering digital consultations with plastic surgeons, opinions, quotes and appointments. This is in addition to the various comparison websites whereby patients leave reviews of individual surgeons. Millennials are often better informed in their understanding due to the ease of access to information from validated sources. Patients now, unlike those of earlier generations, use social media to develop an awareness regarding the predictability of procedures, and more comfortably relay these expectations to their surgeons, with surveys finding that most millennials desire a natural appearance.

One distinction that the surgical profession is very concerned about is that an aesthetic plastic surgeon and a cosmetic surgeon do not necessarily have the same degree of training, even though individuals can undergo surgical cosmetic procedures under the care of either. There is no restriction on any doctor practicing cosmetic surgery on patients; they do not need to have received any formal surgical training (in cosmetic surgery or otherwise), passed the Fellowship of the Royal College of Surgeons examination or have been on the GMC’s specialist register.

Following Professor Sir Bruce Keogh’s Review of the Regulation of Cosmetic Interventions, the Department of Health asked the Royal College of Surgeons of England to set up an Interspecialty Committee on Cosmetic Surgery and develop evidence-based standardised patient information. This work is now almost complete and, in 2017, the College is introducing a certification scheme for surgeons undertaking cosmetic surgery. Surgeons will be required to submit evidence of their training and experience in the types of cosmetic surgery that they wish to perform, and if they meet the required standard they will be certified to perform those procedures. For example, ENT surgeons might be certified in rhinoplasty and bat ear correction (pinnaplasty), whilst breast surgeons may be certified in breast augmentation, breast reduction and/or mastopexy (breast uplift). However, those surgeons would not be qualified to operate on areas outside of their specialty, such as abdominoplasty. However, plastic surgeons with training in procedures done on all parts of the body may apply to be certified for all types of cosmetic surgery. The list of certified surgeons and extensive patient information will be made available to the public through the College’s website, allowing patients to check that their surgeon is not only a fully trained surgeon, but has also been certified in the relevant procedure.

Millennials have an increasing desire for minimally-invasive cosmetic procedures, such as lasers, peels, injections of Botox® and soft tissue fillers, even though signs of ageing which would warrant such procedures are typically not yet apparent. Demand for such procedures has increased by 29% between 2010 and 2014, according to the British Association of Aesthetic Plastic Surgeons. This rise is likely to be attributed to two things: firstly, the development of dependence due to the illusion of being ageless, which many high profile individuals promote on social media. Secondly, the impact on a person’s view of themselves and subsequent rejection of the natural ageing process. However, the effects are short-lived. For instance, Botox® wears off after a few months, and individuals can find themselves committing to many years of treatment.  This can cause the appearance of premature ageing at the additional cost of impaired function, such as overly full lips or a frozen forehead.

The apparent ease of access to these minimally-invasive procedures, and the fact that they are often undertaken in beauty salons by hairdressers and mobile therapists, is worrying. A reputable practitioner would most likely advise against such treatments, but other less qualified practitioners may not be as scrupulous. Despite the significant risks from these procedures, there is a widespread belief amongst the public that these procedures are no more risky than getting a new hairstyle. Yet lawyers are seeing an increase in enquiries about injuries from these procedures performed at beauty salons, such as burns, scarring, and skin discolouration. Of major concern is the lack of effective regulation of individuals who are qualified to carry out minimally-invasive procedures. In 2015, Health Education England published its qualification requirements for practitioners performing such procedures; however, they are not mandatory. The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Dermatology (BAD), working in conjunction with the Care Quality Commission, are leading the development of a regulatory body: the Joint Council for Cosmetic Practitioners. This will hopefully weed out the unqualified practitioners and make treatment safer for patients.

By David Ward FRCS FRCSEd