History of Cosmetic Surgery in the UK

If we define cosmetic surgery as surgery that alters physical appearance, then nearly all human cultures from the Stone Age onwards seem to have adopted practices that altered the appearance of members of the tribe. In Kenya, marks on the face were made by cutting the skin and then rubbing in earth so that the resulting scar was wide and visible. The idea was that a member of any particular tribe was instantly recognisable. Many tribesmen and women had bones or other objects forced through noses and earlobes. They did this, or had this done to them, for the age-old reason that they wanted to fit in and look like other members of their society. This is pretty much the same reason why the majority of cosmetic-surgery patients today seek surgery.

Although it is true to say that cosmetic surgery is still a relatively new speciality in the UK„ it dates back for centuries. The beginnings of eyelid surgery can be traced back to the 10^thcentury in Arabia. The first record of a facelift was in the early 1900s, although it is not known who attempted the very first one.

As early as 600 BC, the first evidence of nose reconstruction (rhinoplasty) was recorded. By the end of the 1^st century, rhinoplasty was common as a result of the uncivilised practice of cutting off the noses and lips of one’s enemies. By the 16^th century, noses were reconstructed after being severed in duels by using flaps of upper arm skin: necessity was the mother of invention!

Otoplasty (correction of protruding ears) was described in the 1850s, although there is some evidence to show that it was performed much earlier. The first breast reduction can be traced back to the 15^th century, while the first silicone implant for breast augmentation was performed in 1963. Prior to that, breasts were enlarged using dermal (deep layer of skin) grafts and even injecting liquid silicone, a practice that was short lived because of the disastrous consequences. The injection of liquid paraffin was also tried at various times since 1889, but the results were poor and the complications horrendous.

The most modern revolutionary cosmetic surgical procedure dates back to the early 1970s when surgeons in Switzerland described for the first time a technique for sucking out fat. The initial trials were not a total success because of the frequency of postoperative complications, notably seromas (large accumulations of fluid under the skin), which took a long time to absorb, and skin depressions. In 1977, a French surgeon, Gerard Motu, perfected the technique by using a blunt cannula (surgical tube) connected to a high negative pressure vacuum pump.

In most countries of the world, when a doctor qualifies as a specialist he sets about establishing a practice. There are various professional ways to do this. The usual way is to inform all of his colleagues that he is available to receive referrals relevant to his speciality, and he also sets about telling as many people as possible what he does and how to find him. Hopefully, sooner or later his reputation grows and his practice increases. Some specialists buy into already established practices as a junior partner and in many countries it is possible to buy a practice from someone who is retiring.

After the inception of the NHS in Great Britain in 1948, the system became quite different. It was only possible to set up as a specialist once one had been appointed a consultant. The supply of consultant posts was wry restricted, so a doctor only became a consultant when a post became vacant. There were always very many more trained doctors than there were posts available.

Doctors who became consultants under this system claim that only the best were chosen, but this was not always the case, as many doctors became disillusioned and either gave up hospital medicine or emigrated. It also meant that, in Britain many fully trained doctors could not get consultant posts and remained so-called junior doctors well into their 40s. This led to the concept that doctors who trained in the NHS needed 14 years or so after qualification to become adept in their speciality. The rest of the world did not believe this and overseas specialists became fully qualified at a much younger age.

The reason for the late appointment of consultants in the NHS was the bottleneck created by the lack of posts available. The training of junior doctors was generally on-the-job training, in an ad hoc fashion, more like an apprenticeship. Often there was no formal training; a junior doctor had to serve his time and hope that a consultant post became available when he was sufficiently senior.

In the NHS in the 1970s there was no formal training in cosmetic surgery. There still isn’t really, because very few purely cosmetic operations are performed in NHS hospitals. Nearly all cosmetic surgery is done in the private sector. Both the authors left the NHS and gained their training by following senior surgeons who had busy private practices.

Plastic surgery was established as a speciality only relatively recently, after the Second World War. Plastic surgeons claimed cosmetic surgery as part of their speciality, but in reality many different types of surgeon have been performing cosmetic surgery for over 150 years. It is not true that plastic surgeons are the only ones who are fully qualified, as they claim, to carry it out. Their own training programme has only recently embraced cosmetic procedures. They spend most of their time carrying out operations on burns, malformations and injuries and their training reflects this. It is quite common even today for a plastic surgeon to become a fully qualified specialist with virtually no experience in cosmetic surgery.

There is little common ground between the usual NHS plastic-surgery patient and those seeking a cosmetic operation. Cosmetic patients are generally much more exacting in their expectations than those who need cancer surgery or skin grafting for burns.

There used to be a total prohibition on any form of advertising by doctors. This was designed to protect vulnerable patients from blandishments from unscrupulous doctors. In reality, it protected and controlled the referral system of private patients by GPs to hospital consultants. Up until the 1970s it was never imagined that this ‘in-house’ system could or would be challenged by anyone. But challenged it was, by a group of entrepreneurs who took advantage of a legal loophole that allowed non-medical people to set up independent private medical services, which then employed surgeons and anaesthetists.

These entrepreneurs had only one thought in mind; medical ethics were certainly not high on the agenda. They were not regulated by any ethical body, and were therefore allowed to publicly promote and advertise medical services in the media. As a result private medical services began to be established offering abortions, medical screening and cosmetic surgery.

Some unscrupulous individuals saw this as a passport to making easy money and established some of the first cosmetic surgery clinics in the 1970s. Many employed hard-sell tactics and adopted the attitude that they were beyond reproach as any mishap could easily be blamed on the doctor. Therefore, they would refuse to take any responsibility in the event of a problem. These individuals quickly gained control of the cosmetic-surgery industry.

Unfortunately, many doctors did not approve of cosmetic surgery in any form and refused to refer their patients. This meant that many patients had no way of finding a surgeon who performed cosmetic surgery unless they contacted one of these clinics. Since that time the number of these clinics and establishments in the UK has grown enormously, particularly since 2001. Every major town and city has several different providers in competition with one another.

As a result of the activities of commercial clinics, the rules on medical advertising have now been very considerably relaxed and numbers of doctors appear in the media hawking their skills. Often they are the same doctors who only a few years ago accused surgeons who worked for commercial clinics of being unethical.

Advertising is still generally disapproved of by most of the profession. However, in Britain today, the majority of cosmetic operations are performed by doctors working for commercial clinics. These clinics have a financial imperative to carry out as many operations as possible and, certainly in the past, dubious methods were used to get patients to sign up. It is however commercial suicide to run an unethical clinic and most, but by no means all, clinics these days treat their patients with consideration and skill. There is still a risk, however, that a vulnerable patient may meet a salesman or woman paid on commission who will say virtually anything in order to get them to undergo treatment.

Whatever the criticism of cosmetic surgery in the past, one thing is patently obvious: in expert hands it is extremely successful and has transformed the lives of many people for the better. It is here to stay and is growing very quickly.