Uncharted territory

It is two years since the PIP scandal, in which the French breast implant made with industrial grade silicone was found to have double the rupture rate of other implants, and was linked to serious health risks. The scandal led to the Royal College of Surgeons (RCS) and others calling for tighter regulation and restrictions on advertising for the cosmetic industry.

Sir Bruce Keogh, Medical Director of the NHS in England, published a report last year which recommended better regulation, better training and proper redress if things go wrong.

Since then, many of those recommendations have not been addressed north or south of the border, and at the same time, the industry is booming.

The British Association of Aesthetic Plastic Surgeons, which represents the vast majority of NHS-trained consultant plastic surgeons in private practice, recently published figures showing a 16.5 per cent rise in cosmetic procedures last year alone. Breast augmentation, still the top surgical procedure in the UK, saw an increase of 13 per cent, despite the PIP implant scandal. Many others get surgery abroad, and there is no way of knowing how many non-surgical procedures like Botox are being carried out. Currently people such as beauticians with no medical training can administer anti-wrinkle Botox injections, even though it is a potent neurotoxin. BAAPS President Rajiv Grover says it is a “Wild West”, and legislation is needed to protect against untested procedures and unqualified practitioners. “Frankly, we are no less than appalled at the lack of action taken,” he said.

One of Keogh’s recommendations that has been implemented, however, is the formation of the Cosmetic Surgery and Speciality Committee, hosted by the English RCS. Glasgow-based NHS plastic surgeon Dr Andy Malyon represents Scotland at the committee as an observer.

“There have been a number of meetings at the Department of Health starting to look at how we can actually eat our way into the absence of regulation at the moment.

“The world of cosmetic surgery and cosmetic non-surgical procedures is a bit of a murky world anyway. We don’t know a lot about what’s going on out there. We don’t know the full extent of what’s happening, where it’s happening and who’s doing it, still,” he tells Holyrood.

A Scottish Cosmetics Interventions Expert Group has been established with Malyon as chairman. It brings together Healthcare Improvement Scotland, NHS Education for Scotland, the Royal Colleges and inspection agencies to formulate appropriate action for Scotland. “Precipitous action often ends up being inappropriate, so we have to get it right,” he says.

A clinically driven high quality care sub-group is also being established to monitor developments in England. Malyon says it will be a long process. “What we’re trying to do effectively is to stay abreast of what’s happening with groups like the SIC in England, and the output from the Department of Health, evaluate what’s coming out from there, look at the issues which are devolved, identify how we can either translate the changes that are planned in England or improve upon them. There’s no reason why we would have to do exactly the same,” he says.

Another part of the work will be to examine people’s understanding and expectations, Malyon says. “Do people believe they are going to places which are regulated? Do people believe they are going to people who have some sort of qualification?”

While regulations are being considered, though, more and more people are opting for cosmetic procedures. Dr Debra Gimlin, a sociologist at the University of Aberdeen, has studied the shift in attitudes towards cosmetic procedures in both Britain and the US. Author of the book, Cosmetic Surgery Narratives, her work focuses on the body and its modification, and on the ways women in different countries explain their body work.

Although the number of men opting for cosmetic procedures is rising, they remain less than a tenth of aesthetic plastic surgery numbers, according to BAAPS. For Gimlin, gender is still at the heart of appearance management. “We’re living in an age where men seem to feel greater pressure to manage their bodies, but I don’t see the corresponding drop in the pressures for women. Body management, appearance management and this kind of stuff, the difference is that women have to do that stuff. They have to do their hair, etc, to some extent, in order to be feminine, whereas men can be masculine without it, right? They may not be attractive, but they’re still masculine.”

Gimlin sees a normalisation of cosmetic procedures in culture. The obsession with celebrity has coincided with many of them having more obvious procedures, and talking more openly about it. The women Gimlin surveyed found it easier to account for and admit to having surgery with each decade, and the change is ongoing. A clear symptom is the rise in television makeover programmes using surgery, she says. “It’s not just one procedure they have, it’s multiple procedures. You don’t get much sense that it’s painful. It’s done to a normal person as a reward for a difficult life, so I think cosmetic surgery here is being treated in much the same way as it’s being treated in the US, and so you’re going to see cultural change as a result,” says Gimlin.

Her anticipation that makeover programmes would act as cautionary tales was unfounded. “I asked all the women I interviewed about them, and they were all like, ‘oh, I just love those, I’d love to be on one’ – I couldn’t believe it. I mean what would be worse in the whole world, than that? Again, it’s things being presented as acceptable, and guess what, they become acceptable,” she says.

Normalisation has meant a decline in disposable incomes has not damaged an industry dealing with expensive procedures. Gimlin points to the work of the French sociologist and philosopher Bourdieu, who argued that taste was relative to social position, and people seek distinction, the thing that makes us look more rather than less part of an elite. “Historically, we look at changes in aesthetics in terms of female body size, and when times are tougher economically, iconographically, beautiful women are heavier. It seems that there is more of a femininity, a kind of voluptuousness, I suppose, that goes along with the lipstick wearing, and I think there’s something about it which suggests plenty, you know? Having not just enough, but more than enough,” she says.

The aesthetic shift has been toward the artificial, Gimlin argues, especially among those with less. “I think it is partly to do with consumer culture. Breast augmentation or other kinds of cosmetic surgery are a version of conspicuous consumption. There’s a kind of a class difference in which those people who have more ready access to finances don’t feel the inclination to show off that they have them; whereas those who are less advantaged are more likely to want to do that.”

For women living in an increasingly competitive and economically divided environment, the narrative is changing, according to Gimlin. “There’s a narrative available now that says ‘I’m having cosmetic surgery in order to make myself more competitive on the job market.’ It’s not just about wanting to look better naked, you know, it’s much more justifiable when framed in terms of an economic asset.”

Gimlin believes attitudes towards healthcare have shifted in the UK as well, with a growth in private health insurance linked to employers or club memberships like gyms. “People are becoming more and more accustomed to privatised medicine, so as medicine is treated as a consumer product, cosmetic surgery can be carried along in that way.”

Last month, Liverpool Women’s Hospital announced it was expanding its private arm to begin offering breast implants. The trust announced all profits from the service would go back into developing NHS services. This has been made possible after the Health and Social Care Act in England removed a cap on how much hospitals can earn privately.

In Scotland, the Government has committed to less reliance on the private sector, but there have been far fewer cosmetic procedures performed via the NHS since the Adult Exceptional Aesthetic Referral Protocol was updated in 2011, meaning procedures require clear clinical assessment. It is thought this will mean training of plastic surgeons in Scotland will require more private sector involvement in the future.

With such a growing industry, there is a worry regulation will struggle to keep up. Dr Malyon says the Scottish Cosmetics Interventions Expert Group is mindful of the pace of change. “This is one of the difficulties, because if you try to regulate on the basis of what’s happening today, you’ll be out of date. By the time I sit down and write a paper, which finds its way through the health department, finds its way to a minister, which finds its way to discussion on the floor in Holyrood, and finally finds its way onto the statute books, that’s not going to happen overnight. We have to make sure what we’re writing is as future proof as we can make it. Who would have thought, ten years ago, that people would voluntarily be being injected with things to make them go brown? Who would have thought people would voluntarily be having all sorts of pastes injected into their lips? It will be trying to do something which is going to be relevant now and will stay relevant into the future,” he says.