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Viewpoint: Freeze the Botax

By: Steven H. Dayan, MD, FACS
Posted: December 3, 2009

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If cosmetic medicine were a team, Botox would be its mascot. It is the most popular cosmetic treatment and has forever changed medicine; arguably, it has shaped a generation. Its breakthrough properties and subsequent popularity are partially responsible for the cosmetic tax even becoming a consideration. Before Botox, cosmetic medicine was a small, contained branch of reconstructive surgery centered on a few physicians per city catering to a niche population. However, much like the tremendous breakthrough influence antibiotics had on the way infections were approached and treated, steroids had on the management of acute and chronic inflammatory diseases, and insulin had on the mitigating morbidity and mortality of a highly perilous viscerally targeted autoimmune process, Botox has forever changed the way cosmetic medicine is measured, perceived and delivered.

Before, the niche population seeking aesthetic medicine was not considered representative of society as a whole, and conventional wisdom categorized this group as belonging to a single, higher-echelon socioeconomic class, self-absorbed or possibly seeking treatment for a personality disorder. It was not only elective, but also selective medicine, not designed or deliverable to the majority. However, a look back reveals the valuable role this cosmetic field has played—and continues to play—in society. Cosmetic medicine, yet to be defined, originated not as a treatment to enhance the beauty of the elite, but more as service trade allowing one to pass into society without discriminating characteristics. Beginning with the Romans and Greeks, plastic surgery allowed conquered nomadic populations to assimilate and hide evidence of nefarious pasts or memberships to unacceptable cults. In societies where nudity was celebrated, the first cosmetic surgeries were performed on early Hebrews, Egyptians and Phoenicians who desired circumcision reversal.

Cosmetic medicine philosophy and techniques didn’t change much thereafter, until the early 20th century when, following World War I, soldiers who survived battlefield injuries returned home with disfiguring facial wounds that prevented them from being comfortable in public. Much like the early Greeks and Romans, disenchanted post-World War I cosmetic surgery patients were the disfigured who wanted to return to society. They desired form, function and assimilation. One of the early post-World War I surgeons was Jacque Joseph, a surgeon living in Germany who was known for his skills at reconstructing complex facial wounds for veterans. He later translated his abilities and knowledge to alter characterizing facial features, such as the noses of healthy ethnic males and females wanting to look “more German.” And thus was born elective cosmetic surgery. However, the goal of this new trade was not perfecting the human form or achieving ultimate beauty, but making patients happy by allowing them the ability to integrate seamlessly into society.

However, following World War II and the advent of antibiotics and safer forms of anesthesia, cosmetic surgery migrated from a tool of inclusion to a tool of separation. Since the days of Nefertiti and Cleopatra, those who have felt they belong to the elite class of society used whatever they could to separate themselves from the underclass. Cosmetic medicine became an instrument of the privileged to flaunt their identities. Like many of the newest trends and fads in pop culture, it started with movie stars. Famous pinups, such as Marilyn Monroe and Rita Hayworth, were getting plastic surgery. Cosmetic medicine was used to separate the starlets from the common folk. No longer was it a vehicle to blend unnoticed into society; it was now being used to stand out. And cosmetic surgeons, in parallel, responded by offering physically altering treatments that were bold, large and sure to emphasize the sexually characterizing features of beauty and youth.

Cosmetic surgery lost some of its original application of allowing one to pass into society unnoticed, and became instead a tool to reinforce class distinction. Moreover, the ability to extend attractiveness or youthfulness beyond what was predetermined genetically became a possibility for an emerging upper class, perhaps leading to its current misrepresentation as a sin. In fact, it was Botox that spread cosmetic medicine to the masses. For the first time, working class individuals seeking cosmetic improvements entered into the market, and the demand has skyrocketed by more than 3,600% in just the last 10 years.1

The benefits of Botox