20/20’s Plastic Surgery Infomercial
Recently, ABC's 20/20 devoted an entire episode to the “cutting edge” of plastic surgery. When the show aired, most viewers were too squicked by the doctor who did his 18-year-old daughter’s boob job to notice the journalistic trainwreck.
20/20 provided an uncritical platform for medically dubious claims while letting potentially unethical behavior by physicians pass without comment. For example, the ethics guidelines of the American Medical Association say that doctors shouldn’t treat immediate family members except in emergencies--doing your own daughter’s boob job would not qualify. But 20/20 ignored the ethical issue and focused instead on the doctor’s parenting style and surgical prowess.
20/20 bills itself as an investigative news magazine. Cosmetic surgery is a multi-billion-dollar industry. A critical assessment of the costs and benefits of popular procedures would be a public service. Like any hard-hitting consumer reporting, a competent investigation of cosmetic surgery would challenge the puffery of the salesman with tough questions. How well does this procedure work? What is the evidence to support the claims of efficacy? Any service that confers subjective benefits (beauty is, after all, in the eye of the beholder) and plays on people’s insecurities is going to attract snake oil salesmen. Some cosmetic procedures are quite safe and very effective, others inflict pain and risk for minimal benefit. Good journalism might help consumers choose wisely.
Instead of practicing journalism, 20/20 made an infomercial. The voiceover promises to show us “the hottest new ways to take off 10 years and 10 pounds.” Later it offers to let us in on the secret of models and actresses: namely that breast implants are “the very latest way to get a lift out of life and everywhere else.” Barbara Walters even signs off by announcing that she needs to get some work done.
The show consists of several variations on a formula. Typically, a plastic surgeon who makes his or her living off a "cutting edge" procedure makes a sales pitch in the guise of an interview. Barbara Walters questions the doctors with the obsequious desperation a dog craning for a cookie. “Does this mean you never have to look old?” she breathlessly asks Dr. Doris Day, a New York dermatologist touting face fillers and high-intensity ultrasounic face tightening.
Like any good infomercial, the sales pitch is followed by a demonstration. We watch the doctor perform the procedure s/he’s selling. (It slices, it dices, it saws through a solid steel rod!) Segments typically end with beaming clients showing off what we’re told are huge improvements. It's hard to tell. In most cases, we don't even get a the standard "before" and "after" shots for comparison.
A quick search of the medical literature reveals that ultrasonic face-tightening may not even work. According to one paper, it provides “a variable and controversial tightening effect, which is not usually apparent, if at all, until dermal remodeling occurs a few months after the treatment.“ 20/20 tells us that the effects of the procedure take a while to show up, but gives no indication that it might be a complete waste of money.
Apart from a woman getting her breasts remodelled after a botched boob job, we don't hear from any patients who experienced complications, or who were unhappy with the results of their surgery.
20/20 should have interviewed independent experts instead of letting the surgeons who were operating on camera shill for themselves.
The cosmetic leg lengthening segment was the most disturbing part of the show. The lower legs are broken with a chisel and then gradually stretched in a metal frame. One of the patients went from 4’11’ to just under 5’2”, the other patient, an anonymous 37-year-old man, went from 5’6” to 6’2”. We learn that recovery from leg lengthening is agonizing and prolonged. The patient has to wear braces that look like tomato cages to gradually ratchet the bone ends further apart. 20/20 doesn't mention the potential complications, which include infections, nerve damage, and premature bone knitting (which requires the doctors to rebreak the bone).
Dr. Dror Paley, a Florida surgeon who performs cosmetic leg lengthening, claims his patients are suffering from “height dysphoria,” which he characterizes as a psychiatric disorder that can lead to suicide, but which can be cured by surgery.
Clearly, the doctor is eager to reframe this extreme procedure as therapeutic, rather than cosmetic. He’s not breaking people’s legs for vanity’s sake, he assures us, he’s curing a dangerous psychiatric disorder. Ethically, the maximum allowable risk for a cosmetic procedure is much lower than for a procedure that's treating a potentially life-threatening disease.
The interviewer asks if people who are on the brink of suicide might be better served by counselling rather than surgery. The doctor replies, self-servingly, that counselling just doesn’t work for these people. Their only hope is to go under the knife.
It turns out, “height dysphoria," (aka "short stature dysphoria") isn’t a psychiatric term at all. It’s just a pseudo-technical way to say that someone is unhappy with their height. Dissatisfaction with one's appearance is not an illness. Supposedly, "short stature dysphoria" applies to people who are consistently unhappy about their height, but happy and well-adjusted in other areas of their lives. If someone is on the brink of suicide because of their height, it's pretty hard to argue that they are otherwise healthy and well-adjusted. The cosmetic leg lengthening industry wants to have it both ways.
The doctor may have painted himself into an ethical corner with his claim to be treating a psychiatric illness. Unlike “height dysphoria,” body dysmorphic disorder is a recognized psychiatric condition in which a person is overwhelmingly preoccupied with some aspect of their appearance. An estimated 1%-2% of the population suffers from BDD, and BDD sufferers account for 6%-15% of all patients seeking cosmetic surgery.
BDD sufferers may be fixated on their height, their nose, their skin, or other features. “Height dysphoria” sounds suspiciously like BDD focused on height. The thing is, cosmetic surgery does not ease BDD symptoms. In fact, many experts argue that BDD should be a contraindication for cosmetic surgery because it doesn’t help and may even make BDD symptoms worse.
Paley's website claims that he does not operate on patients with BDD. But he tells 20/20 that he's curing a psychiatric disorder with surgery. 20/20 should have challenged him to explain how “height dysphoria” differs from BDD. If his patients are as distraught as he says they are, I have a hard time believing that he's screening out BDD cases.
Real investigative reporting on the cosmetic surgery industry could have been worthwhile, but 20/20's credulity did its viewers a disservice.