Plastic surgery has real consequences [TRANSCRIPT]

The world of plastic surgery is wide spread and far reaching. From celebrities to everyday people, body modification has been promoted as a way to improve one’s self esteem, but what happens when that’s not the end result? From hair transplants to breast implants to Botox, there doesn’t seem to be an end to self improvement through body modifications.

Eleanor Cummins is a freelance science journalist for Wired, The New Republic and Slate. She joined CultureShift to chat about the current state of plastic surgery, the long battle to improve the safety of breast implants and understanding self love versus body love.

Listen: Science journalist Eleanor Cummins talks risks and benefits of plastic surgery.

Tia Graham: So Eleanor, we’re just gonna jump right into things. Just talk to me a little bit about the the world of plastic surgery today. Where is it? What are we seeing in terms of plastic surgery?

Eleanor Cummins: Absolutely. So plastic surgery really is bigger than ever. While there were some restrictions with the pandemic moratorium on elective procedures, we see the category growing. So in 2018, there was an all time high with breast augmentations. We saw 1.8 million augmentations, globally. And at the same time, we see an expansion in this category of clinical visits where you can go in for fillers or laser procedures that maybe don’t have the same sort of surgical ramifications of having to go into an operating room, but do qualify as a plastic or cosmetic intervention.

Graham: So outpatient surgeries or outpatient procedures.

Cummins: Exactly, where you can just go in and it’s maybe a few needles and 15 minutes of your day. And you can change, in theory, a lot about how you look.

Graham: Can you talk about one of your recent articles, you talked about male procedures and the increase in some of the procedures we’re seeing men get? Can you talk about one of the most prevalent ones we’re seeing right now?

Cummins: Absolutely. So that’s follicular unit extraction, which is a term for hair surgery. So we are seeing a lot of men being interested in restoring their hair lines. And there is this procedure called FUE that’s really popular. And what it does is it removes individual hair follicles from the back of the head and transplants them into a really bespoke hairline, at the very front of the forehead. And those have become really popular. They can be done in six hours, and they have pretty transformative consequences for your appearance. They’re so precise, because they’re going one follicle at a time, that you really can create a naturalistic hairline, which wasn’t necessarily possible with the old plugging method. So that’s one example of the way that I think we have expectations about who wants to be beautiful, and who will pursue these cosmetic interventions to do it. But the answer really is all of us. It’s something that I think a lot of people grapple with, men as well.

Graham: Why is Turkey such a sought-after place for this particular procedure?

Cummins: Yes. So this procedure is a great example of medical tourism, which is where people go internationally to get surgeries done. And I think the reason that FUE is so common in Turkey is because the procedure is really expensive. It’s so labor intensive to have a doctor and a number of assistants removing these individual follicles and then re-implanting them elsewhere, that a lot of people have started to go abroad where they can get the procedure for maybe half the cost, including hotel and airfare.

Graham: When you’re seeing some of these things, what are some of the costs of this particular procedure? People are flying out to Turkey get this procedure done, what’s the cost?

Cummins: Yeah, so I think that in Turkey, we’re talking maybe about $4,000 for an entire package with a fairly reputable physician. Of course, it varies widely. You will have unlicensed people offering it on the very, very low end for $500, and then people who are offering these very luxury experiences for $10,000. But that sort of middle range there — $4,000 or $5,000 to get to Turkey, get a new hairline and come back — I think is pretty compelling to a lot of people.

Ryan Patrick Hooper: So when we really look at this, we’re seeing more outpatient procedures than ever for women, and the stigma for men, less and less to the point where they go on pretty extravagant trips to get these done. But in your reporting, you’re finding that even though it’s more prevalent than ever, the results are varied in a lot of different ways, whether that’s medically or from a mental health perspective, is that right?

Cummins: Absolutely. I think that there is a really popular idea right now that the reason people pursue cosmetic procedures of any kind is because it’s going to boost their self esteem. And I wanted to evaluate that. What do we actually know from a scientific perspective about whether or not that’s true. And what I found is that there have been a lot of studies that have purported to say, ‘Yes, it does make you feel happier about yourself,’ and others that say, ‘No, it definitely doesn’t.’ But most of those had a lot of methodological flaws, and obviously were in direct contradiction of each other. So in 2018, a researcher named Joseph Sobanko decided to look into this afresh, and he did a study with a number of people who wanted to pursue facial fillers, particularly to reduce the appearance of aging. And so he and his team tested these patients before and after their fillers on a number of different scales. And they were evaluating whether it improved their body image satisfaction, and whether it improved their self-esteem. And I think their findings were really telling. What they found was that body image satisfaction definitely went up. I think about 70% of people felt way better about the way that they looked. But that more fundamental kind of component of self esteem, the way they thought about themselves, and their value in the world was mostly unchanged. And so that self-esteem narrative is really popular, but it seems that it varies by individual. And crucially, it’s also dependent on your expectations going in. If you think that lip filler will change your life, you’ll probably be disappointed.

Graham: Yes, Eleanor. So, you know, switching gears here, just a little bit, we’re gonna talk about breast implants. You talked about it being one of the highest procedures done in 2019. So if you could just talk a little bit about that history there, that long history of breast implants from the early 60s all the way down to when silicone was banned in 1992.

Cummins: Right. So breast implants, I think, are something that people have been pursuing for at least a century. And some of the early methods are very scary. We have accounts of people putting marbles in their breasts, or experimenting with balled up tape to try to get that larger, more voluptuous look. But in the 1960s, researchers sort of perfected this idea of using a silicone implant in a sack and using that as an implant that, in theory, was going to remain totally intact and stable, and give people the appearance they were looking for of a sort of natural but very perky breast. What happened was, within about two decades of these procedures, women started coming forward and saying, “Actually, I have been feeling sick ever since I got these implants.” And so in the 1980s, you start to hear these murmurings of women coming forward and saying that they’ve had a range of symptoms. Today, I think the symptom list for what’s colloquially called breast implant illness ranges from fatigue and brain fog and pain and breathing difficulties, all the way in very rare cases, to a cancer called anaplastic large cell lymphoma. And so as these kinds of anecdotes from people who have had implants for mounting and the evidence sort of saying, “Yeah, there seems to be some statistical power behind this,” the FDA reevaluated whether silicone breast implants should really be on the market, and ended up banning them for about 14 years from 1992 to 2006. Now, at that time the FDA decided to reverse the ban, silicone breast implants were once again widely available. But those complaints of what’s called breast implant illness haven’t stopped.

Graham: And what are researchers saying about the development of this breast implant illness?

Cummins: I think that they’ve had a really hard time getting their heads around it. For one, there is not a lot of really quality data on large populations about this. And that’s not because there aren’t large populations reporting these kinds of concerns. I mean, the FDA truly between 2009 and 2019 received more than 350,000 incident reports just from people in the United States about side effects of their implants and procedures. But the reason that we don’t have this big data is because the manufacturers of breast implants have essentially failed to meet the obligations the FDA set for them in 2006 that said you need to turn in studies of 40,000 [or] 60,000 women and tell us whether or not this is harming them. So those studies were asked for around 2006, they still have not been completed and there doesn’t really seem to be any indication they will be completed. So researchers are just left in the dark. Those that are really determined to help women with breast implant illness have found other ways to get around this and to start to build their own datasets. And what they’re finding is that probably the best explanation we have to date is that when someone receives a silicone breast implant, some proportion of those people will have an inflammatory response to that implant that never stops. And so the thinking here is that what silicone breast implants are causing is an uptick in the number of autoimmune disorders among women who might otherwise have never experienced these sort of side effects.

Graham: So there’s a documentary, “Explant,” which is on Paramount+, I’m not sure if you’re familiar with it, but there’s RuPaul’s Drag Race’s Michelle Visage. Are you familiar with that documentary?

Cummins: No, I’m not. That’s so exciting. Can you tell me more?

Graham: Yes. So the documentary “Explant” is on Paramount+, and it’s following Michelle Visage and her journey of finding well-being after having her breast implants removed after her 30-year battle of being sick and not understanding why, and her finally understanding what was going on. So, here is Michelle right now talking a little bit about her journey with breast implants with Women’s Health Magazine:

[Clip of Michelle Visage]: “I have some pretty big scars on my chest, because I’ve explanted my breast implants after 30 years of carrying these very heavy breast implants around that were making me very, very ill. I have a documentary on Paramount+ called ‘Explant’ where we talk about that journey. I wear the scars with pride, not that you can see them because they are in my breast. But it was a very big deal for me to make that decision and evict my breast implants after all those years and I’ve never felt stronger about something and better about something. I feel amazing and healthier and never been so proud to have no breasts.”

Graham: And Eleanor when you hear that clip, what are your some of your first thoughts?

Cummins: Well, I have to go watch this. Thanks for bringing it to my attention. I think that that just resonates so much with every woman I’ve spoken to and other accounts from people in the public eye about their decision to explant their implant. And I really feel for people who have these kind of mysterious symptoms that they can’t quite sort out, and who in many cases discover that it is an implant that when it was implanted, a surgeon assured them that this was going to be okay, that there probably weren’t any real risks that they were taking. I think that that’s why better consumer education on these topics is so important because people need to know that there are risks and need to be able to look out for those as they move forward if they do go through an implant procedure. Also, this isn’t entirely cosmetic, there are a bunch of other types of silicone implants that people use for reconstructive surgery after a mastectomy. There are also silicone testicular implants for people who have had testicular cancer, the list goes on. And I think it’s just so important to make sure that people are aware of the potential and are cared for if they do develop those symptoms.

Graham: Michelle explains a little bit about why she brought her struggles with breast implants to light and just a little bit about the things that she hopes people understand when they watch it, but just in general, when they go get surgery.

[Clip of Visage]: “‘Explant’ is great, because it is my story. And so many women don’t know that they’re sick from their breast implants. But it’s not me saying, ‘Don’t do it.’ It’s me trying to say we need to have more information, because we’ve been lied to for all these years. So it needs to hold the surgeons responsible to tell their patient, ‘This probably won’t happen, but this can happen.’ So if you get breast implants, just know that you can possibly get an autoimmune, which happened to me, you could possibly get ALCL, which is a breast implant-caused cancer, you could possibly be fine. But we deserve the right to know what we’re putting in our body and our own advocates. And that’s what Explant’s about.”

Graham: Do you believe the doctors are underselling the risks to people about some of the plastic surgery procedures that they’re undertaking?

Cummins: Yeah, I really do. I don’t want to talk about plastic surgery as if it is a total monolith. Obviously, there are incredible providers out there. But nonetheless, I think that there is a really clear conflict of interest with a lot of people who are publishing research on these topics. If you look at breast implant illness studies, many of which coincidentally conclude that there is no such thing, you’ll find that a lot of the authors of those papers have declared conflicts of interest where they’ve received thousands, or maybe even hundreds of thousands of dollars from breast implant manufacturers. I think, too, that in that clinical context where you’re talking to your doctor, it really depends on that individual and whether or not they have been willing to take seriously, either their patients who have brought this up to them in the past, or patients that they’ve simply heard about through, for example, Facebook groups where tens of thousands of people have coalesced around this to say, “What’s going on with our bodies post-implant?” And so I think it’s really crucial that if you are pursuing implants for any reason, you have that conversation with your surgeon about, “What do you think of this literature, how seriously are you taking the more anecdotal concerns that women are bringing to to the table?” and make sure that you’re working with someone who not only wants to tell you the facts, but also wants to listen to you and your concerns, and what you are bringing to the conversation as someone who hopefully has read about this and learned as much as possible before taking the plunge.

Graham: Can you talk about the Rosenberg self-esteem scale, and how it’s been used to determine that scale of body love versus self love after plastic surgery?

Cummins: Yeah, absolutely. So the self-esteem scale that Rosenberg created is a measure where people take it and they’re asked to rank statements. And so there are a number of statements that have to do with what researchers think, psychologically, self esteem is, and are intended to reflect that. So you might be able to say, for example, on a scale of one to five, how do I respond to, “I feel I do not have much to be proud of,” does that really resonate with you? Does that not resonate with you at all? And then someone will tabulate these, and they will be able to say roughly where on the spectrum of self esteem you fall. What has been indicated so far, I mentioned earlier this great study from Joseph Sobanko, is that self-esteem is not uniformly changed by plastic surgery, and in general doesn’t seem to be the main outcome. We’re seeing more of these changes in people’s body image, but not necessarily their sense of worth. So what that may indicate is that maybe plastic surgery is just operating somewhere differently, we’ve kind of confused self esteem for maybe some more precise variables, like body image. But I think what it may also indicate is simply that these procedures don’t always have the outcome that you desire. So there are people whose self esteem maybe dips, people whose self esteem maybe improves, and I think that that depends so much on what their expectations are going in. I think that you can see that within this study [with] facial fillers, but also I know that that’s true from people I’ve spoken to about their breast implants. Things just don’t always meet the image you have in your head, and that can do a number on your sense of your body and of yourself, more broadly speaking.

Graham: So what does this research tell us so far about self-esteem, especially in younger women, men, teens and younger people in general? What does this tell us about their self-esteem as they’re aging?

Cummins: Absolutely. So I think that right now, there is a bit of a hole in the scientific empirical literature looking at how people feel about this. And that’s why I turned to philosophers of beauty like Heather Widdows, who is the author of this incredible book called “Perfect Me: Beauty as an Ethical Ideal” to help me fill in some of these gaps. And what Heather argues in her book is that essentially, we are in a situation where the self and the body have sort of fused culturally, and now we think of our bodies as ourselves. And I know that that kind of sounds like a silly idea, but imagine how many times someone would stop themselves from going to work without putting on that last little bit of makeup that makes them feel like they are presenting themselves properly. This merger of these feelings of how I look reflecting who I really am and becoming me. And so Heather argues that this is potentially could have been a somewhat neutral development in the way we view ourselves, but more often because of consumerism and the beauty industry has become a real source of vulnerability for people as they move through their lives, because more and more of their self esteem comes to rest on the way that they look. And, of course, the way that we look is constantly changing. Aging is inevitable. And if those things are treated as problematic, as things to avoid, then there’s more and more pressure to put time, money, energy and esteem into modifying the body.