Excessive Cosmetic Plastic Surgery : How Much is Too Much?

New York, NY (February 27, 2004)

The American Society for Aesthetic Plastic Surgery (ASAPS) believes it is important to make a clear distinction between such individuals and the millions of normal men and women who elect plastic surgery as a means to enhance their overall sense of well being.

Appropriateness of Multiple Procedures

How much cosmetic surgery is too much? The answer depends on the reasons it is chosen, when it is chosen, and the patient’s expectations. A patient who has a strong personal desire for self-improvement and is able to identify specific, realistic goals for surgery is likely to be a suitable candidate for one or more procedures.

Multiple procedures performed at the same time may be appropriate, with proper safety considerations, in order to create or maintain harmony among physical features. For example, a facelift is often combined with eyelid surgery and a brow lift to achieve harmony among the various “aesthetic units” of the face. Following surgery, all parts of the face may then continue the aging process at a more similar rate.

Over an individual’s lifetime, there may be various stages at which cosmetic surgical or nonsurgical enhancements can improve the quality of life. Procedures may be spaced at intervals of a few years, a decade or more – depending on the individual’s goals.

The following might be a typical sequence of procedures:

  • 30s: Botox injections to address fine wrinkling around the eyes Tummy-tuck and breast lift after childbirth and breast-feeding are completed
  • 40s: Lipoplasty (liposuction) for double chin and fat deposits in hips and thighs Vein injections to eliminate spider veins
  • 50s: Facelift, eyelid surgery

Patient Evaluation for Surgery

One clue as to whether a patient is seeking “excessive” surgery is the source and degree of motivation. An individual seeking cosmetic surgery should always be self-motivated; having surgery to please family members, a significant other or spouse is never appropriate. In addition, strongly motivated patients have been found to experience less pain, recuperate faster, and have a significantly higher index of satisfaction.

Individuals with low self-esteem who obsessively focus on minor flaws or believe that surgery will work a miracle in their lives are bound to be disappointed and dissatisfied. Such persons are not appropriate candidates for cosmetic surgery. In extreme cases, individuals exhibiting these traits may suffer from Body Dysmorphic Disorder (BBD), a rare psychiatric condition characterized by an uncontrollable preoccupation with an imagined or slight defect in appearance. Responsible surgeons try to identify inappropriate patients during their preoperative evaluations, and do not recommend surgery for such individuals.

Informed Consent

Patient safety is paramount, and the risks of surgery must always be carefully weighed against the potential benefits. That is why informed consent is so important. Informed consent is the patient’s informed decision to proceed with a medical treatment or surgical procedure. In order to give informed consent, a patient must be provided with the facts and information necessary to make an educated choice.

Fully informed consent is in the best interests of both patients and physicians. Plastic surgeons use the consultation process to educate patients about the proposed surgery. Every surgery has inherent risks and benefits; the hallmark of informed consent is the understanding of risks and benefits, and realistic expectations as to outcome. The surgeon must consider the patient’s safety over the patient’s desires.

During the consultation, the plastic surgeon considers such factors as whether: the patient has difficulty describing the desired change; the patient is unreasonably bothered by what, objectively speaking, is a minor imperfection; the patient’s friends and family are supportive or opposed to the procedure; the patient appears depressed or excessively anxious; and the patient has a history of dissatisfaction with cosmetic surgery. If the patient is seeking to repeat a procedure that has been performed in the past, the surgeon must evaluate whether sufficient improvement can be achieved to warrant another operation.

Patients seeking cosmetic plastic surgery may have expectations that are not consistent with what is possible. It is in both the patient’s and surgeon’s best interests to bring the patient’s perspectives in line with the surgeon’s before any commitment to surgery. The alternative is regret instead of satisfaction after surgery.

As the leading organization of plastic surgeons certified by the American Board of Plastic Surgery (ABPS) who specialize in cosmetic plastic surgery of the face and body, ASAPS strongly believes that it is in the best interests of prospective patients that inappropriate candidates for surgery are eliminated through the consultation process. It is also in the surgeon’s self-interest. However, surgeons are not psychiatrists, and even the most thorough consultation cannot always identify the surgical candidate who is unsuitable for psychological reasons. Inappropriate behavior may not be manifested during the interview process; in fact, it is sometimes carefully masked.

Shared Responsibility

It is ASAPS’ position that patients seeking cosmetic surgery have the responsibility to research prospective physicians and make sure they are properly credentialed, certified by the ABPS, with hospital privileges for the procedure being considered (even if the procedure will be performed in an office-based surgical facility). In addition, patients scheduling office-based cosmetic surgery should confirm that the facility is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) or equivalent agency, state licensed or Medicare-certified. Shared responsibility between patient and surgeon helps to ensure realistic expectations and satisfying surgical results.


Individuals age uniquely and at different rates depending on heredity, lifestyle, sun exposure and other factors. The American Society for Aesthetic Plastic Surgery (ASAPS) provides the following chart as a “typical” timeline for the enhancement and rejuvenation of appearance through cosmetic surgical and nonsurgical procedures:

MID 20s to MID 30s
Early frown lines between brows Botox injections
Small or asymmetrical breasts Implants
Localized fat deposits Lipoplasty
MID 30s to MID 40s
Gradual hooding of upper eyelids Upper eyelid surgery or brow lift
Puffiness under eyes Lower eyelid surgery
Fine wrinkling around eyes Skin resurfacing and/or Botox
Frown lines between brows Botox or endoscopic forehead surgery
Fine wrinkling around lips Skin resurfacing/chemical peel
Nasolabial folds or creases Soft Tissue Filler
Fat deposits in hips, thighs, abdomen Lipoplasty
Muscle weakness/loose abdominal skin Mini or full tummy tuck
Loss of volume/tone in breasts Breast lift with or without implants
Spider veins Sclerotherapy (vein injections)
MID 40s to MID 50s
Sagging eyebrows Brow lift
Double chin Lipoplasty
Vertical cordlike structures in neck Neck lift/tightening procedure
Descent of cheek fat Mid-facelift
Development of jowls Lower-facelift
Slight drooping of nasal tip Rhinoplasty
Thinning of lips Lip augmentation
Pattern baldness Hair restoration
60s and BEYOND
Facial wrinkles and creases Skin resurfacing/chemical peel/Botox/Soft Tissue Filler/Fat injections
Recurring facial laxity Repeat facelift
Excess fat and skin in upper arm Upper arm lift

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