cosmetic surgery – past, present, future

Cosmetic Surgery:Cosmetic Surgery:Past, Present and Past, Present and

FutureFutureMartin T Donohoe, MD, FACPMartin T Donohoe, MD, FACP

Cosmetic Surgery is a Cosmetic Surgery is a Branch of Plastic SurgeryBranch of Plastic Surgery

Plastic surgeons repair congenital Plastic surgeons repair congenital malformations (e.g., cleft lip and malformations (e.g., cleft lip and palate), disfiguring wounds, animal palate), disfiguring wounds, animal bites, burn injuries, and perform bites, burn injuries, and perform reconstructions after surgeries for reconstructions after surgeries for chronic and/or malignant conditionschronic and/or malignant conditions

Cosmetic surgery is largely elective Cosmetic surgery is largely elective and designed to augment “normal” and designed to augment “normal” appearanceappearance

Plastic Surgery CharitiesPlastic Surgery Charities

Operation Smile - correcting Operation Smile - correcting congenital defects in patients in the congenital defects in patients in the developing worlddeveloping world

Face-to-Face: The National Domestic Face-to-Face: The National Domestic Violence Project (sponsored by the Am Violence Project (sponsored by the Am Acad of Facial Plast and Reconstr Acad of Facial Plast and Reconstr Surgeons) – for domestic violence Surgeons) – for domestic violence victimsvictims

InterplastInterplast

History of Reconstructive and History of Reconstructive and Cosmetic SurgeryCosmetic Surgery

600 BC: Hindu surgeon reconstructs nose 600 BC: Hindu surgeon reconstructs nose using a piece of cheekusing a piece of cheek

By 1000 AD: rhinoplasty commonBy 1000 AD: rhinoplasty common Due to common practice of cutting off noses Due to common practice of cutting off noses

and upper lips of enemiesand upper lips of enemies 1616thth Century: Gaspare Tagliacozzi (“the Century: Gaspare Tagliacozzi (“the

father of plastic surgery”) reconstructs father of plastic surgery”) reconstructs noses slashed off during duels by noses slashed off during duels by transferring flaps of upper arm skintransferring flaps of upper arm skin Also used to reconstruct “saddle nose” Also used to reconstruct “saddle nose”

deformity of congenital syphilisdeformity of congenital syphilis


1798: Term plastic surgery (from the 1798: Term plastic surgery (from the Greek "plastikos," fit for molding), Greek "plastikos," fit for molding), coined by Pierre Desaultcoined by Pierre Desault

19th century: developments in 19th century: developments in anesthesia and antisepsis make plastic anesthesia and antisepsis make plastic surgery safer, techniques improvesurgery safer, techniques improve

Skills developed during the World Skills developed during the World Wars I and II applied to victims of Wars I and II applied to victims of birth defects and automobile and birth defects and automobile and industrial accidents industrial accidents


Eugenics movement, post-WWII Eugenics movement, post-WWII prosperity, rise of movies/TV all prosperity, rise of movies/TV all increase popularity of cosmetic increase popularity of cosmetic surgerysurgery

1923: first modern rhinoplasty1923: first modern rhinoplasty

1931: first public face lift1931: first public face lift

History of Reconstructive History of Reconstructive and Cosmetic Surgeryand Cosmetic Surgery

1950s: first hair transplants1950s: first hair transplants 1990s onward: more procedures 1990s onward: more procedures

carried out in doctors’ offices carried out in doctors’ offices and free-standing surgical and free-standing surgical centerscenters

2000s: Aesthetic medicine, 2000s: Aesthetic medicine, medi-spas, luxury clinicsmedi-spas, luxury clinics

Medi-SpasMedi-Spas

Generate over $1 billion revenue Generate over $1 billion revenue annually in USannually in US

Offer cosmetic procedures, Offer cosmetic procedures, massage, aromatherapy, massage, aromatherapy, cosmeceuticalscosmeceuticals

Overseas medical spa tourism Overseas medical spa tourism increasingincreasing

Motivations for Cosmetic Motivations for Cosmetic SurgerySurgery

External: avoidance of ethnic prejudice; External: avoidance of ethnic prejudice; fear of age discrimination; coercion by fear of age discrimination; coercion by spouse/parent/bossspouse/parent/boss

Internal: desire to diminish unpleasant Internal: desire to diminish unpleasant feelings like depression, shame, or social feelings like depression, shame, or social anxiety; to alter a specific feature they anxiety; to alter a specific feature they dislike; desire for a more youthful, dislike; desire for a more youthful, healthy look that signals fertility healthy look that signals fertility (women); interest in developing a strong, (women); interest in developing a strong, powerful look that may facilitate career powerful look that may facilitate career advancementadvancement

Motivations for Cosmetic Motivations for Cosmetic SurgerySurgery

20% of women and 10% of men 20% of women and 10% of men describe themselves as describe themselves as unattractiveunattractive

Much higher than in the 1990sMuch higher than in the 1990s

Arguments for Cosmetic Arguments for Cosmetic SurgerySurgery

Aging as a physical illnessAging as a physical illness Aging as a mental illnessAging as a mental illness Substitution of happiness for Substitution of happiness for

health as the goal of medical health as the goal of medical treatmenttreatment

A business service provided to A business service provided to those who desire it, can pay, and those who desire it, can pay, and accept the risks involvedaccept the risks involved

Representations of Cosmetic Representations of Cosmetic Surgery in Women’s Surgery in Women’s

MagazinesMagazines 2008 study2008 study Only 48% of articles in magazines like Only 48% of articles in magazines like

Cosmo and O, The Oprah Magazine Cosmo and O, The Oprah Magazine discuss the impact of cosmetic discuss the impact of cosmetic surgery on emotional healthsurgery on emotional health

Most articles link cosmetic surgery Most articles link cosmetic surgery with enhanced emotional well-being, with enhanced emotional well-being, regardless of the patient’s pre-regardless of the patient’s pre-existing emotional healthexisting emotional health

2009 National Plastic 2009 National Plastic Surgery StatisticsSurgery Statistics

Total cosmetic surgical Total cosmetic surgical procedures: 1.5 millionprocedures: 1.5 million

Total cosmetic minimally-Total cosmetic minimally-invasive procedures: 11 millioninvasive procedures: 11 million

Total reconstructive procedures: Total reconstructive procedures: 5.2 million5.2 million

- Source: American Society of Plastic - Source: American Society of Plastic SurgeonsSurgeons

Cosmetic SurgeryCosmetic Surgery

91% of patients women91% of patients women

66% Caucasian; 17% Asian-66% Caucasian; 17% Asian-American; 12% Hispanic; 5% African-American; 12% Hispanic; 5% African-AmericanAmerican

2/3 report family incomes 2/3 report family incomes < $50,000< $50,000

More popular on West CoastMore popular on West Coast


34% of patients have multiple 34% of patients have multiple procedures done at the same procedures done at the same timetime ““Drastic plastic”Drastic plastic”

40% of patients are repeat 40% of patients are repeat patientspatients


Complications rare but possibleComplications rare but possible E.g., infections, bleeding, E.g., infections, bleeding,

hyponatremia, allergic hyponatremia, allergic reactions, anesthetic reactions, anesthetic complicationscomplications

Revision rates as high as 10%Revision rates as high as 10% E.g., face lift lasts 10 yrsE.g., face lift lasts 10 yrs

Cosmetic Surgery Cosmetic Surgery 2009 prices – Do not include anesthesia, OR 2009 prices – Do not include anesthesia, OR

facilities, other costsfacilities, other costs

12.5 million minimally-invasive 12.5 million minimally-invasive procedures ($10 billion):procedures ($10 billion): 4.8 million botox procedures4.8 million botox procedures 1.2 million hyaluronic acid fillers1.2 million hyaluronic acid fillers 1.1 million chemical peels1.1 million chemical peels 910,000 microdermabrasions910,000 microdermabrasions 890,000 laser hair removals890,000 laser hair removals 390,000 vein sclerotherapies 390,000 vein sclerotherapies

(strippings)(strippings)

Cosmetic Surgery Cosmetic Surgery 2009 prices – Do not include anesthesia, OR 2009 prices – Do not include anesthesia, OR

facilities, other costsfacilities, other costs

11.7 million surgical procedures:11.7 million surgical procedures: 341,000 liposuctions: $2,769341,000 liposuctions: $2,769 256,000 rhinoplasties: $4,216256,000 rhinoplasties: $4,216 289,000 breast augmentations: $3,331289,000 breast augmentations: $3,331 203,000 blepharoplasties (eyelid 203,000 blepharoplasties (eyelid

reconstructions): $2,809reconstructions): $2,809 115,000 abdominoplasties (“tummy 115,000 abdominoplasties (“tummy

tucks”): $4,936tucks”): $4,936 104,000 face lifts: $6,396104,000 face lifts: $6,396

Cosmetic Surgery:Cosmetic Surgery:Other ProceduresOther Procedures

Breast reductionsBreast reductions

Chemical peelChemical peel

Forehead liftForehead lift

Upper arm liftUpper arm lift

Cosmetic Surgery:Cosmetic Surgery:Other ProceduresOther Procedures

Buttock liftButtock lift Thigh liftThigh lift LiposuctionLiposuction

““The Mommy Makeover” The Mommy Makeover” increasingly popular increasingly popular (abdominoplasty and liposuction)(abdominoplasty and liposuction)

Most popular cosmetic Most popular cosmetic surgical procedures for surgical procedures for

men (2009 stats)men (2009 stats) Rhinoplasty: 66,000 Blepharoplasty: 30,000 Liposuction: 22,000 Breast reduction: 17,000 Hair transplantation: 13,000

Other popular procedures Other popular procedures for menfor men

Scalp reduction (for male pattern baldness)

Cheek implants Ear reshaping Pectoral implants Chin augmentation (implants) Calf implants

Most popular cosmetic Most popular cosmetic surgical procedures for surgical procedures for

women (2009 stats)women (2009 stats) Breast augmentation: 289,000 Rhinoplasty: 190,000 Liposuction: 176,000 Blepharoplasty: 173,000 Abdominoplasty: 111,000

Cosmetic Surgery Cosmetic Surgery WorldwideWorldwide

Countries with the most plastic Countries with the most plastic surgeons: US, China, Brazil, and Indiasurgeons: US, China, Brazil, and India

Country with the most cosmetic Country with the most cosmetic sugery operations per capita = Brazilsugery operations per capita = Brazil

City in America with the most plastic City in America with the most plastic surgeons per capita = San Franciscosurgeons per capita = San Francisco

History of Breast History of Breast AugmentationAugmentation

With a few exceptions, large With a few exceptions, large breasts in vogue since antiquitybreasts in vogue since antiquityBrassieres and corsets used to Brassieres and corsets used to

enhance sizeenhance size 1919thth Century: surgical breast Century: surgical breast

enlargements attempted using enlargements attempted using ivory, glass, metal, rubber, and ivory, glass, metal, rubber, and paraffinparaffin


1895: Czerny performs first reported 1895: Czerny performs first reported successful human mammary reconstructionsuccessful human mammary reconstruction actress who had undergone removal of a actress who had undergone removal of a

fibroadenomafibroadenoma transplanted lipoma from her hiptransplanted lipoma from her hip

1903: Charles Miller inserts "braided silk, 1903: Charles Miller inserts "braided silk, bits of silk floss, particles of celluloid, bits of silk floss, particles of celluloid, vegetable ivory, and several other foreign vegetable ivory, and several other foreign materials”materials” granulomatous (foreign body) inflammatory granulomatous (foreign body) inflammatory

reactions disfiguring and painfulreactions disfiguring and painful


1903-1950s: petroleum jelly, 1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins beeswax, shellac, and epoxy resins used; use of paraffin caused cancersused; use of paraffin caused cancers

Early 1950s: liquid silicon injections Early 1950s: liquid silicon injections usedused

1962: first US woman to receive 1962: first US woman to receive encapsulated silicon breast implantsencapsulated silicon breast implants


1992: FDA bans silicone breast 1992: FDA bans silicone breast implants except in strictly controlled implants except in strictly controlled trials for breast cancer trials for breast cancer reconstructive surgery due to reconstructive surgery due to reports linking the implants with a reports linking the implants with a variety of connective tissue diseases variety of connective tissue diseases and neurological disorders.and neurological disorders.

Subsequent analyses show no such Subsequent analyses show no such linkslinks


2005: FDA allows silicone breast 2005: FDA allows silicone breast implants back on market (with registry)implants back on market (with registry)

A minimum of 15% of modern silicone A minimum of 15% of modern silicone implants will rupture between the third implants will rupture between the third and tenth year after implantationand tenth year after implantation

Today: fat transfer, newer generation Today: fat transfer, newer generation silicone implants, saline implants, silicone implants, saline implants, dermal fillersdermal fillers


2007: Stem cells and fat derived from 2007: Stem cells and fat derived from liposuction used to grow breast tissue liposuction used to grow breast tissue in clinical trials in Europein clinical trials in Europe

2008: Israeli surgeon develops 2008: Israeli surgeon develops “breast lift procedure” involving “breast lift procedure” involving internal titanium bra with silicone internal titanium bra with silicone cupscups

2008: MyFreeImplants.com 2008: MyFreeImplants.com Facilitates communication and fundingFacilitates communication and funding

Breast Implant ComplicationsBreast Implant Complications(most to least common)(most to least common)

Capsular contractureCapsular contracture Implant ruptureImplant rupture HematomaHematoma Wound infectionWound infection

Breast implants decrease sensitivity Breast implants decrease sensitivity of screening mammography among of screening mammography among asymptomatic women, but do not asymptomatic women, but do not increase false-positive rate nor affect increase false-positive rate nor affect tumor prognostic characteristicstumor prognostic characteristics

Breast Implant Complications Breast Implant Complications Five Yrs After SurgeryFive Yrs After Surgery

Cosmetic implants – 12%Cosmetic implants – 12% After prophylactic mastectomy After prophylactic mastectomy

– 30%– 30% After mastectomy for breast After mastectomy for breast

cancer – 34%cancer – 34% Latest trend: microsurgical Latest trend: microsurgical

breast reconstruction using breast reconstruction using implants or autologous tissuesimplants or autologous tissues

New Breasts for Graduating New Breasts for Graduating SeniorsSeniors

11,326 procedures performed on 18-11,326 procedures performed on 18-year olds in 2003year olds in 2003

Phenomenon suggests poor Phenomenon suggests poor parenting, through the capitulation parenting, through the capitulation of financially well-endowed parents of financially well-endowed parents to the whims of their children, who to the whims of their children, who likely have self-esteem problems and likely have self-esteem problems and are not yet emotionally (nor perhaps are not yet emotionally (nor perhaps even physically) matureeven physically) mature

Breast Augmentation for Breast Augmentation for Females Under Age 18Females Under Age 18

4,108 procedures on women 18 4,108 procedures on women 18 and under in 2008and under in 2008

US and EU: breast augmentation US and EU: breast augmentation surgery allowed on those under surgery allowed on those under age 18 only for medical reasonsage 18 only for medical reasonsYet 50% of procedures done Yet 50% of procedures done

for purely cosmetic reasonsfor purely cosmetic reasons

Headline from Headline from The OnionThe Onion::Plastic Surgeon General Warns Plastic Surgeon General Warns

of Small Breasts Epidemicof Small Breasts Epidemic

The Adonis ComplexThe Adonis Complex

38% of men want bigger pectorals; 38% of men want bigger pectorals; 34% of women want bigger breasts34% of women want bigger breasts

Each year, men spend over $2 Each year, men spend over $2 billion on health club billion on health club memberships and $2 billion for memberships and $2 billion for home exercise equipmenthome exercise equipment

Tommy John surgeryTommy John surgery To enhance elbow strength and To enhance elbow strength and

improve pitching velocityimprove pitching velocity

Anabolic Steroid AbuseAnabolic Steroid Abuse

Supplement industry boomingSupplement industry booming 3 million American men have 3 million American men have

swallowed or injected anabolic swallowed or injected anabolic steroids since they became widely steroids since they became widely available in the 1960savailable in the 1960s

2.8% of current high school males 2.8% of current high school males have used (50% increase over last have used (50% increase over last 4 years); rates among girls may 4 years); rates among girls may be even higherbe even higher Use associated with violent behaviorUse associated with violent behavior

Penile SizePenile Size

Ancient Greeks believed small Ancient Greeks believed small penis was superiorpenis was superior

Later, phallic identity and Later, phallic identity and phallocentrism increasingly phallocentrism increasingly popular – “penis is central to popular – “penis is central to man’s identity, virility”man’s identity, virility”

Penile SizePenile Size

55% of men satisfied with their 55% of men satisfied with their penile size; 85% of women penile size; 85% of women satisfied with their partner’s sizesatisfied with their partner’s size

No correlation between shoe No correlation between shoe size and penile lengthsize and penile length

Penile Size and Penile Penile Size and Penile Reconstructive SurgeryReconstructive Surgery

1971: First penile augmentation surgery1971: First penile augmentation surgery Girth enhancements with fat injections, Girth enhancements with fat injections,

Alloderm (derived from human skin)Alloderm (derived from human skin) Penile lengthening proceduresPenile lengthening procedures Complications: scar, keloid, penile Complications: scar, keloid, penile

lumps, sexual dysfunction, further penile lumps, sexual dysfunction, further penile shorteningshortening

Augmentation procedures not sanctioned Augmentation procedures not sanctioned by American Urological Associationby American Urological Association

Cosmetic Surgery Odds and Cosmetic Surgery Odds and EndsEnds

Most common cosmetic procedure in Most common cosmetic procedure in Asia = eyelid surgery, to create a Asia = eyelid surgery, to create a crease above the eye (up to 60% of crease above the eye (up to 60% of Korean women)Korean women)

Trisomy-21 surgery (covered in Trisomy-21 surgery (covered in ethical issues slide show)ethical issues slide show)

Reconstructive Surgery – The Reconstructive Surgery – The LatestLatest

Hand transplantsHand transplants Face transplantsFace transplants

2005: first procedure on female dog-2005: first procedure on female dog-mauling victim (10 worldwide through mauling victim (10 worldwide through late 2010, 2 associated deaths)late 2010, 2 associated deaths)

15-20 hour procedure (including 5 hours 15-20 hour procedure (including 5 hours for harvest); involves multidisciplinary for harvest); involves multidisciplinary teamteam

Ethical issuesEthical issues Lifelong immunosuppression requiredLifelong immunosuppression required

Cosmetic NeurologyCosmetic Neurology

Interventions to enhance the Interventions to enhance the cognitive and emotional brain cognitive and emotional brain functions of the neurologically functions of the neurologically non-diseasednon-diseased

Currently being pursued by the Currently being pursued by the pharmaceutical industry (via pharmaceutical industry (via drugs to increase intelligence) drugs to increase intelligence) and the military (via interventions and the military (via interventions to create more effective soldiers)to create more effective soldiers)

Cosmetic Military Cosmetic Military NeurologyNeurology

““Go-go pills" (amphetamines) used by Go-go pills" (amphetamines) used by US soldiers in WW IIUS soldiers in WW II

Modafinil (wakefulness-promoting Modafinil (wakefulness-promoting agent) improves pilot alertness and agent) improves pilot alertness and performance in helicopter flight performance in helicopter flight simulations.simulations.

Many military pilots today rely on Many military pilots today rely on caffeine and other stimulants, including caffeine and other stimulants, including amphetamines, to complete missionsamphetamines, to complete missions

Cosmetic NeurologyCosmetic Neurology

Raises concerns about:Raises concerns about:Distributive justiceDistributive justiceInformed consentInformed consent

In the military setting or In the military setting or in childrenin children

Cosmetic Surgery – The Cosmetic Surgery – The FringesFringes

The Jewel Eye: implantation of tiny The Jewel Eye: implantation of tiny platinum jewels into conjunctiva platinum jewels into conjunctiva (20 minutes, $3900)(20 minutes, $3900) Am Acad Ophth warns not proven safeAm Acad Ophth warns not proven safe

Umbilicoplasty, Umbilicoplasty, lengthening/shortening toes to lengthening/shortening toes to improve “toe cleavage,” fracturing improve “toe cleavage,” fracturing and resetting jaw to alter smile, and resetting jaw to alter smile, forehead implantsforehead implants


Genitalia redesign: foreskin Genitalia redesign: foreskin restoration, mechanical and restoration, mechanical and cosmetic phalloplasty, vaginal cosmetic phalloplasty, vaginal tightening/alteration of tightening/alteration of angle/dimensions, partial labial angle/dimensions, partial labial excisions, fat injection into labiaexcisions, fat injection into labia 4500 procedures in 20074500 procedures in 2007 ACOG: “safety and effectiveness ACOG: “safety and effectiveness

have not been documented”have not been documented”


The Jade Lady Membrane Man-Made The Jade Lady Membrane Man-Made HymenHymen Marketed in ChinaMarketed in China Blood-colored fluid released during sexBlood-colored fluid released during sex

Labial dyes (“My New Pink Button”)Labial dyes (“My New Pink Button”) Furries: lovers of anthropomorphized Furries: lovers of anthropomorphized

animalsanimals Surgical enhancementsSurgical enhancements ConventionsConventions


Deliberate amputations of body partsDeliberate amputations of body parts Apotemnophilia – attraction to the Apotemnophilia – attraction to the

idea of being an amputee (a idea of being an amputee (a paraphilia)paraphilia)

Not to be confused with Not to be confused with acrotomophiliacs – sexually attracted acrotomophiliacs – sexually attracted to amputeesto amputees

Wings, chimeras, and stem-cell Wings, chimeras, and stem-cell cosmesiscosmesis


Sarah Burge (born 1959) holds Sarah Burge (born 1959) holds world plastic surgery record:world plastic surgery record: Over 100 proceduresOver 100 procedures Cost = $850,000Cost = $850,000

Celebrity plastic surgery:Celebrity plastic surgery: Michael Jackson, Pamela Lee, Meg Michael Jackson, Pamela Lee, Meg

Ryan, Cher (?), many othersRyan, Cher (?), many others

Prime Time Cosmetic Prime Time Cosmetic SurgerySurgery

ABC TV’s “Extreme Makeover”ABC TV’s “Extreme Makeover”

Fox TV’s “The Swan”Fox TV’s “The Swan”

MTV’s “I Want a New Face”MTV’s “I Want a New Face”

FX’s Nip TuckFX’s Nip Tuck

PetsPets

Neuticles (artificial pet testicles)Neuticles (artificial pet testicles)““To boost your pet’s self-image”To boost your pet’s self-image”Over 250,000 sold through mid Over 250,000 sold through mid

20082008No FDA-approved artificial No FDA-approved artificial

testes for humans, so cancer testes for humans, so cancer victims buy and have plastic victims buy and have plastic surgeon installsurgeon install

PetsPets

We value our pets, but…We value our pets, but… In 2008, almost 1200 people In 2008, almost 1200 people

purchased stem cell surgery for purchased stem cell surgery for their dogstheir dogs

Pet cloningPet cloningPet jewelryPet jewelryOver $3 billion pet Over $3 billion pet

pharmaceutical marketpharmaceutical market

ConclusionsConclusions

Body modification common today Body modification common today and throughout historyand throughout history

Risks involvedRisks involved Obesity a major public health Obesity a major public health

problemproblem The body modification and weight The body modification and weight

loss industries marred by loss industries marred by hucksterism, false claims and hucksterism, false claims and conflicts of interestconflicts of interest

ConclusionsConclusions

Beauty has different definitions in Beauty has different definitions in different times and in different different times and in different culturescultures

The health professions can play a The health professions can play a constructive role in supporting safe constructive role in supporting safe and healthy behaviors and and healthy behaviors and promoting realistic ideals of beautypromoting realistic ideals of beauty

More education needed at all levelsMore education needed at all levels

Covered in Other Slide Covered in Other Slide ShowsShows

Ideals of beauty and body Ideals of beauty and body modificationmodification

Female genital cuttingFemale genital cutting Body weight and the obesity Body weight and the obesity

epidemicepidemic Ethical and policy issuesEthical and policy issues

ReferencesReferences Donohoe MT. Beauty and body modification. Donohoe MT. Beauty and body modification.

Medscape Ob/Gyn and Women’s Health Medscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at2006;11(1): posted 4/19/06. Available at

http://www.medscape.com/viewarticle/http://www.medscape.com/viewarticle/529442529442

Donohoe MT. Cosmetic surgery past, Donohoe MT. Cosmetic surgery past, present, and future: scope, ethics and policy. present, and future: scope, ethics and policy. Medscape Ob/Gyn and Women’s Health Medscape Ob/Gyn and Women’s Health 2006;11(2): posted 8/28/06. Available at 2006;11(2): posted 8/28/06. Available at http://www.medscape.com/viewarticle/542448

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cosmetic surgery – past, present, future

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