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Freeze the Botax


Dr. Steven H. Dayan, MD shares his view of the proposed tax on elective cosmetic procedures.

Opinion Editorial by Dr. Steven H. Dayan

Check out StopCosmeticTax.org to learn about how to contact your representatives and take a stand in the campaign against the Botax.

As Americans debate healthcare reform and our elected officials search for methods of funding the proposed one trillion dollar plan, cosmetic medicine has been thrust to the forefront of the conversation as a vehicle for generating revenue. Affectionately known as the "Botax," a play on the most popular cosmetic medical treatment in the world, the tax would charge a 5% tax not just on Botox, but on all "cosmetic" medical procedure performed by a licensed medical professional.

This is not the first time such an idea has been proposed. A similar bill was signed into law in New Jersey in 2004. However, it has fallen far short of its expectations. Having collected 59% percent less than what was projected and costing three to four dollars in government expense for every dollar collected, its failings have resulted in its repeal lead by assembly member, Joseph Cryan, the original sponsor. However, Governor Corzine vetoed the repeal and the law remains in place.

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The concept of taxing products and services that are considered self indulgences is not new. Sumptuary taxes or "sin taxes" on cigarettes, alcohol, and gambling started as early as the 18th century when our early government taxed whiskey and tobacco. Sin taxes are justified by many as a penalizing tax on society tolerated ills that are both financially and morally burdensome to the nation. Self indulging 'sin' behaviors are tolerated in the U.S. by a silent majority despite the fact that there will be 100,000 deaths from alcohol related diseases this year, one in two people will be involved in an alcohol related car accident in their lifetime, and 440,000 deaths per year occur from tobacco related disease. The costs go far beyond the dollars. Therefore, to justify the impact on society by penalizing and dissuading those that choose these vices makes argumentative sense. While sin taxes have been deemed worthy funding for important initiatives, cosmetic medicine has now been arbitrarily selected to join this celebrated group of self fulfillment "sins" based primarily on a misconception from its past.

Besides the bureaucratic nightmare, questionable feasibility, and overt gender discrimination that relates to this proposed bill, an equally valid concern is the likely violation of personal freedoms and the negative influence on the least publicly understood, but perhaps most valid field of medicine to society. Prior to hastily including cosmetic medicine within the feast of sins from which to cipher a relatively small amount of revenue a closer look at cosmetic medicine, its origin, role and impact on American society today is warranted.

If cosmetic medicine were a team, Botox would be its mascot. It is the most popular cosmetic treatment in the world 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. Prior to Botox, cosmetic medicine was a contained small 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 we think of and treat infections, steroids had on the management of acute and chronic inflammatory diseases, and insulin 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.

Prior, the niche population seeking aesthetic medicine was not considered representative of society on a whole, and conventional wisdom categorized them as belonging to one socioeconomic class, self-absorbed, or possibly seeking treatment for a personality disorder. It was not only elective, but also selective medicine not designed and/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 rid of discriminating characteristics. Beginning with the Romans and Greeks, plastic surgery allowed conquered nomadic populations to assimilate and hide evidence of a nefarious past or membership to an unacceptable cult. In a society where nudity was celebrated, the first cosmetic surgeries were performed on early Hebrews, Egyptians, and Phoenicians who desired circumcision reversal.

For 2500 years, cosmetic medicine philosophy and techniques didn't change much until the early 20th century following World War I when for the first time soldiers survived battlefield wounds and returned home with disfiguring facial wounds that prevented them from being visible 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 or "pass" without being recognized. They desired form, function, and assimilation. One of the early post World War I surgeons was Jacque Joseph; a German marked for surgery surgeon who was known for his skills at reconstructing complex facial wounds of veterans, translated his skills and knowledge to alter characterizing facial features such as the noses of the 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 identity. Like many of newest trends and fads in pop culture, it started with movie stars. Famous pin-ups such as Marilyn Monroe and Rita Hayworth were getting plastic surgery. Cosmetic medicine was use to separate the starlets from the common folk. No longer was it a vehicle to blend unnoticed into society, rather 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 sexually characterizing features of beauty and youth.

Cosmetic surgery lost some of its original manifesto of allowing one to pass into society unnoticed. Now it became a tool to reinforce class distinction, and a level of being obviously altered was tolerated. Moreover, while wanting to look one's best is a cornerstone of human behavior, 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 skyrocketed over 3600% in the past 10 years.[1]

Besides the cosmetic improvement, patients were mentioning they received more favorable treatment from others after receiving Botox. This posed an interesting question. What was causing the perception of better treatment? Was it that after undergoing a cosmetic medical procedure one feels better and projects a better image or was it that others perceive the treated person more favorably because they are more attractive, resulting in the advantageous treatment?

It is well known and researched that the subtleties humans find attractive in one another are often perceived at a subconscious level. Evolutionary biologist have done extensive studies validating the importance of certain physical characteristics such as symmetry, youthfulness, and body proportions as important indicators of beauty and maximum fertility. Moreover, for hundreds of thousands of years, humans have been enhancing gender specific character traits, whether it's with clothes, makeup, perfumes, or adornments attempting to appear more fertile and attractive to a potential mate. And to the unknowing observer, people who get cosmetic medical treatments are thought to be more attractive, successful at dating, and even better athletes.[2]

Perhaps the perceived improved treatment from others is not solely due to a physically improved appearance, but as a result of an invigorated self-esteem resulting in projection of a more favorable attitude that is reciprocated. A report published early this year indicated that cosmetic treatments alleviated symptoms of depression, and while this study was small and uncontrolled, it launched an interesting dilemma for further discussion.[3] In a double-blind randomized placebo controlled study, patients who received Botox showed an improved quality of life at two week and up to three months after their treatment.[4] It is easy to speculate that one who feels better about the way they look experiences an improved self-esteem, acts more confidently, and remits a better quality of life. Furthermore, Botox has been shown to correlate with an increase in a more positive mood.[5] In which case, would treating a disease that affects 9.5% percent of our population[6] with cosmetic treatments or plastic surgery still be subjected to a cosmetic tax? Conversely, perhaps the 10 million Americans treated this year with cosmetic procedures1 can apply for a cosmetic tax exemption believing they suffer from a mood disorder disease. As we begin to study and objectively quantify the benefits of cosmetic medicine to the individual, what is cosmetic becomes even more blurred.

Although cosmetic medical treatments have been labeled as a vain luxury for the rich and famous to discuss while sipping champagne on their yachts, a closer look reveals that these treatments have a much bigger role for many individuals from all backgrounds. Yes, Botox can reduce wrinkles, but it also can provide facial symmetry to stroke victims, reduce migraine headaches, and prevent excessive sweating. Once the theme of sci-fi movies, surgical facial transplants are now a reality, allowing hope to the severely disfigured and banished from society. Breast implants are a potential feminine saving procedure for the 1 in 26 women who will undergo cancer curing mastectomy.[7] Does a 50-year-old post-menopausal breast cancer survivor need her breast? No, not for survival, but certainly it is a critical quality of life and cosmetic issue. Will this be subjected to a cosmetic tax? Where do we draw the line between what is and what isn't cosmetic? What about the 57% of females who suffer from balding[8] or the 1.1 million HIV victims who experience facial wasting?[9]

These patients undergo treatments to alleviate the cosmetic effects of these conditions, none of which are medically necessary for survival, but all of which have a cosmetic and quality of life issue.

Also up for discussion, what about children with ears that stand out, young developing females with asymmetric breast, or teenagers with acne? How about treatments for obesity? Is it or isn't it a disease? If a disease, then liposuction, stomach stapling, and facelifts after massive weight loss will not be subjected to a cosmetic tax? Where does it stop?

Should we arbitrarily consider taxing other cosmetic indulgences such as manicures, massages, and eyebrow waxing? Who will decide what is and isn't cosmetic- the physicians, a government body, or perhaps a cosmetic czar?

And if the doctor, in attempts to protect his or her patients, doesn't collect the tax according to the letter of the law and is subject to an audit, will his/her patients' records be subpoenaed and exposed to the public? Will privacy laws prevail or will Americans tolerate their individual freedoms being compromised in the name of a cosmetic tax?

No longer is cosmetic medicine a treatment limited to an elite class. The majority, 90%, undergoing cosmetic medical procedures are now middle class households earning less than $90,000.[10] And as benefits are becoming further established, more of the population wants to take part in it.

Botox and cosmetic procedures are becoming increasingly affordable, no longer are the benefits exclusive to one class of society. Cosmetic medicine today is a field of study providing improvement in quality of life issues for many Americans. The widespread availability, increasing competition, and proven benefits have driven the price of non-surgical cosmetic medical treatments closer to that of a hair cut than a facelift. The effects of cosmetic medicine on our society are just beginning to be realized, but if millions of Americans can enjoy a better quality of life, what impact would this have on their productivity both at work and at home? It is intuitive to assume that one who enjoys a better quality of life contributes more positively to society both economically and emotionally. Unlike other sins that can be erosive to society, such as alcohol, cigarettes, and arguably fast food, scientific and empirical evidence indicates cosmetic medicine can provide value and strength to society.

At a time when taxing cosmetic procedures is being debated and our elected legislators may be in charge of judging what is or isn't cosmetic, we need to examine the effects cosmetic medicine has on both the individual and society with clear objectivity. Cosmetic medicine is not a field devoted to stretched faces, large breasts, and thin tummies. The caricature of Pamela Anderson, Joan Rivers, or Kenny Rogers is not the norm and does not define the practice. Rather, it is a field of medicine that today is developing products and services that make one feel better about themselves.

Conventional wisdom likes to brand cosmetic physicians as purveyors of beauty and this couldn't be further from the truth. Our research and scope of medicine is targeted toward making the majority of Americans feel better about themselves with safe and effective treatment options. Cosmetic medicine allows traumatized victims, whether congenitally, physically, or emotionally, a path for returning to society and being productive. In addition, it gives all classes of individuals additional tools to obtain an improved quality of life and satisfy one of the most primal human instincts, wanting to look our best.

Cosmetic medicine is a field of medicine that is designing, developing, and delivering treatments that provide a bolt of self-confidence to an individual and a surge of well being that is contagious and beneficial to society. The bureaucratic difficulties of instituting the tax plus the compromise of personal freedom and disproportionate targeting of the middle class, all suggest an arbitrarily suggested misguided tax. Encourage Americans to invest in themselves, don't dissuade it.

source: Steven H. Dayan, MD, FACS

[1] The American Society of Plastic Surgeons Annual National Clearinghouse Statistics. Available at: http://www.plasticsurgery.org . Accessed November 30, 2009.

[2] Dayan SH, Lieberman ED, Thakkar NN, Larimer KA, Anstead A. Botulinum toxin a can positively impact first impression. Dermatol Surg. 2008 Jun;34 Suppl 1:S40-7

[3] Finzi E, Wasserman E. Treatment of depression with botulinum toxin A: a case series. Dermatol Surg. 2006 May;32(5):645-9

[4] Unpublished data on file

[5] Lewis MB, Bowler PJ. Botulinum toxin cosmetic therapy correlates with a more positive mood. J Cosmet Dermatol. 2009 Mar;8(1):24-6

[6] Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

[7] Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, Graff JJ, Katz SJ. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009 Oct 14;302(14):1551

[8] Gan DC, Sinclair RD. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005 Dec;10(3):184-9.

[9] CDC 'HIV Prevalence Estimates -- United States, 2006' MMWR 57(39), 3 October 2008

[10] 2005 ASPS survey.