Increased risks from cosmetic surgery?

But every operation involves risk: There are repeated tales of complications, or of operations that have gone wrong, endangering the health of the patients. Only recently, the founder of a French manufacturer of breast implants, which had been filled with cheap industrial silicone not licensed for use in medical products, was sentenced to four years in prison.   But does cosmetic surgery involve potentially fatal risks? What would be the implications of such a change of risk for life insurers? A team headed by Andreas Armuss and Alban Senn, both of whom are insurance medical officers in Munich Re's Centre of Competence for Medical Underwriting and Claims Consulting, analysed the industry and its special risks.

The cosmetic surgery sector is heavily fragmented. Its operations range from minor procedures to major surgery, and each operation involves specific risks. But what precisely is the definition of "cosmetic surgery", and which operations are actually relevant for risk management in life insurance? For the purposes of the risk analysis, Berger and Armuss focused on operations without medical indications, in other words, procedures that are carried out purely on aesthetic grounds, and which are performed by medical staff in accordance with particular standards. These include liposuction, breast operations, nose straightening, and face-lifts. Excluded from the analysis were reconstructive operations, such as those required after cancer illnesses, accidents or burns. The latter are performed as part of a medically indicated treatment, and the risk is generally determined on the basis of the underlying condition. Similarly, minor operations such as Botox treatment, piercings and micro-implants were not considered, because these fall under a grey area where there is little standardisation, documentation or controllability, and because such procedures are normally not included in statistics.

Adequate numerical data forms the basis for every qualified risk assessment. Unfortunately, in the present instance, hard facts are missing; in contrast to other types of surgery, there is much less data on the negative impacts of and complications from cosmetic surgery. This is because cosmetic surgery is usually a private concern, and is not covered under the public healthcare system. Up until now, hardly any government has devoted much energy to regulating and monitoring the medical beauty industry. Of course the industry itself endeavours to implement certain standards in its own interests and to rule out complications, simply to avoid reputational damage. However, studies within the industry tend to focus on the subject of client satisfaction, rather than on side-effects and risks.

The scarcity of data concerning the medical risks is in sharp contrast to the large number of operations being performed around the world: for example, between 1997 and 2010, the number of cosmetic procedures performed increased each year by 10 percent on average. Industry associations forecast that this upward trend will continue. The increasing demand is also driving development in this highly dynamic segment of modern medicine. New surgical techniques are constantly being developed and applied, even though their long-term consequences have not been adequately researched.

The largest market for cosmetic surgery is Asia, closely followed by North America and Europe. Liposuction and breast enlargements are the most frequent types of operation. Around 10 million women worldwide have received a breast implant so far. The clientèle now extends to every income bracket. A breast enlargement costs around €4,000 on average, which is an affordable amount for many people nowadays.

Breast operations were the procedures most thoroughly examined in the study. Even though the procedure involved is surgically complex and only performed under a full anaesthetic, mortality is low, more or less comparable with the risk of dying during natural birth. This fact was confirmed by a major study carried out in Canada in 2006. No increased mortality in comparison with the general population was established among 40,000 women who underwent breast enlargement for cosmetic reasons.

The risk of breast cancer does not appear to be affected by cosmetic surgery either. According to a study published in the British Medical Journal in 2013, no increased risk of breast cancer was found among tens of thousands of women following a breast implant. At the same time, there are still no reliable predictions on whether breast implants affect the diagnostic accuracy of examinations to identify breast cancer, such as mammography. The greatest risk with a breast operation is that of a post-operative infection, which generally does not entail any long-term restrictions, provided it is promptly and professionally treated. An infection occurs in between two to five percent of patients following the operation. Roughly eight percent of patients suffer encapsulation in connective tissue, which requires further surgery, but this likewise has no effect on occupational ability or mortality. The same is true for tears in the implant. Approximately 15 percent of patients find themselves back on the operating table within 12 months of their first breast implant. It is therefore advisable to defer a life insurance application for one year after an operation of this kind. This applies in particular for disability covers. In addition, cases should be critically assessed where applicants have undergone repeated or excessive cosmetic surgery. This could be an indication, for example, of a distorted, or even pathological, body image.

Dr. Armuss summarises the findings as follows: "At the present time, we perceive no increased mortality risk with policyholders who undergo cosmetic surgery. However, caution is advised in the case of disability products in the first few months after cosmetic surgery because the complication rates are relatively high. However, cosmetic surgery has developed into a fast-growing and highly dynamic industry. At the same time, the legal minimum requirements in terms of quality and safety are often inadequate, and the long-term risks are frequently unknown because of a dearth of epidemiological studies. So we need to keep an eye on developments in this market, to allow us to recognise risks at an early stage and manage them safely in life insurance."