First, do no harm: ethical practice and patients with body dysmorphic disorder

I have been around a long time in terms of medicine, aesthetics and life in general. I have watched the rise of cosmetic medicine from its humble beginnings to the burgeoning specialty that it is today. When I trained in 1990, the only injectable product available for cosmetic treatment was collagen produced from a specially bred herd of cows in the US. I remember the training day when only three doctors in Scotland were interested in having anything to do with something so ‘trivial’ and that was seen as less than worthy of a doctor's time. The Collagen Corporation started in 1975 in the US but is no longer active.

In a world where both men and women are living longer, patients want a face that reflects their internal feelings of youthfulness

The perception of the injectable aesthetic industry at that time was not very flattering, or indeed ethical, but was seen as a big money maker, with one journalist in the LA Times describing collagen for aesthetic use as ‘sticky glop’ and a ‘goo of natural proteins’ made from ‘cowhide’ and ‘the stuff’, sold to doctors, who then injected it under patients' skin to smooth wrinkles (Day, 1985). From the tone of this piece, it gives the distinct impression that collagen was seen as a fast money-maker. Indeed, it was nothing to be sniffed in the business world, as, by that time, only 10 years after the company was formed, the biomedical concern had made millions of dollars marketing implants to fill in facial lines and skin defects. Around a quarter of a million people in 25 countries were being injected and bring in 18 million dollars in revenue with a significant chunk of it coming in from the Beverley Hills doctors' offices. The perception of an unhealthy alliance between vanity and money-making was clearly taking shape. Collagen for cosmetic purposes may seem a bit obsolete these days, with all the different products and procedures that are widely available, but there were some things that were useful, and many are now recommending we should still do today. For example, there was a minimum of a 4-week cooling off period before patients proceeded to treatment. Admittedly, it was because of the possibility of allergy, but it also gave patients the time to assess information and come to a good decision for themselves. Often, this led to patients not coming back as they had changed their minds, or perhaps found the cost prohibitive. It was also important to let them know that the product was temporary, and if they liked the result, then this would be an ongoing financial commitment that they may or may not want to undertake. While some patients were lost, this stopped them making decisions that they perhaps felt they were being pressured into, as well as giving them time to actually go over all the new information they were presented with. Buyers regret was, and still is, always something to be aware of. Most patients were in their 40s and quite secretive about what procedure or treatment were having and had a desire to hold back time, rather than to look a lot younger or different. In short caution was the order of the day, and expectations as to what could be easily achieved were much more limited than they are now. Patients could be delighted with results, but never told anyone else that they had had anything done.