As Americans debated health care reform and our elected officials sought out methods of funding the proposed $1 trillion plan, cosmetic medicine was thrust to the forefront of the conversation as a vehicle for generating revenue.

Known as the “Botax,” a play on the most popular cosmetic medical treatment in the world, the proposed 5% tax would have affected not only Botox treatments but all “cosmetic” medical procedures performed by a licensed medical professional.


This is not the first time such an idea had 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% less revenue than what was projected—and costing $3 to $4 in government expense for every $1 collected—its failings have resulted in its repeal led by New Jersey assemblyman Joseph Cryan, the bill’s original sponsor. However, Gov Jon Corzine vetoed the repeal and the law remains in place.

The concept of taxing products and services that are considered “self indulgent” 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 whisky 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 whole nation.

Self-indulging “sin” behaviors are tolerated in the United States 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, justifying the impact on society by penalizing and dissuading those who choose these vices makes argumentative sense. While sin taxes have been deemed worthy for funding important initiatives, cosmetic medicine has now been arbitrarily selected to join this group of “sin taxes” based primarily on misconceptions.

Besides the bureaucratic nightmare, questionable feasibility, and overt gender discrimination that relates to a cosmetic tax, an equally valid concern is the likely violation of personal freedoms and the negative influence on the least publically 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, our representatives need to take a closer look at cosmetic medicine, its origin, role, and impact on American society.


If aesthetic medicine was 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 members of the US Senate to consider a cosmetic surgery tax in the first place.

Prior to the appearance of 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 of antibiotics on the way we think of and treat infections, steroids’ effect on the management of acute and chronic inflammatory diseases, and insulin’s effects on mitigating morbidity and mortality of a highly perilous viscerally targeted autoimmune process, Botox has forever changed the way aesthetic medicine is measured, perceived, and delivered.

Before Botox, the aforementioned niche population seeking aesthetic medicine was not considered representative of society as 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 an elective, selective medicine that was 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. Aesthetic medicine, yet to be defined, originated not as a treatment to enhance the beauty of the elite, but more as a service trade allowing individuals to pass into society minus some of all 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 in an unacceptable cult. In a society in which nudity was celebrated, the first cosmetic surgeries were performed on early Hebrews, Egyptians, and Phoenicians who desired circumcision reversal.

For 2,500 years, cosmetic medicine philosophy and techniques didn’t change much until the early 20th century and following World War I, when for the first time soldiers survived battlefield wounds and returned home with disfiguring facial wounds that prevented them from wanting to be seen in public.

Much like the early Greeks and Romans, disenchanted post World War I cosmetic surgery patients who were disfigured 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 surgeon who was known for his skills at reconstructing complex facial wounds of veterans. He 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.” This was the birth of elective aesthetic surgery. However, the goal of this new trade was not to perfect the human form or achieve ultimate beauty, but to make patients happy by giving them the ability to integrate seamlessly into society.

However, following World War II and with the advent of antibiotics and safer forms of anesthesia, aesthetic 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. Aesthetic medicine in the latter 20th century became an instrument of the privileged to flaunt their identity.

As with many of the newest trends and fads in pop culture, this phenomenon started with movie stars and famous “pin-up” celebrities such as Marilyn Monroe and Rita Hayworth, who got plastic surgery.

In this manner, aesthetic medicine was used to separate the starlets from the common folk. No longer was it a vehicle for people to blend unnoticed into society, but rather it became a means to stand out from the crowd. Plastic surgeons, in parallel, responded by offering physically altering treatments that were bold, large, and certain to emphasize sexually characterizing features of beauty and youth.

Aesthetic surgery, therefore, 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.”

Botox spread aesthetic medicine to the masses. For the first time, working-class individuals seeking cosmetic improvements entered into the market; and the demand skyrocketed more than 3,600% 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 biologists 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, in an attempt to appear more fertile and attractive to a potential mate.

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 2 weeks and up to 3 months after their treatment.4

It is easy to speculate that someone 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 that case, would treating a disease that affects 9.5% of our population6 with cosmetic treatments or plastic surgery have been subjected to a cosmetic tax?

Conversely, perhaps the 10 million Americans treated this year with cosmetic procedures would have been required to apply for a cosmetic tax exemption, believing they suffered from a mood disorder disease. As we begin to study and objectively quantify the benefits of aesthetic medicine for the individual, what is considered cosmetic becomes even more blurred.


In the past, cosmetic medical treatments were 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.

Although Botox can indeed reduce wrinkles, it can also provide facial symmetry to stroke victims, reduce migraine headaches, and prevent excessive sweating.

Once the domain of sci-fi movies, surgical facial transplants are now a reality, allowing hope for the severely disfigured and those who have been banished from society.

Breast implants are a potential femininity-saving procedure for the 1 in 26 women who will undergo cancer-curing mastectomy.7 Does a 50-year-old postmenopausal 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 balding8 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 involve important quality-of-life issues.

Also up for discussion: What about children with ears that stand out, young developing females with asymmetric breasts, or teenagers with acne? How about treatments for obesity? Is obesity a disease? If it is a disease, then liposuction, stomach stapling, and facelifts after massive weight loss would not have been subjected to the so-called Botax? Or would it?


Although these arguments could be considered “moot” by some, keep in mind that it would be very easy for our representatives to re-insert the “Botax” into the health care reform bill.

What if it were? Where would the burden of responsibility lie in implementing the tax?

If the ultimate arbiter is a physician who, 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? Would privacy laws prevail or would Americans tolerate their individual freedoms being compromised in the name of a cosmetic tax?

Aesthetic medicine is no longer 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 the benefits of aesthetic treatments become further established, more of the population will seek you out for consults.

The use of Botox and aesthetic procedures is becoming increasingly affordable, and currently aesthetic medicine 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 nonsurgical cosmetic medical treatments closer to that of a haircut 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 aesthetic 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.

Aesthetic 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 people feel better about themselves.

Old-style wisdom brands the aesthetic practitioner as the purveyor of beauty. 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.

Aesthetic 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 people additional tools to obtain an improved quality of life and satisfy one of the most primal human instincts—wanting to look our best.

Our field of medicine designs, develops, and delivers treatments that provide a bolt of self-confidence to an individual and a surge of well-being that is contagious and beneficial to society.

Steven H. Dayan, MD, FACS, is a clinical assistant professor at the University of Illinois, the medical director at DeNova Research of Chicago, and a regular contributor to PSP. He can be reached at .


  1. The American Society of Plastic Surgeons Annual National Clearinghouse Statistics. Available at: 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;34 Suppl 1:S40-47.
  3. Finzi E, Wasserman E. Treatment of depression with botulinum toxin A: a case series. Dermatol Surg. 2006;32(5):645-649.
  4. Unpublished data on file.
  5. Lewis MB, Bowler PJ. Botulinum toxin cosmetic therapy correlates with a more positive mood. J Cosmet Dermatol. 2009;8(1):24-26.
  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). Arch Gen Psychiatry. 2005;62(6):617-627.
  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;302(14):1551.
  8. Gan DC, Sinclair RD. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005;10(3):184-189.
  9. CDC “HIV Prevalence Estimates—United States, 2006” MMWR 57(39), 3 October 2008.
  10. 2005 ASPS survey.