Recent data released by the British Association of Aesthetic Plastic Surgeons show that more people are having cosmetic and weight reduction surgery than ever before: the number of surgical procedures performed by members of the Association in 2007 was 12% greater than in the previous year.1 The increased demand for cosmetic surgery was not limited to women — 18% more procedures were performed on men compared with the previous year. The greatest increases were in anti-ageing procedures, such as facelifts and eyelid surgery, which both increased by over 36%. Data recently reported by the American Society of Plastic Surgeons show that almost 12 million cosmetic surgery procedures were performed in the United States during 2007, representing a 59% increase from the number performed in 2000.2 Current Australian figures are difficult to establish but seem to be rising.3

An important driving factor behind the increase in cosmetic and weight reduction surgery may well be the large number of “reality” television programs that focus on weight loss and appearance change. Recent data from patients seeking first-time cosmetic surgery reveal that many were regular viewers of “appearance medicine” programs, and that four out of five reported that plastic surgery reality television influenced their decision to undergo cosmetic surgery.4 Dentists also report that “extreme makeover” programs have recently increased the demand for cosmetic dental procedures.5

Two categories of programs are particularly relevant. In the first category are programs with a focus on weight reduction through drastic diet and lifestyle changes. Recent examples in Australia include The biggest loser Australia and Overhaul; in the United Kingdom, they include Supersize vs superskinny and Superslim me. Contestants in such programs compete to make the fastest or most dramatic changes in weight. In 2007, The biggest loser Australia averaged over a million viewers per episode, and the finale drew nearly two million viewers.6 The winner of this series lost 70 kg, which represented 47% of his starting weight.

In the second category of programs, participants undergo extensive surgical and cosmetic procedures to improve their lives. In the UK, this category includes Supersize surgery and Make me perfect. In the US, popular examples are The swan and I want a famous face, where participants compete to make the most drastic changes in appearance through strict diet and exercise regimens, and cosmetic surgery procedures.7 The winner of the 2004 series of The swan underwent 13 cosmetic face, dental and body procedures, including brow, eye and mid-face lifts, liposuction, fat transfer to the lips, and abdominoplasty.

The portrayal of cosmetic and weight loss procedures on television typically distorts the speed and difficulty of these changes. Most programs focus on the few individuals who have the most dramatic changes in appearance, thus exaggerating the likelihood of positive outcomes. Condensation of time, to fit a television program format, also makes the rate of weight loss and other appearance changes seem extremely rapid. Complications, infections and failed procedures are barely mentioned, giving the impression that negative outcomes are rare. Moreover, the environments in which appearance medicine programs are filmed are often highly artificial, as they provide time and resources (such as equipment, personal trainers and chefs) that are not readily available to the public at large.

The recent increase in numbers and popularity of appearance medicine programs has heightened the potential for harm to both participants and viewers. Given the dissatisfaction that participants typically express about themselves and their lives at the programs’ commencement, the extreme psychological pressure that is created during filming, and the difficulty of maintaining rapid weight loss, it would be surprising if all participants and their families walked away unscathed. However, we have been unable to find any follow-up studies of program participants.

Another concern is that viewers may be negatively affected by appearance medicine programs. A recent study demonstrated that women who felt societal pressure to be thin had significantly lower self-esteem scores after viewing an episode of The swan, compared with a home improvement program.8 Viewers may find it easier to identify with participants of reality shows than with actors in scripted television programs. This process may contribute to inflating viewers’ expectations of the transformations they themselves could achieve through surgical procedures, and the ease and speed with which these changes occur.9

The issue of the negative effects of appearance medicine television highlights the differences between public concern for the welfare of participants in medical research and television program participants. While researchers need to convince ethics committees that their participants will not be harmed, or induced by money to participate in risky experimental procedures, similar well developed constraints do not exist for television programs. Ethical safeguards for those who choose to participate in such programs are needed, as is research into the effects of these programs on both viewers and participants. Both would help improve participant selection procedures and ensure that vulnerable individuals are not placed in potentially damaging situations.