A longer version of this article has already appeared in the Journal of Aesthetic Nursing, for which Constance is a regular columnist.The objective of this series of articles is to highlight the history of nursing in the establishment, attainment and development of the nursing science of medical aesthetics.
Aesthetic medicine originates from the practise of aesthetic surgery, which is rooted in and an element of plastic surgery. Although aesthetic surgery can be traced back 2,500 years, plastic surgeons emerged in the US as a result of the Civil War, at the end of the nineteenth century, and in Europe as a result of the World Wars.
British plastic surgery developed during the First World War due to the brutal nature of trench warfare that caused mutilation on an unprecedented scale. Surgeons performed reconstructive and surgical grafting procedures alongside general surgery but none specialised in the specific area of plastic surgery until Major Harold Gillies, serving in the Royal Army Medical Corps in France, recognised the value of a dedicated reconstructive surgical multi-discipline approach. As a result, the first centre devoted to facial repair was established at the Queen Mary’s Hospital in Sidcup, Kent. Widely considered to be the ‘father of plastic surgery’, Gilles worked with a team of surgeons, nurses and specialist staff from 1915 onwards and pioneered many plastic surgery techniques.
By the 1930s, there were four plastic surgeons practising in England. They worked closely with nurses in establishing the professional partnerships and collegiality we still see today. Although surgeons were already dealing with a limited number of aesthetic issues, the widespread injuries caused by bombing, with the possibility of surviving such injuries, accelerated the developments in the aesthetic nursing aspects of the speciality. The comprehensive contribution that nurses made to the early work in plastic surgery was developed further into a comprehensive nursing model, caring for the person’s needs as a whole, a crucial element for successful treatment.
To a great extent, what also influenced much of the development of aesthetic surgery and nursing were the diverse attitudes associated with how contemporary Americans and Europeans reacted differently to injury. What, in Europe, was taken to be a mark of the heroes, was in America considered to be a mark of social rejection. To resolve this, the American Association of Plastic Surgeons, the first of its kind, was created in the United States in 1921.
Aesthetic medicine can be traced back to the late 1800s, shortly after the invention of the syringe, when the first chemical agents were used for facial augmentation. The first injectable filling agent was paraffin. Initially greeted with enthusiasm, it was injected by doctors for what was called the “cosmetic effect”, to fill out wrinkles and breasts in an effort to allow their patients to maintain a youthful appearance or to reconstruct facial deformities. The fashion was much in demand and many unscrupulous doctors injected paraffin with no control, in high doses and repeatedly. It was soon abandoned after the complications of migration, embolisation, and granuloma formation were described.
In 1927, a Los Angeles plastic surgeon, H.P. Bames, published what appears to be the first article on cosmetic phenol peeling and considered this procedure a part of plastic surgery. In 1946, Joseph C. Urkov, a Chicago based plastic surgeon published an article, in which he shared his 15 years’ experience treating 2,000 patients with pits, scars, and wrinkles. Most of the credit for chemical peeling however, has been attributed to the role of lay operators in the United States, who used age old traditional formulations of croton oil-phenol-based peels up to the late 1940s and early 1950s.
Beginning in the 1920s, lay peelers using croton oil-phenol formulas were renowned and made a lucrative living, treating many, if not most, of the leading Hollywood stars of the day. They often played on the notion that they had a “special secret” that physicians did not. They were also well- known to physicians, who it was said, brought their own faces and their wives to the peelers so as to avail of their expertise. Leading lay peel personalities from the 1920s, such as Gradé and Kelsen in Hollywood and two from Miami, Coopersmith and Maschek, are some of the lay peelers who dominated the field until the 1960s, when they began to suffer legal attacks in what is commonly referred to as a “witch-hunt” (which it has been evidenced, were often directly instigated by newly educated physician peelers). This lead to the use of phenol and croton oil becoming illegal except for when it was being used by a physician treating a patient. This became the deciding factor, which eventually put lay peelers out of business and transformed their customers into patients.
Notwithstanding physicians’ concerns about, there was nevertheless, considerable professional interaction and exchange between lay peelers and many plastic surgeons. As a result, some plastic surgeons came into possession of the techniques and some also gained knowledge of the ingredients and the formulas. By 1952, dermatologist George Miller MacKee, Chairman of the New York Skin and Cancer Hospital, published his experience with phenol peels for post-acne scarring. Although there are accounts of notable lay peelers in Hollywood, Palm Springs and Florida in the late 50’s, by that time, as they were illegally using phenol, and lay-peelers having fallen into disrepute, had made their exit. During the 1960s two American plastic surgeons, Tomas J.Baker and Howard L. Gordon, revived and finally legitimised phenol-based peeling by discussing it at national plastic surgery meetings and demonstrating their results.
In Southern California, in the spring of 1975, a group of nurses who worked for plastic surgeons and who needed continuing education to renew their licenses regularly attended educational meetings with the plastic surgeons. At one of these conferences, several plastic surgical nurses from the area met and held the first organizational meeting, of the American Society of Plastic & Reconstructive Surgical Nurses (ASPRN), during which their aesthetic work was also presented.
The first injectable wrinkle filler, Zyderm, was developed in 1979 by a team from Stanford University, California, for the Collagen Corporation. Researchers extracted bovine collagen fibres from cow hide and enzymatic digestion was used to break down the fibre units. By 1981, bovine collagen was the first dermal filler agent to be approved by the U.S. Food and Drug Administration (FDA) for cosmetic injection. Although the use of chemical peeling had already been established within the scope of practise in the field of plastic surgery and dermatology nursing, by the mid 80s, nursing protocols for collagen injections were also being further developed and offered by a select coterie of British plastic surgeons and nurses in the UK. Medical aesthetics was rooting itself at this point, as a nursing element of a specialist non-surgical entity. At this juncture, nurses were either working together in specialist aesthetic plastic surgery practises, or alternatively, they worked in independently nurse lead and nurse owned medical aesthetic practices.
As medical aesthetic nursing practise continued to professionally develop throughout the second part of the 90s, what uniquely manifested itself and influenced it within the arena of practise, was how other developments that were taking place within the marketplace of product development, were influencing nurse practise and nurse culture also. Zyderm had the monopoly amongst dermal fillers until 1994, when the market was revolutionised by the first hyaluronic acid products. Hyaluronic acid is a polymer of disaccharide units – each made of d-glucuronic acid and d-N-acetylglucosamine – that connects to other extracellular constituents, including collagen, to form a matrix. It was used in the 1980s as a fluid replacement in osteoarthritis and as a physical cushion in cataract surgery. Although a medical company developed it as a replacement for the vitreous liquid, which could be used in the eye during surgery, it was never used in this way. Instead, as a result of an ingenious bio-tech private equity innovation, it took off as dermal filler. Unlike bovine collagen, patients did not require testing in order to assess if they were allergic. Hyaluronic acid itself is broken down very quickly in the skin. Once chemists and developers started to cross-link the polymer, linking chains of hyaluronic acid together or to other molecules such as polyacrylamides to form longer-lasting gels, a range of new dermal fillers started to emerge with a variety of different properties. Some bio-dynamic agents, such as Nu-Fill, even appeared to stimulate free-collagen development.
Restylane®, a Non-Animal Stabilised Hyaluronic Acid (NASHA) gel, manufacture red using patented technology, was launched in the UK in 1996. Although a Swedish manufacturing company’s scientific break-through, Restylane® heralded the way for other dermal fillers to enter the market, one such example being Juvederm , whilst other lesser known dermal fillers entered the UK medical aesthetic product supply chain also. As nursing practise protocols and skills sets were much in evidence in the growing medical aesthetics manpower sector, the demand for product providers to demonstrate and offer professional education, training and development, alongside sales and marketing support for their products and treatments, led to a further utilisation of nurse expertise. Clinical nurse trainers working with Q Med in the area of demonstrating injection techniques, rank amongst the front- runners who were involved in conducting professional skills training and education, while the product supply companies, which numbered but a few at this stage, started to emerge as a critical niche, that would add further impact to the medical aesthetics sector landscape that exists today.