Cosmetic surgeries in Norway and other Western countries have increased considerably in recent decades. The term cosmetic surgery refers to plastic surgery and procedures on the epidermis and dermis (known as minimally invasive procedures) in which the main indication is cosmetic in nature. A study from the American Society of Plastic Surgeons (ASPS) shows that the number of cosmetic surgeries in the USA increased from about 6.7 million in 2000 to some 18.1 million in 2019. Women comprised over 90 % of the customer group (1). In Norway, the number and trend over time has not been officially quantified, but a leading provider states, for example, that in one year they performed about 20 000 procedures, including minimally invasive procedures (2). The most popular procedures within plastic surgery are breast augmentation and breast lift, as well as liposuction, rhinoplasty and abdominoplasty (3).
Many have criticised the marketing of cosmetic surgery. The US plastic surgeon Eric Swanson argues that this type of surgery contradicts medical tradition, partly because the customers have decided they want the treatment before the consultation (4). In addition, sales consultants are used instead of medical personnel, promising customers amazing results while downplaying the risk. Rufai and Davis find similar tendencies (5). They scrutinised the websites of English clinics and found that the clinics’ sales techniques violate guidelines set by the UK’s Department of Health and Social Care. In a study by Taylor, a clear connection was shown between the marketing of cosmetic surgery and women’s own justification for the surgery (6).
Marketing cosmetic surgery is under-researched in a Norwegian context, but there is stringent legislation, specifically a regulation from 2005, that regulates this type of practice (7). The purpose of the regulation is to ensure that marketing is done in a reasonable, sober and unbiased manner. It is not permitted to refer to other sources whose marketing has violated the regulation. To prevent the perception that a certain physical appearance is preferable, it is not permitted either to market in a way that can be offensive or that can play on people’s flaws or biases against normal physical variations, e.g. by using value-laden expressions such as ‘saddlebags’ or ‘bulldog cheeks’. Pre- and post-operative photos are not allowed. The same applies to photos that can be offensive or play on flaws. Discriminating between genders or downplaying the risks of the surgery is not permitted either.
In addition, the regulation states that cosmetic surgery marketing cannot contain offers of credit, consumer loans or discounts for having several procedures simultaneously. The name of the medically responsible person must be clearly stated, and complete, unbiased information must be provided. When a potential customer contacts the provider, the duty to provide information to patients pursuant to section 10 of the Health Personnel Act applies. Moreover, in discussions of various procedures, the information must reflect medically justifiable methods pursuant to section 13 of the same Act (8).
Although the regulation is strict, the dividing line between marketing and information is nonetheless blurred (9). In this study, we have investigated how cosmetic surgery is offered and which underlying messages come to the fore through various strategies. We draw attention solely to offers targeting women, who comprise the largest customer group (1).
Material and method
The article is based on a qualitative content analysis of text and photos from 36 private clinics that perform cosmetic surgery. According to HelseSmart.no, there were 68 such clinics when the study began. In addition, there are individual enterprises that offer cosmetic surgery and/or minimally invasive procedures such as lip augmentation and Botox treatment. Our sample consisted of large, well-known clinics and small clinics, but not those that only offered minimally invasive procedures. Clinics in the sample were either sought out directly or found via HelseSmart.no. Data were collected over the course of one calendar year, starting in January 2018, and updated in January and November 2020.
The data material consists of text, photos and video clips from the 36 clinics. We sought out the most common cosmetic surgeries, which are breast augmentation, breast lift, liposuction, rhinoplasty and abdominoplasty, but we also looked at buttock augmentation and combination treatments, which are increasingly in demand. Some of the data material is taken from newspapers, but most comes from the clinics’ websites with links, including to customer accounts. Marketing strategies are often dynamic, with text and photos changing over time, but the form of expression was stable in the period of data collection.
The volume of data material was relatively large. For example, clinics use 5–10 pages of text to describe breast augmentation with silicone, depending on the layout, plus links to patient accounts and equipment suppliers. The number of photos of surgically altered breasts varies from 0 to 20, but normally each clinic uses at least one illustration. Some clinics also present animated videos of breast augmentation, informational videos with medical staff and video clips with patient accounts. In the analysis, we focused on how providers present themselves and their services, whom they target and how they do so.
Each element or aspect was sorted by category and then grouped and re-grouped in several rounds. The underlying messages and patterns were interpreted based on use of layout, colours, photos, headings, language, terminology and video clips. We also examined the material as a whole and identified both common features and special characteristics. In that round, we drew on Norman Fairclough’s critical discourse analysis (10). The term ‘discourse’ is defined here as a certain way of expressing oneself that reflects a particular way of thinking about the topic. The material covers an expanded concept of text, consisting not only of written words, but of photos, videos and layout as well.
The term ‘critical discourse analysis’ is used here to mean a detailed method of analysing the texts in light of a critical perspective on texts’ social function. This approach has been used in analyses within a number of research fields, such as by Benestad (11) and Johansen et al. (12). Fairclough directs attention towards the phenomenon that is the object of study, towards how the interests of certain groups come to light, and towards how discourses help to create and/or maintain imbalance in the power relation between groups. According to Fairclough, language is never used neutrally, but rather expresses a certain perspective of the world, either through word choice or pictures. Discourses are both constructing and constructed, meaning that they influence perceptions or practices while the discourse itself is affected by established perceptions and practices. The data material contains no personal information.
Results
Below we show seven different strategies that clinics use to varying degrees in their marketing. The strategies’ underlying messages and patterns are highlighted and illustrated with quotes or descriptions of photos, colour use or layout.
Refers to customers as patients
A common strategy used by providers is to refer to and address the customers as patients. In the example below, the statement suggests that a person receives better treatment as a patient than as a customer:
‘As the industry has unfortunately become more and more commercialised over time, the sales aspect can become more important than the medical aspect (…). Therefore, you should always ask yourself: Do I feel like a patient or like a customer? In the first instance, your interests will probably be looked after better than in the second.’
Prioritising the patient role over the customer role might give the impression that the surgeries are medical treatment. This perception is strengthened by the provider giving the impression that it is acting as a medical practitioner and caregiver, thus diverting attention away from the sales aspect. Moreover, all the clinics’ websites use words such as safety, competence and experience. The text is often illustrated with photos of the staff as they are, for example, working in the operating room or talking to a patient. The photos give the impression of satisfied, trusting patients.
Normalises cosmetic surgery
Most of the providers state that cosmetic surgery has become common. Some also stress that prices have become affordable for most people and that cosmetic surgery in Norway is kept within reasonable limits. This normalisation is also manifested in how the procedures are talked about, especially with regard to breast augmentation. For instance, a provider writes that ‘we operate on hundreds of patients every year’. Other examples involve rhinoplasty: ‘Cosmetic rhinoplasty (popularly called a “nose job”) has become a common operation within plastic surgery.’
Fashion trends can create a demand for new types of surgeries, which are then offered by a growing number of clinics. One example is the ‘Brazilian butt lift’ (buttock augmentation using the person’s own fat). This procedure was not offered in Norway just a few years ago, partly due to complications (13), but now there are ten clinics that offer it (of which eight are included in this study). One clinic writes:
‘Having rounded, supple buttocks is seen by many as both attractive and youthful. Demand for surgical buttock augmentation or lift was traditionally highest in South America, especially in Brazil where the procedure is called a “Brazilian butt lift” (BBL). This trend has spread to the West and has now become one of the operations with the greatest increase in demand.’
A paradox of this normalisation is that many providers place an emphasis on discretion and make customers aware that their premises are anonymous and arrival is discreet.
Directs attention to physical flaws
Statements that encourage dissatisfaction with one’s own body are widely used, even though the message is generally subtle. An example of this is the marketing of breast augmentation, where one provider writes: ‘For many women, their breasts are an important part of their personality and self-esteem’. Another provider states the following: ‘Breast augmentation with silicone implants can give small, saggy breasts a normal size and shape’. The psychological aspect is also mentioned, such as: ‘For women, dissatisfaction with their breasts can be a burden. This is why many women contact us with questions and requests for information.’
A subtle encouragement to look at oneself with a critical eye also applies to the face, including the nose, where one provider writes: ‘A harmonic nose “is not noticed”. But a nose that does not harmonise with the face due to its size or deviant shape will attract attention’. The list that follows identifies what will attract attention, understood in a negative way: large nostrils, broad nose, high nose bridge, large curvature of the nose or a tipped nose.
Many providers also make negative statements about ageing, with headings such as: ‘Turn the clock back ten years’. The text elaborates on negative signs of ageing: ‘Are you bothered by loose skin, deep wrinkles, tired eyes or sinking cheeks? Then a facelift might be the solution for you’. The statements present signs of ageing as something unattractive that can be difficult to live with, especially for women.
Some clinics state that some aspects of the body (e.g. small, saggy breasts or a special nose shape, etc.) can be ‘cosmetically and socially shameful’. Some use various descriptions of signs of ageing and variations in appearance such as worry lines, bat wings, marionette lines, hamster cheeks, gummy smile, saddlebags, bulldog cheeks and/or turkey neck. The word so-called often appears in front of the actual description and can be applied to legitimise use of the terms. In addition, there is often indirect encouragement to scrutinise one’s own body, such as the buttocks, with the suggestion that an operation could be the solution: ‘(…) if the butt cheeks are too flat or square so that you want this part of the body to be round and more shapely’.
One of the clinics summarises its services in one sentence: ‘Let us inspire you with our services.’ Implied: Here you will find something about your own body that should be corrected.
Plays on femininity and sensuality
Plays on femininity and sensuality in texts, photos and layout are expressed, in part, in the following way: ‘A breast augmentation can help you to have the womanly figure you have always wanted (…)’ or ‘(…) Breasts lose their natural shape and firmness and begin to sag. This can make a woman feel less feminine, which can lower her self-confidence and cause embarrassment, affecting her social life’. In some cases, photos of surgically altered breasts are shown, sometimes partially covered by the woman’s hands, other times shown in sexy underwear. The photos seem to be manipulated by using soft contours and neutral colours or black-white shading. On one website, it is possible to click on a ‘breast photo gallery’ with 15 close-ups of breasts accompanied by the text ‘(…) so that if you are considering breast surgery, you can view and possibly find the size of breasts you want yourself’. The photo series ends with a consultation form. Also with regard to buttock augmentation, both the text and photos (such as bikini-clad buttocks covered in sand) indicate what can be sexy and feminine.
Other types of surgery that promise increased femininity and sensuality are lip enhancement, where some providers write that ‘many women dream of having soft, full lips (…)’. Moreover, noses are defined as either feminine or masculine, as this example shows: ‘There is often a desire for the nose to be less domineering and more feminine or less masculine’.
In addition, some providers use layouts with links to accounts from people who have undergone surgery. These comment on factors that providers cannot talk about if they follow the regulation, such as statements about complexes due to small breasts. One woman who had a breast lift and breast augmentation says that her five-year-old daughter said it was a miracle when she got to see her mum’s new breasts.
Defines natural appearance
All of the providers emphasise the natural result, as this example shows:
‘Whether you want to improve what you have or regain what you have lost, the goal is the same: to follow the model of natural Scandinavian beauty with naturally attractive proportions and proper balance; a breast augmentation will give you natural, beautiful breasts.’
The following quote also exemplifies the claim that the surgeon delivers a natural result: ‘(…) Dr [name] puts great emphasis on achieving a natural outcome.’ However, there is often disharmony between the text and photos, whereby the text stresses that the surgeon focuses on a natural appearance, while the photos show the opposite. Photos of the breasts, waist, buttocks, lips or face are often incompatible with a natural appearance, but by using terms such as natural beauty and the like, providers can create ideas about what is naturally beautiful.
Promises a better self-image and quality of life
The suggestion of rewards beyond what the actual product contains is expressed, for example, in the following way:
‘The goal of cosmetic surgery and aesthetic treatments should not be to change you into someone else. However, we can improve or restore your appearance, or just correct something you are bothered by. This can in turn improve your quality of life.’ The potential to get rid of mental health problems is also suggested: ‘If done for the right reasons, plastic surgery on the face or body can be a positive experience, and you can also get rid of physical, social and/or psychological discomfort.’ Some market their services by stating that previous patients have achieved a better quality of life, such as this: ‘The tummy tuck is one of the most common operations at our clinic and has given many patients a new quality of life.’ Promises about concrete effects that exceed the individual product or service are not uncommon, such as this: ‘We are committed to giving you a better quality of life – regardless of the reason.’
Offers package solutions and financing schemes
The offers also include arguments for quicker and better results, fewer operations, and fewer days of sick leave if multiple surgeries are performed at the same time. This can be understood as a ‘package solution’, even though a discount is not explicitly mentioned. Some package solutions are marketed under the name Mommy Makeover, which is an offer of several surgeries in one. The text of the advertisement implies that childbirth may have left its mark – understood as an unattractive mark – that can be corrected with the help of various surgeries. Relevant combinations are ‘tummy tuck combined with breast augmentation, intimate plastic surgery combined with breast augmentation, tummy tuck with figure shaping’ or six other combinations involving parts of the body that could have been impacted (negatively) during pregnancy and childbirth. Some imply that combination treatments can be less expensive: ‘Please note that with this type of combined surgery, patients receive a discount of up to 15 % on additional procedures and a 50 % discount on figure shaping.’
Combination solutions are also offered for facial surgeries: ‘By having several procedures done in the same session, you avoid taking sick leave more than once. You will also avoid multiple periods of discomfort from the procedures.’ In a local newspaper, a clinic regularly advertises a 50 % discount on mimic wrinkles by joining its customer club. Some clinics also have a half-price autumn sale.
Some clinics offer financing schemes, stating that personal finances should not be an obstacle to larger surgeries or that customers can get a discounted price on larger surgeries, such as breast augmentation, if they make their decision by a certain date.
Discussion
The study reveals several underlying messages. A common signal is that the female body is an object that can and should be moulded in keeping with cultural (and stereotypical) understandings of how such a body should or must look. This is also clearly seen in descriptions of what the body should not look like, for example that saggy breasts or a special nose shape can be socially shameful, that buttocks can be too square or that childbirth has left physical marks.
Beliefs about the ideal appearance, including what is feminine and sexy, seem to be shaped to a large extent in the room where changes are performed – by the providers: Women should hide any trace of lived life (such as age and childbirth), and natural variations of the body are unattractive and a burden for women. All the providers use the expression natural result, thus creating an impression that enlarged breasts or buttocks, altered noses and smooth skin reflect what is natural. Photos of surgically altered body parts often surpass nature itself and are seldom compatible with an actual body.
A further expression of objectification is that many of the photos presented seem to be taken with what Mulvey calls the ‘male gaze’, which regards women as sexual objects (14). Franklin, Lury and Stacey assert that nature and culture are two aspects of the body that resemble each other, but here the difference is that culture is chosen over nature: in the form of surgery (15). Culture makes demands on nature, where the new ‘natural appearance’ surpasses the natural. Thus, the body industry puts constant pressure on girls and women regarding their appearance in such a way that especially those who are most vulnerable continually scrutinise themselves for physical flaws and shortcomings – and can be easy prey for the industry (16–20).
Another strategy that emerges is the portrayal of cosmetic surgery in medical terms or as treatment of disease, for example by using the term patient instead of customer. According to the Health Personnel Act (10), a patient is a person who turns to the health and care services for health care or one who the health and care services provide health care to. This places the patient status within the medical sphere of responsibility and simultaneously supports an imbalance in the power relation in which the patient is in an inferior position.
It may be difficult for the customer to notice whether a healthy condition is being medicalised or portrayed in medical terms or if information is slipping into pure marketing. Content marketing assumes a form that resembles editorial journalism. Information about the surgeries (including what can be fixed) via photos of body parts and an easily accessible consultation form can be perceived as encouragement to fix one’s own body. When the websites resemble editorial journalism, the sales motive can be difficult to recognise. In addition, the headings use positive words that are repeated frequently, such as safety, security, guarantee, competence, expertise and experience. Photos, which are a central tool in marketing, also seem to be used to create a sense of security (21).
The study shows that providers of cosmetic surgery reach out to potential customers by suggesting that the features of certain body parts can be a burden and contribute to low self-esteem, diminished sensuality and poor quality of life and that this can be remedied and improved with various procedures. What is written before the description of the actual product and before the presentation of specific services is important for convincing the customer. In marketing theory, this is called presuation, and the subsequent advertisement for the surgery can therefore be perceived as an offer of help rather than as a sales campaign (22).
The data material suggests that the clinics are aware of official requirements. For example, they do not show before-and-after photos and they provide information on medical competence and how the surgery is performed. At the same time, they present various surgeries as common, play on flaws and biases about normal physical variations, and they promise rewards on many levels via text and photos. Financial advantages are offered as well. There is an extremely fine line between information and marketing, which can easily slip into pure marketing. However, a separate legal study should investigate whether the strategies violate laws and regulations.
In this study, marketing strategies are analysed from one point of view, but such strategies can be studied in other ways and through the lens of other theoretical perspectives in order to expand knowledge about this research field. A crucial aspect not addressed in this study is how women who have undergone cosmetic surgery experienced the marketing aspect compared to the product they received. This issue is important to explore in a separate study.
