Postimees · Luxurious Estonia (Luksuslik Eesti) · 2026
Who decides whether it is cosmetic surgery or a medical need?
English translation of the original Estonian article. Original headline: Kes otsustab, kas tegu on ilukirurgia või meditsiinilise vajadusega?
See the original design in the magazineThe line between medical treatment and cosmetic surgery is often much thinner than one might think. A mole that slowly grows or changes in some other way over time is a reason to see a doctor. Likewise, an upper eyelid that droops over the eye, becoming less attractive over the years and eventually limiting vision, may need surgical intervention. Depending on how serious the situation is, it is either a medical need or a cosmetic procedure. From a surgeon's point of view there is also a third situation, in which the need for treatment and cosmetic surgery are completely intertwined.
Clarity comes from Dr Indrek Mikomägi, who practises at Tartu University Hospital and at Niine Skin Clinic in Tallinn. As a head and neck surgeon, he specialises in the surgical treatment of tumours in this area and has trained further in plastic and reconstructive surgery in Europe, the United Kingdom and the United States. Both sides meet in his work every day: removing tumours and aesthetic surgery of the facial area, both medically necessary and cosmetic. That is why he is the right person to ask how decisions are made.
Better safe than sorry
Cosmetic surgery and skin cancer may seem like two completely different things from afar, but with moles these topics often meet in the same doctor's office. That is exactly why it is worth starting with why these marks on the skin deserve attention from a health point of view. The most common cause of skin cancer is ultraviolet radiation.
As the autumn winds pick up, many start planning their holiday somewhere warm. Yet one must remember that in the south the sun is considerably more intense and especially dangerous for Nordic skin. The old saying "better safe than sorry" helps us remember that skin protection should be thought of before the trip – not when the skin has turned bright red after the first day on the beach. The Estonian Cancer Society recommends a protection factor of at least 30 and reapplying the cream every two hours.
Skin cancer, however, does not come only from travelling. Skin also receives ultraviolet radiation during the Estonian summer and in solariums. A rather sobering fact is that, according to the Estonian Cancer Society, about 250 cases of melanoma and 1,400 cases of non-melanoma skin cancer are diagnosed in our country every year. A fact highlighted by dermatovenereologist Dr Tiina Toomson, who compiled the society's information materials on skin cancer and melanoma, makes one reconsider lying in the sun all day: the risk of melanoma is believed to double if a person has had more than five sunburns in their lifetime. So if a mole starts to change after strong ultraviolet exposure from the sun, that is the right moment to see a doctor.
The same incision, but different reasons
One reason people come to the Niine Skin Clinic is that a mole or other skin growth bothers them and they want it removed. Exactly the same incision, however, can mean two different things. In one case it is an aesthetic matter; in another, a medical reason may emerge later. The difference often only becomes clear once the growth has been removed, sent for examination and an unwelcome answer comes back.
According to the clinic, you don't even need to book a separate dermatologist consultation to have a skin growth removed. You can go straight to the procedure, and after assessing the growth on the spot the doctor makes the final decision on removal.
Skin growths are examined at high magnification, assessing their structure, blood vessels and pigment. A useful tool for this is the dermatoscope, a special optical medical device that allows far more precise viewing than the naked eye. As a rule, this also reveals how serious the situation is and whether further tests are needed.
According to the guidelines compiled by Dr Toomson, skin growths that clearly differ from the others in colour, shape or size deserve attention. Dr Vahur Valvere, president of the Estonian Cancer Society, emphasises that skin cancer is one of the most common forms of cancer, but in most cases successfully treatable if detected early. The organisation recommends consciously checking your own and your loved ones' skin at least twice a year.
In most cases, the removed tissue is sent for histological examination. This tells whether the change was benign or malignant.
"The doctor always decides on the need for and the method of removal on the spot, after a thorough examination. Based on dermatoscopic features, an assessment is made as to whether it is a purely aesthetic matter or whether there are warning signs that require further examination and greater medical intervention," says Dr Mikomägi. A similar point of decision comes up most clearly with the eyelids, where one and the same operation can be either a cosmetic procedure or a medically indicated need.
An operation with a thousand-year history
With eyelids, however, the answer comes not from a laboratory; the doctor decides, based on how much the eyelid actually interferes with vision. The tricky-to-spell word blepharoplasty means eyelid surgery, and it is by no means a new trend in cosmetic surgery. According to various sources, the history of the procedure goes back to around the 10th century. Today it is one of the most common procedures in facial aesthetic surgery.
Here, beauty and medicine meet again. A sagging upper eyelid is usually a cosmetic concern, but in some people it noticeably restricts the field of vision. In that case it is no longer a cosmetic procedure but a justified medical need to improve visual function.
With the eyelid, beauty and need can be distinguished quite clearly through examination. One patient comes because of their reflection in the mirror, another because of their eyesight, even though the operation is the same. In a surgeon's work, however, there are situations where the two can no longer be separated.
The line between a cosmetic procedure and a medical need
There are situations where the need for treatment and cosmetic surgery are no longer two different things, but two stages of one and the same operation. When a tumour is removed from the head or neck area, the surgeon's work does not end with cutting it out. Afterwards the face and/or neck must be restored so that the result looks natural. Proportions, function and how the person sees themselves in the mirror afterwards all matter. Here medical need and aesthetic goal are intertwined, and this is exactly what Dr Mikomägi does.
"Every therapeutic incision is planned from the very beginning based on the patient's needs and with the precision characteristic of cosmetic surgery," the doctor confirms. The same surgeon, the same incision, the same precision. Only the reason why something is done differs.
So the line between cosmetic surgery and medical treatment cannot always be drawn by the procedure, but rather by the reason – and sometimes the line disappears altogether. With a mole, the answers come from examination and histology; with an eyelid, from a visual field test. In both cases the decision is made by a doctor, based on what the examination shows.
On the surgeon's operating table, though, this line changes nothing. The incision is planned just as carefully whether the reason is treatment or a cosmetic procedure, because the result stays on a person's skin for years. A good surgeon assesses the situation from two points of view at once, both medical and aesthetic. The same appointment that someone comes to with one concern often also answers questions they didn't know to ask. So going to a doctor for the sake of beauty is not vanity. Taking care of your health and appearance doesn't have to be a luxury, but a conscious and dignified choice.