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Mirror, Mirror

If you could fix one thing about yourself, would you? And would you stop there? Andrew Postman examines the ethics of a new age of plastic surgery.

A beautiful young woman visited a cosmetic surgeon, wanting him to perform a breast lift and reduction. The procedure she desired was less invasive than the traditional method-the incision encircles the areola rather than running from there down to where breast meets ribcage-but also more complicated, intended for a subset of patients more problematically endowed than she. The surgeon declined her request and advised her not to pursue the surgery. Her breasts were close to perfect. Thirteen other surgeons apparently agreed, also refusing to operate.The 15th surgeon she visited said yes "and ruined her," one of the first 14 surgeons told me. "I still hear about her. She's never recovered. Her life is over."The brilliance of this story-and I'm not at all questioning its veracity; I've heard others like it-is how it carves two birds with one scalpel. From it we learn that (1) there are butcher-surgeons out there and (2) there are unhinged patients, too. While I believe the doctor told me this story out of caveat emptor goodwill, it's actually the second implication that lingers. Because it's just such reports of the Unhinged Subject-the sad, desperate ones; those suffering from body dysmorphic disorder; the Michael Jacksons and Jocelyn Wildensteins (the New York socialite who has allegedly spent millions on countless surgeries, with the result of looking almost feline)-which in part have helped cosmetic surgery's popularity.That's no typo: I mean "helped," not "hurt." As long as supermarket tabloids publish images of the latest iteration of characters like Michael and The Bride of Wildenstein, the rest of us can mollify ourselves. Hey, we're not that pathetic, we'd never pursue that level of transmogrative grotesquery, so what's wrong with the occasional nip or tuck? Each skin peel and cheek implant that Michael gets-pardon; allegedly gets-thrusts him so much further into Freaksville that we're bound to separate the world into Us and Them. And because of the stunning advances the last decade has seen in cosmetic-surgery techniques, instruments, and medicines, Us and Them no longer means Those Who Don't and Those Who Do but rather Those Who Sort of Like Themselves and Those Who Privately Loathe Themselves.With such a broadening pool of patients, though-from 1997 to 2005, according to the American Society for Aesthetic Plastic Surgery (ASAPS), cosmetic procedures in this country increased by 444 percent, to 11.5 million-how does the surgeon tell, from just an initial consult, who's an Us and who's a Them? How can he tell which patient will translate into a "Doc, you changed my life!" holiday card, and which a malpractice suit? (Virtually every top surgeon, insists one, has been the subject of at least one suit.) For their part, prospective patients, if diligent, have ample guidance-checking out board certification, membership in reputable national organizations, word of mouth-when trying to distinguish the mostly good surgeons from the bad ("the guy down the street," as several surgeons routinely label the amoral butcher who expresses no qualms about doing anything to anyone). The doctor, though, often relies solely on intuition, from cues picked up in a brief conversation, to determine a patient's psychological soundness. But is that a reliable system? The staggering number of hours top surgeons put into sharpening their technical skills notwithstanding, there's no accurate measure for judging people and their real needs. And while admittedly it's in their interest to steer clear of patients they suspect can't ever be satisfied, there is also the incentive in place to now and then embrace an obsessive, whose patronage may result in a vigorous ongoing business relationship. Cosmetic surgery, more than any medical specialty, brings together doctor and patient speaking different languages. The cosmetic surgeon-"a psychiatrist with a scalpel," as one doctor charitably characterized it-is first and last a technician, trying to determine if the desired procedure can be done, and done well. The patient, meanwhile, wants to know if she or he will look-and hence feel-better. Yes, they're both ostensibly concerned with aesthetics, but in the same way the federal government is ostensibly concerned with a balanced budget."We're not taking care of a functional disorder or removing cancer," says Dr. Cap Lesesne, a top Park Avenue surgeon. "We're operating on perception."At the initial consult, the surgeon often asks some version of, "What don't you like about yourself?"-the recurring salvo asked of potential patients by the plastic surgeons on the popular TV show Nip/Tuck. But even though the question seems nonpartisan, surgeons are still, well, surgeons. ("What's the difference between God and a surgeon?" the wife of one of the Nip/Tuck surgeons quizzed a friend. "God doesn't think he's a surgeon.") So doctors have been known to volunteer an opinion or two-even though it's elective surgery, and even though no one asked. "One surgeon I went to about my naturally hooded eyessaid I needed my upper and lower eyes done, and an upper and lower browlift, too," said Jan (not her name), who writes about beauty for a national women's magazine.
Some of us are too narcissistic even to consider cosmetic surgery; some of us are so insecure that if we did pursue it we'd never be happy with the result.
"Then, on his own, he said the bump in my nose was quite bulby. I'd always thought my nose was my best feature. But ever since he-someone who's essentially a sculptor-said that, I've never looked in the mirror and not thought something was wrong with it."

Once upon a time, not just anyone could seek out a face-modifying operation; you had to earn it by, say, getting mangled-a nose nearly sliced off in a duel, perhaps, or an ear bitten off by a dog. (Without anesthesia and sterilization, which only began to be mastered during the mid-19th century, surgery, especially on the face and head, was dangerous and horrifically painful.) Plastic surgery is documented in Egypt 5,000 years ago (the treatment of mandibular and nasal fractures), then more extensively in India 2,500 years later (the beginning of reconstructive surgery and skin-grafting), and its goal for centuries was basically the same as that of all medicine: restore function. Form was not the concern. There was a burst of surgical techniques for solely aesthetic purposes-repairing a syphilitic's rotted nose, for instance-in the mid-19th century, and their practice was considered downright immoral. "Physical appearance represented one's inner character, so attempts to transform it were heretical," says Victoria Pitts-Taylor, an associate professor of sociology at Queens College and the Graduate Center of City University of New York. She is the author of the upcoming Surgery Junkies: Wellness and Pathology in Cosmetic Culture. Into the early 20th century, Americans and Europeans frowned on the use of surgery for cosmetic purposes.Then came plastic surgery's Great Shift: The Great War.During World War I, with thousands of soldiers suffering facial wounds, the culture began to accept the necessity for cosmetic surgery. Suddenly "plastic surgeons achieved a prestige they hadn't known before," says Pitts-Taylor, and the abundance of all those damaged faces "allowed them to improve their skills considerably."After the war, though cosmetic surgery was still derided for its unique place in medicine-its stated goal was not to correct physical pathologies but to deal "with purely external characters for which the only guidance is the patient's whims," as the major Italian text on rhinoplastic surgery put it 75 years ago-a second shift occurred, again expanding the pool of possible candidates. Surgeons, channeling Freud and Adler, referenced then hot-button notions like "inferiority complex" and argued that having "some kind of ugliness or stigma caused shame, and to refigure that ugliness would ameliorate the problem," says Pitts-Taylor. And that's more or less where we remained for decades-through the cookie-cutter ski-jump noses, the silicone and then saline breast implants, the self-flagellating plastic-surgery jokes by Phyllis Diller and Joan Rivers-until the face of cosmetic surgery changed profoundly once again, thanks to "the most recent development": in this case, the quick fix.The last decade has seen a huge rise in nonsurgical procedures-Botox to paralyze muscles into serenity; collagen, Restylane, fat, and other injectables to plump up the face (after decades of surgeons cutting away, believing in addition by subtraction, they finally figured out that plumpness was also a hallmark of youth); lasers to resurface skin and eliminate wrinkles, splotches, and other imperfections. In 2005, more than 80 percent of U.S. cosmetic procedures were nonsurgical. Meantime, surgeries have become more subtle (mini-facelift, micro-lipo, endoscopic browlift), resulting in smaller scars. Recovery time has diminished, as has price, as has stigma. TV can't seem to air enough shows on the power of blade-aided transformation (Nip/Tuck, Extreme Makeover, The Swan, Dr. 90210, I Want a Famous Face, etc.).
Today, the field of candidates has expanded because a new kind of person considers cosmetic surgery. No longer are you stuck with a large nose, with basset-hound jowls, with deformity. On a wide scale, cosmetic surgeons are now regularly called to fix not what is abnormal but to reshape what's normal; a growing portion of surgeries are devoted not to ameliorating stigma but to enhancing what was already attractive."Now, when the patient walks into the surgeon's, she's not necessarily admitting there's something wrong with her," says Pitts-Taylor, who sees in this culture shift a persuasive, marketable narrative for an entire not-yet-even-that-saggy generation. She suggests that the normal-ization of cosmetic surgery is made more complete-even morally justifiable-because the surgical establishment, as well as its prime audience, has deftly appropriated what Pitts-Taylor labels the language of liberal feminism, an indulgence, something "I do for myself."The elevation of form to where it nearly rivals function is increasingly evinced in how some other specialists operate. "Twenty, thirty years ago, cancer surgeons basically just hacked out the problem area," says Dr. Jason Cohen, a Los Angeles-based surgical oncologist. "Now, the clear margins we require [around the cancer] are far smaller than they used to be. Part of that is due to advances in chemo and radiation, and research showing you can have lesser margins without compromising success. But part of it is also due to patients knowing more what they want to look like. I'll do a smaller margin around the face than I will around the abdominal wall, because down there there's more skin and I can move it up." Although Dr. Cohen often closes the incision himself, some patients prefer a plastic surgeon. "There'll be a little negotiating between us, like two lawyers trying fine. It's another thing to bring in that picture and say, 'I want to look like Jennifer Aniston.'"
Who's to say-yet-that a Botox shot every few months, with some lipo thrown in every other year, doesn't have as much to do with basic up-keep and Darwinian imperative as it does with vanity?
One of the biggest impediments to patient satisfaction is TV's unrealistic portrayal of how cosmetic surgeries go. "TV and print make certain procedures seem low risk and they're not," says Dr. Lesesne. "Women come in wanting ribs removed for a better shape, thinking it's an easy procedure. But it's not so low risk." He cites bariatric surgery-"stomach stapling"-as another procedure potentially more complicated than credulous patients may realize."Some patients think you can do surgery without a scar," says Dr. Michelle Copeland, a New York plastic surgeon. "Or they don't understand that there's still a recovery period, even if it's shorter than it used to be."Who might raise a "red flag" about the kind of patient they'll be after surgery? Topping the list, according to many surgeons, are those who want something fixed or enhanced because someone else wants it-for example, the many women who come in for breast implants that their boyfriends or husbands are pushing for. Another indicator of trouble may be especially difficult behavior in the weeks and days leading to the operation (calling the office frequently, questioning everything from when to pay the bill to stopping certain medications, repeatedly changing one's mind about the scale of the operation).Then again, given that this all concerns the complicated, often inscrutable subject of Beauty, maybe none of the above applies. "I believe it's a myth that Michael Jackson is a plastic surgery victim," says Dr. Lesesne. "If he'd been unhappy with his face and wanted to reverse it, he could have, to an extent. He never did. We may think it looks bad. I don't believe he does."Does our ease with, and frenzy for, cosmetic surgery have less to do with pursuing the beauty ideal and more with pragmatism and convenience? If all these advances contribute to better results, less scarring, and faster healing, why the hell not do it?"We've never lived as long as we're living now," says Dr. Copeland. Who's to say-yet-that a Botox shot every few months, with some lipo thrown in every other year, doesn't have as much to do with basic upkeep and Darwinian imperative as it does with vanity?"I can go to the gym all I want, and I do-I'm a size zero-but I can't reverse all the sun damage from having played so much golf, tennis, running, skiing," says Ann, 48, a public relations executive who is thoroughly unneurotic (though Ann is not her real name) about the blepharoplasty (eyelid lift) and mid-facelift she has undergone in the last two years. "People were looking at me like, 'Oh my god, you have this cute little body,' but I'm seeing the sun damage. Plus my eyelids are heavy and I wear contacts, and it was getting to be more of a problem. My son said I looked as if I was always stoned."We have the technology. Just do it.There is no formal code of ethics or guide for judgment for those who perform cosmetic procedures, and it's a particularly fragmented professional discipline, since it doesn't have to be a surgeon trying to make you look better. You can get Botox at a spa. Surgical practitioners needn't be board-certified, or specialize, in that surgery-so, for example, an ear, nose, and throat doctor can potentially do breast implants; oral surgeons, facelifts; hand surgeons, body tucks; osteopaths, threadlifts (also known as "lunchtime facelifts"); ophthalmologists, eyebrow lifts, and so on. That's not to say that these practitioners are necessarily less competent at what they do, but they have likely trained far less, and been subject to far less oversight, than board-certified plastic surgeons. (It might be noted that any competent surgeon spends a fair amount of his or her time fixing surgeries botched by other practitioners.)Whether these procedures can be said to have a positive effect on their patients is also hard to measure. On one hand, there are the numerous thank-you notes and return visits by satisfied customers. Then again, one study of obese women showed that the weight "lost" via liposuction did not lead to the health benefits delivered if the weight had been lost through exercise and improved diet; another study showed that almost half of all lipo patients gained weight again. Nor can return business be trumpeted as an irrefutable sign of satisfaction, as one might in almost any other business; the patient might just be suffering from body dysmorphic disorder (though some question just how widespread the disorder is, if it exists at all). Recent studies show that women who've had breast implants are approximately three times more likely to commit suicide than those who haven't.Should surgeons screen their patients? Surely, doctors would be appalled at the idea, as would surgical candidates. For many doctors, the decision to proceed is based on a chat with the consult; on a feel. A minorityof doctors give written questionnaires, with queries such as Do you use antidepressants? Have you had cosmetic surgery before? Were you happy with it? Interestingly, Pitts-Taylor interviewed numerous surgeons nationwide and found that New York-based surgeons tended to think that a Yes to the antidepressant question was insufficient grounds to disqualify the patient-Who in Manhattan isn't taking them?-whereas surgeons in the South did think the use of anti-depressants raised a red flag.Surely the best, neatest solution to all this was offered by a friend, a brain surgeon, who says, only partly facetiously, that he would like to pioneer the field of cosmetic neurosurgery. "I'll go in and manipulate the brain so that the patient thinks she looks better than she does," he says.Hey, you know what? That is one gorgeous scar.

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