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Body Work

Cosmetic surgery is booming, but are its results more than skin deep?

by Val Pendergrast
The clinking of glasses and clattering of plates creates a pleasant lunchtime cacophony at this popular strip-mall eatery, and the waiter is friendly but not obsequious as he nods his approval over our selection of chicken pot pies. Sandy glances around furtively and waits until he's safely out of earshot before approaching the subject she's come to discuss. Between bites of broccoli, she deftly steers the conversation toward breasts--not the tender chicken we're savoring by the mouthful, but women's breasts, and hers in particular.

Chatting about bigger breasts over a chicken pot pie doesn't seem to strike Sandy as incongruous; she's fluent in the lingo and not the least bit nervous about her upcoming surgery. Scheduled to go under the knife in less than 72 hours, the fortysomething businesswoman discusses the motivation behind her decision to undergo augmentation. After a benign lump was removed two years ago, she says, her breasts were left slightly lopsided. Unwittingly, she pulls her cardigan across her smaller breast, underscoring her self-consciousness.

'It's a big decision," she says, nodding her head. "But I want to be more balanced. I want to feel better about myself." Balance isn't all she wants--she wants larger breasts. She smiles a Cheshire-cat smile as she relates her instructions to her surgeon.

"I told him, 'Don't scrimp. Do all you can do.'"

Her luminous green eyes sparkle as she envisions her post-op trip to the mall for swimwear.

"I can't wait to start trying on bathing suits," she says excitedly. "That's always been the most depressing thing for me, because I've never been very...gifted in that area."

Despite the pain--and the $3,800 price tag--she knows will accompany her larger breasts, her mind is made up. "I've made the right decision," she says confidently.

She's not alone. According to the American Society of Plastic and Reconstructive Surgeons, some 393,000 Americans--52,000 of them in the Southeastern U.S.--elected to alter their appearance through cosmetic surgery in 1994. From tummy tucks to breast augmentation, liposuction to collagen injection, tattooed makeup to hair transplants, improving one's physique via potentially dangerous surgical procedures has become increasingly popular. Once a luxury exclusive to the rich and famous, aesthetic surgery has come to the masses.

A variety of factors account for the increased popularity. Prices, while still exorbitant for some, have not kept up with inflation, making cosmetic surgery as affordable as a luxury vacation, with longer lasting effects. The maturation of the industry and technological advances have made procedures safer and less invasive. Media exposure has taken away much of the stigma and given aesthetic surgery an air of respectability. And as Baby Boomers have begun to cross the threshold into middle age, society's largest demographic group is holding on for dear life to preserve the illusion of youth.

If beauty really is only skin-deep, why are so many women and men subjecting themselves to physical and financial discomfort just to increase their bustline or shave a couple of years off their age? Is a preoccupation with physical appearance simply superficial and vain, or is it indicative of a more serious societal illness? Dr. Karen NoLand, an instructor of Women's Studies at UT, says the increase in aesthetic surgery reflects a deep self-hatred, especially among women.

"We rearrange everything. Rather than learn to live with our bodies, to love our bodies, we set about to rearrange them," she says. "We have such a narrow definition of what people can be."

Surgeons who perform cosmetic surgery insist that patients who look good feel better about themselves, and feeling better about themselves enhances the quality of their lives: Self-esteem through surgery.

But like all surgical techniques, aesthetic surgery comes with a boat-load of side-effects, warnings and horror stories. Is the pain--and the price--of cosmetic surgery really worth it?

What Price Beauty?

It's been barely seven weeks since Liz underwent eyelid surgery and a brow lift, but the stylish, petite 50-year-old mother of two grown women looks as rejuvenated as if she'd spent the 50 days at a seaside spa instead of on her feet cutting hair. It's her second time under the knife; eleven years ago, she had the bags and puffiness removed from beneath her eyes and since then has been waiting for the time to be right to tackle the lids and brows. A walking testament to her surgeon's skill, her scars are hidden and the results look natural. Though she still has numbness and a "charlie horse" over one eye, "that's to be expected," she says.

"I had a lot of problems around the eyes," she explains, "Bags under my eyes--that's a characteristic on my dad's side--and droopy eyelids--that's a characteristic on my mom's side."

Her goal in having her eyes done, she says, was not to be 50 and look 20, but to "look real good" for 50. She does.

Her improvements didn't come cheap--$4,500 for the lids and lift, plus the $1,400 she spent eleven years ago--but she has no regrets. Though she's heard from friends and customers that her doctor is more expensive than other Knoxville surgeons, cosmetic surgery was not anything she intended to haggle over.

"It's not like a bad haircut where you say, 'Oh, it'll grow out,'" she says emphatically. "Plastic surgery doesn't grow out. If somebody's going to do any cutting on me, I want him to be the best. I didn't check around to see if somebody was cheaper."

With ball-park prices ranging from $2,000 for liposuction to $5,800 for a full face-lift, a combination of procedures can easily run $10,000 or more. Because most procedures are not covered by insurance, aesthetic surgery is performed on a cash-in-advance (or charged to a credit card) basis. Despite the cost, surgeons have no shortage of patients.

The waiting room of the Aesthetic Plastic Surgery Associates looks fit for a king. Tastefully decorated in muted shades of gray and plum, Grecian columns frame the doorways, giving the room a hushed, reverent feel. The soothing, piped-in strains of James Taylor waft gently through the air.

"I don't have to sell people surgery," Knoxville plastic surgeon William J. Schneider says without a trace of defensiveness. The tall, lean, angular doctor explains that his professional philosophy is based on honesty, not telling the patient what he or she wants to hear.

"My job is to spend a long time talking to patients and screening them," he says. If he believes a patient's post-op expectations are unrealistic or questions their motivation, he doesn't hesitate to show them the door. The day before, he says, he turned away a woman requesting liposuction who "really needed to lose 40 pounds" instead.

"I know I'm not telling you what you want to hear," Schneider told her gently, "and I feel bad about that." Still, he says, it's vital to him that his patients be informed and realistic about what they can expect the surgery to accomplish. Aesthetic surgery is not a fix-all or a trip to the fountain of youth, he insists.

"I have patients that argue with me saying, 'You told me I wouldn't look younger, but I look five years younger,'" Schneider says, "but I certainly don't go into it with that as a promise." The goal, he explains, is not a prettier or younger version, but better. Achieving that goal, he says, brings him immense personal and professional satisfaction.

With so many other fields to choose from, why would a doctor choose to specialize in cosmetic surgery?

"You can see what you're doing--for better or for worse," he says. "General surgeons do wonderful things--they take out gall bladders and make people feel better, but you don't see any of that. No one knows what their gall bladder looks like--nor do they want to. I really like seeing the results of what I do."

From the looks of things, his patients do too. He pulls out an album of "before and after" photos and flips through, pointing out breasts, thighs, lips, and lids. If the "after" shots of newly-augmented breasts sporting provocative tan lines are any indication, Schneider has plenty of satisfied customers.

Beauty and the Breast-- and the Nose, Thighs, and Eyes...

There are any number of improvements a talented surgeon can perform, but breast augmentation ranks, along with liposuction, nose-reshaping, eyelid surgery, and full face-lifts--in the top five most popular procedures nationwide. Rather than deter women from just saying no to bigger breasts, the recent furor over leaking silicone implants have made saline implants the "safe" alternative. Though invariably some implants leak, leaving a patient with a "flat tire," the harmless saline is absorbed by the body. A woman with a "flat" has only to return to her surgeon for repair.

Breast enlargement takes approximately 90 minutes to two hours in the operating room and requires only two relatively small incisions in the fold of skin underneath a woman's breasts. Deflated implants are inserted, either between the muscle and breast tissue or, in a more painful but more natural-looking procedure, behind the muscle. Once in place, the saline is injected, and voila! Made-to-order breasts. A common complaint is that the breasts are initially hard--painfully so in some cases--but after four to six months, the surrounding muscles relax and the skin stretches, resulting in more natural looking and feeling breasts--and some darn happy women.

Liposuction, though well publicized, is the most misunderstood of all plastic surgeries. Widely perceived as a weight-reduction method, it's best suited to men and women who are within a few pounds of their ideal weight. Common targets are "saddlebags," those pockets of stubborn fat situated on some women's thighs that dieting and exercise doesn't budge. Liposuction--where thousands of fat cells are removed via an instrument similar to a vacuum-- isn't recommended for men or women whose weight tends to fluctuate more than five or ten pounds in either direction. That's because even though the fat cells are gone forever once they're removed, liposuction doesn't prevent new fat from accumulating in nearby cells. The result: uneven, bumpy, mottled skin where new fat cells nest alongside fat-free ones.

Liposuction is a relatively quick procedure, lasting usually one to two hours, depending on the location and extent of surgery required. If the patient carefully monitors his or her weight and exercises sensibly, the results of liposuction are usually permanent.

Trim, athletic-looking, and attractive in her form-fitting denim jumper, Melody has a figure most mothers would envy. Before her babies were born, she says, she'd always been skinny. But after the kids, her metabolism changed and she gained 10 pounds. With dieting and exercise, she lost the weight, but kept the belly. Frustrated, she decided to have her tummy tucked.

"I'm used to being skinny," she explains. "I just wanted to be in good shape, and stay that way."

With a little liposuction and the removal of post-pregnancy skin that had lost its elasticity, she's regained her pre-pregnancy shape with only one flaw: a wide smile of a scar stretching across her abdomen.

"I told my kids it's a big smiley face so they wouldn't worry," she says, flashing a toothy grin.

Melody admits there was a lot of pain right after the surgery, and cautions that "people who can't stand pain shouldn't have it done." But in the seven weeks since her surgery, she's healed nicely and has only a bit of swelling.

"I don't think this is for everybody," she says, "but it's made me feel better."

Cosmetic surgery is primarily a female inclination--88 percent of aesthetic surgery is performed on women--but the percentage of men has been steadily on the rise in recent years. Rhinoplasty--commonly called a "nose job"--tops the list for men, though liposuction is increasingly popular with the male sex. The extent of nose-reshaping varies with individual noses; some are reduced in size, some are enlarged, some are reshaped, some are re-angled. Most rhinoplasties take only one or two hours in the operating room and the new nose lasts a lifetime.

Eyelid surgery is not exclusive to either sex and is one of the few aesthetic surgeries potentially covered by insurance, but only in cases where the droopiness of the upper lid impairs a person's vision. In this procedure, excess skin is removed from the upper eyelid, leaving a scar in the fold of the eyelid where it's rarely visible. Puffy bags below the eyes can also be corrected by removing fat pads, skin, and muscle. The permanency of eyelids surgery varies widely, lasting anywhere from a few years to a lifetime.

Complete face-lifts are delicate operations, concentrating as they do on one of the most sensitive--and visible--parts of the human body. Full face-lifts are usually reserved for people over 40, when facial skin loses its natural elasticity and begins to sag. This complicated procedure takes several hours and requires the removal of excess fat and skin and redraping of skin across the facial skeleton. Advances in endoscopic surgery--operating underneath the skin using special instruments that allow the surgeon to view the procedure on a video screen as he works--require much smaller incisions and create fewer visible scars. Though face-lifts can produce dramatic results, effects are semi-temporary--an average of five to 10 years.

Is Your Face Your Fortune?

Few people would argue that looking good does indeed make us feel better about ourselves. The issue that concerns critics of cosmetic surgery is not why individuals want to look their best, but why they are willing--even eager--to go to extremes to enhance an external image that's superficial at best. NoLand's interpretation is that few people are strong enough not to bow to the external pressure to look a certain way. "(They're) letting other people define who they are and who they should be."

Cosmetic surgery may indeed be beneficial for an individual, says Beth Haiken, an assistant professor of history at UT, but the popularization of cosmetic surgery "says something incredibly depressing about our society." Haiken, whose book Eye of the Beholder: A History of Cosmetic Surgery in the United States will be published this fall by Johns Hopkins University Press, says the increase of cosmetic surgery is directly related to our "modern consumer culture" and a pervasive sense of powerlessness. As the world becomes more diffuse and less controllable, she says, people focus on themselves to regain a sense of control over their lives.

"Individuals...think that changing their faces or their bodies will change their lives and will give them more negotiating power, either socially or professionally." Does it work?

"(People who've had cosmetic surgery) say it does, assuming everything goes OK," Haiken says. "There is definitely a psychological effect."

Haiken explains that the development of a "visual culture" stemming from constant bombardment of magazines and television creates expectations about how we should look. "It's become no longer acceptable to look old," she says. NoLand agrees. "You've got 10,000 megahertz telling you every second of your life that you're fat, old, and flabby, and almost no one telling you you're OK as you are."

Though Haiken doesn't make value judgments about men and women in pursuit of an ideal image, she questions their methodology.

It's one thing to look one's best, to dress well, to stay fit, she says, "but buying a new suit is different from the having your face cut open."

"Everybody wants to feel good about themselves, to have people like them, to be effective in their lives," she says, "but aren't there more significant ways to accomplish this?" NoLand puts it simply: "People need to examine why it takes a new nose or bigger breasts to feel good about themselves."

Mirror, Mirror...

Modern society does place an inordinate emphasis on physical attractiveness. As Haiken notes, we're bombarded daily by advertising appealing to our quest for beauty. L'Oreal's slogan, "It costs more, but I'm worth it," is a not-so-subtle reminder that beauty comes at a price. Even children's fairy tales--Mirror, mirror, on the wall, who's the fairest of them all?--underscore the pervasive belief that beauty is a thing to be envied, sought, and bought, regardless of the cost. Has our pursuit of beauty gone too far?

"Probably," says Edmund "Ted" Andrews, recently retired after 31 years as a plastic surgeon, "but I don't think it's immoral for people to want to improve their appearance." Like buying a motorcycle or sports car, if cosmetic surgery is available and affordable, he says, why not?

As to society's tendency to equate physical appearance with desirability, it's just human nature to be attracted to beauty.

"From a philosophic aspect I can say, why sure, you ought to base your judgment on a person's intellect and their worth or whatever, but," he grins and pauses for effect, "I married a pretty girl."

Reconstructive surgery--rebuilding a breast after a mastectomy, repairing a cleft lip or cleft palate--was the focus of Andrews' career, but he's never had any qualms about occasionally performing aesthetic surgery. What he does worry about are surgeons who limit their practice to aesthetics.

"To me, it's a terrible waste of training for someone who has met those qualifications to confine their practice to aesthetic surgery," he says, "because they have the knowledge and technique to do an awful lot of things besides that."

Plastic surgery as a specialty requires arduous training beyond medical school, including certification from the American Society of Plastic and Reconstructive Surgeons. Board-certified physicians are guaranteed to have undergone four years of college, four years of medical school, one year of internship, a minimum of three years in general surgical training and two full years of specialized work in plastic surgery. Andrews cautions anyone considering aesthetic surgery to call the ASPRS before selecting a surgeon to ensure they're certified.

"I can put a sign on my door that says I'm a cardiovascular surgeon, because in this country, when you are licensed, you are licensed to practice medicine and surgery," he says. "Anybody that's got an M.D. or a D.O. after their name can claim to be a plastic surgeon."

Choosing a board-certified plastic surgeon is important, Andrews says, but satisfaction with the results is just as dependent on a patient's expectations as the surgeon's abilities.

It's very important that patients have realistic expectations, not only as to the quality of the results, but also the effect surgery will have on their life and their relationships, Andrews says.

"Because if you operate on a person who thinks that his love life, his job situation, and everything else wrong with his life is because of a hump on his nose, protruding ears, small breasts, or loose skin--a cosmetic operation doesn't improve any of those things." He pauses and shrugs apologetically. "I can't make your wife love you if she doesn't."

While there are obvious psychological implications to changing one's body structure, Schneider and Andrews agree that if aesthetic surgery is done for the right reasons, there's no reason not to consider it.

"I think it's healthy," Andrews says.

"People are realizing that it's something that regular people are doing," Schneider says. "But the truth is, the only good reason to have plastic surgery is for one's self."

There is one procedure that Schneider says he'd never consider doing, despite its growing popularity among men in other parts of the country: penis enlargement.

"No way," he says adamantly. "I'm not interested in doing that. I don't know of any plastic surgeons in Knoxville who are doing that, and I would be surprised if any of them do do it."

His concern is based on the psychosexual motivation of men seeking penis enlargement. Unlike women's breasts, which are visible despite clothing, the size of a man's penis is known only to himself and any sexual partner he may have.

"In all fairness, I've said that most women who come in for breast surgery come for very healthy reasons," he says. "I guess that's possible with men who want penis enlargement, but I have no interest in it."

"The scary part is the enhancements are marginal at best," Schneider says, and the risk of permanent impotence is always a possibility.

"It makes me very uncomfortable," he reiterates. "Very uncomfortable."

There's one last barb that naysayers are wont to throw at individuals considering cosmetic surgery: vanity. To consider aesthetic surgery implies vanity, and vanity is considered superficial, egotistical, and shallow. But is vanity such a terrible peccadillo?

"I think people are recognizing that vanity is not a sin," Andrews replies philosophically. "Vanity is putting your best foot forward."