Change of Face...Change of Fate

Is our national obsession with appearance a new sickness, or is it a perennial human concern? And is it a way of revealing—or concealing—the true self?

I spent an afternoon in the office of New York plastic surgeon Joseph Michael Pober, M.D., watching him change a woman's life. She was only 4'11", and before she came to him she had the flat-chested, bony body of a child, a big nose, and heavy-lidded eyes that drooped downward.

He had already given her breasts and reshaped her nose in two previous surgeries. Now he performed a brow-lift. At one point, as he forced gauze through an incision and up into her forehead to soak up blood, he joked that he was like a magician stuffing a white scarf up a sleeve and pulling out red. But there was magic before me, and I was stunned by the truth of the old cliche: a single stitch, lifting a single muscle forever, altered her brow and eyelid about a centimeter and rendered her pretty. Such a small dislocation, such a shift in fate.

When he was finished, I asked if I could see her breasts, and she groggily assented. We pulled down the sterile blue paper. She let me touch them: They were full and firm but pliable, like a taut water balloon. There was no scar except for a faded line in either armpit, barely visible under the creamy talc of her deodorant.

If a single pair of breasts wasn't enough to dazzle me, an hour later one of Pober's secretaries slipped out of her lab coat to show me her implants. She wore a white cotton camisole and the voluptuous curve under the stretchy cotton was breathtaking. Pulling the camisole up, she proudly let me touch her breasts.

It sounds surreal, and it was—but even more so when I went home and examined myself. I usually find my body lovely, but that night I was a troubled Narcissus. My breasts—size 34C—seemed unremarkable, and when viewed from the side they gently sagged. I imagined the doctor's devastating assessment, one I'd heard again and again that day as we flipped through before and after pictures of patients: "Yes, her breasts are nice, they're fine [before], but these are great [after]. It changes her whole look. She looks ten years younger." Inevitably, he was right.

Plastic surgery is one of those subjects that almost everybody gets stirred up about. The mere potential to alter your appearance, and maybe your destiny, raises difficult questions. Is plastic surgery life enhancing? Is our national obsession with appearance a new sickness—or a perennial human concern that has taken many forms, from Chinese foot-binding, to ritual scars tribal peoples adorn themselves with, to corsets and stays? Is it a way of revealing—or perhaps concealing—the "real" self? Is there any moral distinction between a $3,000 suit and a $3,000 nose job? What is plastic surgery—a simple act of self-help or an incredible tangle of contradictions that reflect the complexity of modern culture?

Complex it is. This is a world where postmenopausal women are having babies, where the essential code of life—the human genome—is being mapped, where we've begun to cure illness by altering genes themselves, where antidepressants fine-tune us into happier humans. Plastic surgery is part of this Noah's ark where biology is no longer destiny. We have always attempted to master nature, but the fiercest site of the power struggle is now our body. It's heroic, tragic, comic, incredible, ridiculous, and wonderful by turns—but it's clearly one of the great dramas of our time.

In 1992, nearly 80,000 women had plastic surgery on their breasts; 30,000 had them enlarged, 8,000 had them lifted, and another 40,000 had them reduced. (This does not include the 30,000 who had their breasts reconstructed after a mastectomy.) Sixteen thousand Americans had tummy tucks, 20,000 had chemical peels, 40,000 had collagen injections, 50,000 had nose jobs, 50,000 underwent liposuction, and 60,000 had eye jobs.

Men now make up 13 percent of all cosmetic surgery patients. Baby boomers—age 35 to 50—are the hungriest of all: 41 percent of all plastic surgery procedures are performed on them, compared to 27 for 19-34-year olds and 22 percent for 52-64-year olds. The three favorite procedures among baby boomers are eyelid surgery, collagen injections, and liposuction—clearly intended to ward off signs of aging and preserve perpetual youth.

There has, actually, been a revolution in the field, which has gone from a half-despised stepchild of medicine to a lucrative and respected profession. "Aging is the field of the future," claims Manhattan dermatologist and plastic surgeon Douglas Altcheck, M.D. "When I trained I was an oddball, one of the very few dermatologists who had surgical training. Now almost every medical school in the country has a strong teaching program in dermatologic surgery. Dermatology is now the most difficult residency to get, because it's considered such an interesting field."

From Stepchild To Star

Other surgeons echo him: "When I chose plastic surgery at Harvard it was looked on as a frivolous and unnecessary profession, almost a prostitution of science," says Pober. "And there was a religious overlay to the criticism, as if you were changing God's work. But God doesn't come into the question anymore. Today it's totally different, it's a way of changing your own genetic lineage, your own future, your own fate."

It's the promise of plastic surgery that has invaded our senses, even more than the act itself. At most, half a million Americans undergo cosmetic surgery annually. But the tabloids, talk shows, and media are saturated with the subject—and who hasn't indulged in armchair fantasy about it? We talk about it, think about it, speculate on who's gotten it.

Plastic surgery has become far more than a utilitarian act; we see it as a battlefield of good and evil, honesty and lies, body and soul. Roseanne Arnold recently claimed in Vanity Fair that her breast and face surgeries were part of a healing process in recovering from childhood abuse. Healing the soul through the body is a common motif; a woman I know had her eyes done after a bout with cancer. She felt the bags under her eyes were a direct consequence of her illness and that by removing them she could erase any visible reminder and begin life anew. Just last week a friend of mine said of a colleague's face-lift, "It wasn't a face-lift, it was a spiritual lift. It's incredible. Her whole spirit has lifted."

Plastic surgery is no longer just the stuff of popular culture; it has mesmerized art critics as well, our most interesting commentators on standards of beauty. In a long piece for Art in America last year, renowned critic Barbara Rose speculated on the meaning of Orlan, a French performance artist who has made the operating room her art gallery. Orlan has undergone many procedures to alter her face and body. As Rose said: "Orlan's brutal, blunt, and sometimes gory imagery flatters neither herself or the public; it transmits disquieting and alarming signals of profound psychological and social disorder. She absorbs and acts out the madness of a demand for an unachievable physical perfection."

Is that perfection even tangible? "You really can't have a sense of perfection today, because everything in this society is so transitory," says psychologist Marcella-Bakur Weiner, a professor of gerontology at Marymount Manhattan College who has authored several books on aging and body image. "It's like a piece of glitter held out to you and you look at it and, chameleon-like, it has already changed. A new ideal comes in and you're struggling for that. And as you've almost attained it, again it has changed. Perfection in this society is so shifting and amorphous that you don't know what you're striving for. When truth changes every moment it's like living in a household where the mother says one thing Monday and another thing entirely on Tuesday. Our society is like that now—very schizophrenic."

The Perfection Chase

That elusive promise of perfection sometimes reaches so deep into the core of a person that it becomes a kind of madness. We all know about the people who've had 20 or 30 surgeries; and last year alone two plastic surgeons were killed. One Chicago surgeon was killed by a man who said he was upset that surgeons were changing people to look like the Aryan race; a Washington surgeon was killed by a woman who was displeased with her face-lift. And some detractors seem afraid we're going to become a country of Dorian Grays, whose inner lives leave no telling marks on our "perfect" faces.

Why is the whole subject so galvanic? Perhaps it's as simple as the fountain of youth. As I interviewed surgeons around the country, I found myself half-bewitched by the promises of this profession and the beguiling high-tech nature of some of the newest procedures. Like the rest of medicine, plastic surgery has become increasingly refined and specialized.

Invisible Scars

Liposuction can be used to contour bodies, not just remove fat; I saw a photo of a beer-bellied man in Pober's office who was given the look of a muscled washboard stomach simply by artful liposuction. Chemical peels have become an industry in and of themselves: today, the skin is actually made younger with chemicals that increase the turnover of skin cells.

Face-lifts now are performed with incisions behind the ears, or in some cases, through the ear canal itself—a more laborious procedure that leaves no visible scar anywhere. These delicate surgeries are accomplished with laparoscopes, the same instruments used, for instance, in surgery performed on embryos in the womb.

Meanwhile, the plushness of youth can be "regained" by different techniques. Fat suctioned out during liposuction can be condensed, purified, and injected in wrinkles, cheeks, and aging hands—and the extra fat can be frozen for future use. Plastic surgeon Toby Mayer, M.D., in California, grafts fat into the gaunt cheeks of marathon runners. Thinning lips can be returned to Cupid-bow shape by taking skin from a fold in the buttock and grafting it into the lip; this is a technique pioneered by Myron Whitaker, M.D., of the University of Pennsylvania Center for Human Appearance, in Philadelphia.

In Florida, Jane Steinberg, M.D., offers medical tatoos on lips and eyes. It's permanent makeup: the lips are plumped up and lined with color, and the eyes are given permanent liner and brows. Soon we may be able to clone our own skin (a technique already used in burn surgery) and have it stored for later use.

How does this embarrassment of riches influence patients? "There's a difference in the way patients present themselves now," observes George Sanders, M.D., of Los Angeles. "They are more open about surgery and what they want. By and large, it's become very acceptable to have cosmetic surgery." Myron Whitaker says things have calmed down since the '80s, when patients asked for "radical changes, bone change where they were actually changing the fundamental shape of the face by shifting bone. The '90s has seen more face-lifts, more surgeries where you are just taking the person back in time and not changing their fundamental look."

Surgeons notice that patients now come in as informed customers, having analyzed their "flaws," with a sense of the changes they want. "What would you change about my face?" I asked Pober. "I won't tell you what to do. I'll discuss what you want," he replied. He showed me photos of patients whom he felt had made aesthetically incorrect decisions: a woman who had asked to liposuction only her hips and not her thighs; a man who had a nose job and did not strengthen a receding chin with an implant. The doctor did what they asked. (The man came back 10 years later for the chin implant.)

"Women used to come in with their husbands," says Sanders. "Now they come alone. And they are younger; they come in their late thirties and early forties. I get a lot of single women in their fifties and sixties, who are divorced and working." More men are coming, too. "From the moment a young girl pierces her ears and puts on fingernail polish, she's changing her appearance. It's accepted among women. For a long time it was not accepted among men, but now they are coming in for their eyes, or for peels and skin care. I get men who say, 'Gee, my wife had this done, and I really liked how it looked on her.'"

Ordinary People

The doctors I spoke with pointed out that their patients were generally not actors or stars—the vain and the rich, as the media portrays them—but most often working professionals who wanted to look good in order to remain competitive in the workplace. This was especially true of middle-aged women. In fact, the influence of a two-career society on plastic surgery was a frequent theme. "Women in their fifties and sixties need to look energetic to maintain that competitive edge," said Los Angeles's Sanders.

Men, too, "are turning to plastic surgery, particularly with the tighter job market and age discrimination," explains Debbie Then, Ph.D., a social psychologist in Berkeley who lectures at Stanford, and whose work has focused on body image. "More men are interested in collagen, eye-lifts, and face-lifts because they're starting to experience appearance-related discrimination in the workforce. They're competing with younger men and with women."

Most surgeons also noted the obvious: We're a society that fears and despises age. "In today's society, looking old is not accepted," says Sanders. "It's a stigma, it's associated with a lack of energy and a dwindling of the mental faculties. I don't think anybody wants to appear old to anybody else. Our society over the last 20 years has become absolutely obsessed with youth."

Toby Mayer concurs: "At 55 someone looks in the mirror and they don't recognize what's looking back. Their face sags, there are bags under their eyes, they look tired, depressed, and angry. They don't want to look 20, they want to look good for their age."

Are the doctors just caught in their own house of mirrors? I don't think so. At 36, I find myself reacting with pleasure when asked if I'm in my twenties. Why the hell should it matter? The other day a 19-year-old who was flirting with me asked my age and when I told him, said, "I thought you were about 31. But I knew you weren't in your twenties." I asked how he knew. "I looked at your hands," he said simply. I felt uneasy, almost violated. My age indicated, I suppose, a loss of sexual power on my part.

I remember a gesture—poignant, fleeting, and unforgettable— made by a woman in her fifties when she introduced me to a male friend. He smiled at me, and for the brief moment that his eyes lingered on me she lifted her chin and stroked the faint wattle of flesh under it. It was a gesture of fear, and concealment.

What Babies Know

"Most people think looks shouldn't be important, but unfortunately they are," says Elaine Hatfield, Ph.D., professor of psychology at the University of Hawaii, and coauthor of Mirror, Mirror: The Importance of Looks in Everyday Life. "One study found that if you show two pictures to people and tell them you'll pay them if they guess correctly about the personalities of the people in the photographs, they will guess the good-looking people are kind, nurturing, patient, and happy."

In fact, according to Debbie Then, "studies of children as young as 18 months show that they prefer to look at a more attractive face." Then also cites a recent study conducted at the University of Western Michigan, where girls in kindergarten perceive thin friends to be nicer, neater, more popular, and smarter than chubby friends.

"The problem," says Then, "is that our society is conflicted about appearance. On the one hand, everyone knows that looks matter a lot. On the other hand, there is a real taboo about trying to improve one's appearance. People who get plastic surgery are considered vain, self-absorbed, and conceited. Here you have to look good, yet you're not supposed to do anything about it. If we could be more upfront about 'looksism' and the prevalence of plastic surgery, it might relieve some of the pressure."

Plastic surgery's appeal may in part be due to the chaos in gender roles today, according to Ann Kearney-Cooke, Ph.D., a psychologist specializing in body-image disorders in Cincinnati. "There has been so much change occurring in the sex roles that some people are holding on to body shapes as a way to say, I'm a man, I'm a woman. Plastic surgery helps emphasize the feminine and masculine, allowing the body to become a symbolic attempt to figure out what masculine and feminine are today."

I think of a friend, a small-breasted woman who became a bodybuilder and then got breast implants. Before the surgery, she used to describe her body as that of "a 15-year-old boy." Now she must have the implants removed for medical reasons. I asked her a few weeks ago how she felt. "They're going to look even worse than before," she said. The sentence was factual, but the tone carried a whole sea of emotion. It was as if she were speaking of two children who were about to be maimed. There was incredible tenderness and despair in her voice. "They" were not just breasts, "they" were her feminine self, the self she thought she had acquired by surgery, and now would lose, and would have to search for elsewhere.

When did we decide that we could—and therefore would—alter our destinies? When did we begin to look at the mind and the body as biological templates that we might alter at our will, shaping a more ideal life for ourselves? It all began with the Cartesian split between mind and body, according to Kenneth Gergen, Ph.D., a professor of psychology at Swarthmore College and author of The Saturated Self (Basic Books, 1991). "We already came into the present century prepared to manipulate and alter the body. The mind is figured as more central than the body and has the right to alter the body."

Add to that our century's "theology" of science, where rational, scientific reasoning prevails over nature. "One of the basic, shared ideas of this century is that you should think strategically and scientifically, Naturally, if the mind and body are separate and you're thinking strategically, you are invited to do so with your body. Use it, alter it, build it, clothe it, reshape it, take the fat off, put muscles on, cut off things, add things, give it drugs—all to fit an image that is rationally derived. I tend to look at all this in horrified amazement, particularly at what I call 'designer mood drugs.' We have six million people in this country on Prozac, and that's an open invitation to the pharmaceutical companies to develop all sorts of new drugs."

According to psychiatrist Peter Kramer, M.D., author of the best-selling Listening to Prozac (Viking, 1993), there is a direct analogy between cosmetic surgery and psychopharmacology. "When I wrote Listening to Prozac I specifically meant to signal the coming to the fore of a whole set of ethical issues raised about modern biology. I coined the phrase 'cosmetic psychopharmacology' for that reason. Plastic surgery is a legitimate undertaking, used for clear medical conditions like burn injuries or facial anomalies, but it is also used to take people from a normal but unrewarded state of appearance to another normal but more rewarded state of appearance. That form of plastic surgery is called cosmetic surgery and there is an explicit analogy between that and giving a medication which might enhance or enrich someone's life. I think the analogy goes even deeper. Cosmetic surgery is used psychiatrically, for better or worse. "

Often worse, says Kramer, because, "I think there are people who have profound psychic disturbances who undergo radical procedures ranging from repeated nose jobs to sex-change operations in search, in part, of a different feeling state. There are studies of patients on waiting lists for sex-change surgery showing that those who are treated with psychotherapy instead do just as well as those who get the surgery. I think a lot of what is going on in plastic surgery is treatment of self-esteem."

Attractiveness Junkies

Contrary to expectations, Kramer points out, many of those who seek plastic surgery are not the ugly and the flat-chested, but those already very attractive by consensual social standards. "But their self-esteem is so dependent on that attractiveness that they need even more of it. That is one of the large functions of plastic surgery. It may be 'successful' in that regard—but you can never get enough of it."

Listening to Prozac captured the attention of America in part because it asked difficult questions about the "real" self. If a woman, after years of therapy, found that on Prozac she felt, for the first time, like her "real" self, what was one to conclude? The same phrase pops up when people speak of plastic surgery. A 51-year-old New Jersey woman who had just gotten a face-lift and was still not fully recovered told me, "After my hysterectomy I aged terribly. The grooves around my mouth were the worst. People used to say, 'You'd be so pretty if you smiled.' I was smiling, but those lines made me look so unhappy."

"I didn't look like I felt. It was like wearing a mask all the time. About a year ago I walked into a plate-glass mirror because I didn't recognize myself. I thought it was another woman coming toward me and when I stepped to the right she stepped to the right also and I walked straight into the mirror. I didn't know it was me."

The notion of the real, or core, self is a troublesome one in this era. It seems the body has become a modern battlefield for our conflicts about the self. Are people changing how they look to hide who they are? Or are they altering their looks to fit their inner self? Consider the face. Facial expressions are a vast, complex, and subtle language that may actually be inherited genetically. Studies have shown that humans are innately inclined to make facial expressions indicating a wide range of emotions, and that even blind children make these expressions.

And emotions may indeed carve themselves on a face. John Greden, M.D., chairman of psychiatry at the University of Michigan Medical School, has found that key vertical frown lines linked by a horizontal curve are actually a good indicator of emotional agitation and clinical depression. Facial shape and lines help us read and assess others. Plastic surgery may alter that animated map, occasionally smoothing it out so that it is less expressive. But perhaps, in the case of a person with genetically programmed jowls, surgery alters a "false" indicator, allowing the face to more precisely fit the inner personality. When writer Joan Gage gave a detailed, two-part, stitch-by-stitch account of her first face-lift in Vogue magazine, she wrote, "I am delighted with the result. I think I look approximately my age but more like the real me."

Psychologists like Kenneth Gergen question whether there is a core self in today's society: "Because of technology we have many different audiences, many more types of people we have to appeal to. We have an audience in our home, our community, friendships all over the world, people in the business setting, people that we know on television or through our media. All these different groups have different senses of the ideal person, so we have a lot more criteria to meet. We end up being fragmented and emptying out the notion of any kind of core being."

Gergen believes that the current fad of body-piercing is actually a rebellion against these overwhelming standards. The body is indeed the site of the battle, but it is an act of defiance against standards of perfection. "If you live in a world where you've got to measure up in so many ways, you can't do it. One response is to challenge the standards in the most horrific way possible, by mutilating the body as a mode of social rebellion."

Non-Person To Person

No one will ever be able to untangle the cause and effect of body and self. The two are as intertwined as the double helix of DNA itself. "Often plastic surgery modifies the body image, and that modifies behavior," notes Cincinnati's Kearney-Cooke. "There's a lot of evidence to show that plastic surgery changes patients' perception of themselves." People who are beautiful draw others to them," explains Berkeley's Then. "People want to be with other good-looking people, because they hope the benefit will rub off on them. And so when people say they're getting surgery ,just for themselves, it's hard to separate out what is 'self.'"

That was brought home to me when Betty, a 62-year-old Georgia businesswoman, called me the day after I interviewed her. At first she told me she'd gotten a face-lift for pragmatic reasons, to "look like I did when I was younger. I own a business and call on customers. It's very important to look good if you're in competition with people who are young and look good."

But when she called back, her tone had changed from ebullient to somber. "I didn't tell you the most important thing," she said. "When you get to be my age, people stop noticing you. That's everybody, anywhere. You become a nonperson. After my facelift, people noticed me again. They noticed me being alive. I became a person again."

Perhaps the most interesting aspect of plastic surgery is that, as pragmatic as it seems, it reveals us as we really are. It's not just about nip and tuck, it's about life and death in America. Harold Brodkey, an eminent writer who has been chronicling his death from AIDS in The New Yorker, said it marvelously: "It is the basis of America—the forward-looking thing. We will create a nation, and we will have gardens and swimming pools and corrective surgery. America is defined by what it does next."

In short, you cannot meet the future if you look like the past.