Cosmetic Interventions for the Very Young, Teens, and the Very Old

CHILDREN

Cosmetic interventions as defined in this book—alterations of normal features—are rarely if ever appropriate for young children. However, children do undergo a variety of procedures to correct deformities related to imperfect development, injuries, or other causes. In many cases these deformities are corrected for the purpose of improving the child’s appearance and social integration rather than for any functional need. In this chapter I will not discuss surgery for cleft lip and related defects, microtia (severe underdevelopment of the ear), large moles, or treatment of large blood vessel abnormalities like hemangiomas because these deformities often have functional impact and do not properly belong in a book about purely cosmetic procedures.

Body image develops in childhood and evolves throughout adolescence. For the most part a child’s body image will adjust fairly easily to physical changes, although certain longer- lasting physical conditions may have more profound effects (for example, obese children may grow up to be adults who, despite normal body weight, see themselves as fat). For this reason surgeons try to complete reconstructions of congenital deformities during early childhood whenever possible.

Procedures for children that may have improvement of appearance as the primary goal include ear surgery (otoplasty) for prominent ears, excision or laser treatment of small blood vessel tumors (telangiectasias, spider angiomas, small hemangiomas), ear tags (branchial cleft remnants), treatment of port wine stains, and correction of problems related to ear piercing.

Fortunately, it is sometimes possible to obtain insurance coverage for these kinds of surgery in children, even when the same policy would not cover treatment of an adult with the same condition. In some cases, surgery can be performed with local anesthesia, although younger children and some older children do better with sedation or general anesthesia, especially for more extensive procedures such as bilateral otoplasties and laser treatment of large port wine stains.

Children should undergo procedures requiring anything more than local anesthesia only in a hospital or accredited ambulatory surgery facility that is properly staffed and equipped to take care of children. Fortunately, children usually do well after surgery. The two main categories of risks for children are those associated with general anesthesia, especially for the very young infant or any child with a respiratory illness, and those related to healing problems in a child too young to cooperate with postoperative wound care, thereby leading to poor scarring or the need for further surgery.

TEENS

Statistics

Of the roughly 333,000 cosmetic procedures performed on patients under the age of eighteen in 2005, the vast majority were performed on teens. Most of these were of the minimally invasive variety, often to treat acne-related conditions or for hair removal. Of the less than 80,000 reported invasive surgeries on minors, nearly two-thirds were rhinoplasties.

Psychological Considerations

Adolescents tend to fixate on visible body parts that fall anywhere outside the “average.” Typically, noses for boys and breasts and noses for girls receive the most self-scrutiny. Many teenagers, like adults, find the idea of a cosmetic intervention appealing and have a body feature that they feel could benefit from a little tweaking (even though most do not pursue surgery).

As a society we must be concerned about the effects of mediaperpetuated cultural “norms” on children. For those teens who do undergo cosmetic interventions, however, the psychological risks seem to be lower than they are for adults. Teenagers actually incorporate physical changes into their body image more readily than do adults.

One potentially psychologically risky practice that many cosmetic surgeons discourage is the “family combo.” Most commonly this scenario involves a mother and daughter undergoing the same operation (often rhinoplasty or breast augmentation) by the same surgeon on the same day. In the daughter’s case the procedure may be a birthday or graduation present. The emotional traps are numerous for the patients and the surgeon, especially if one patient gets a better result or has problems. Just as important, the mother who might otherwise be the designated caregiver becomes herself a patient, in competition with her daughter for attention during the recovery period.

Eating Disorders

Many parents are concerned about body image disturbances leading to unhealthy behaviors, including eating disorders, in their adolescent girls. Our culture is permeated with images of young girls that, for many parents, are too sexualized, too thin, or both. Cultural historian Joan Jacobs Brumberg (in Fasting Girls: A History of Anorexia Nervosa) and others have written at length about how our society has so successfully harnessed female sexuality to the interests of capitalist marketing.

An eating disorder is generally defined as a pattern of dangerous weight-control behavior usually associated with body image disturbance. The most well-known eating disorders are anorexia nervosa and bulimia nervosa. Although these potentially lethal medical problems can develop in members of almost any demographic group, they are disproportionately seen in young women and girls and may affect up to 20 percent of female college students. Eating disorders require aggressive psychiatric evaluation and treatment, and as a general rule cosmetic interventions are not appropriate for these patients. Having said that, there is some evidence that, in carefully selected patients, certain procedures such as breast reduction surgery may be helpful in the treatment of girls and women whose eating disorders stem from a specific body issue like overly large breasts.

Marketing to Teens

Since the dawn of the modern advertising age, the beauty industry has found teenagers, a population group already obsessed with appearances, to be an eager audience for its sales pitches. Teenagers report getting almost all of their information about cosmetic medical care from television and teen magazines. Undoubtedly, future surveys will add the Internet to this short list of information sources that exercise substantial influence over teens. There has been considerable controversy in recent years over the effects of advertising on teens, especially girls, and whether it predisposes them to eating and other body image disorders, self-esteem problems, and diffi culty handling pressures to be sexually active, among other concerns. The barrage of images of thin bodies, all irregularities airbrushed away, jar against the reality of increasing childhood and adolescent obesity in America. On top of the predatory media attention, teens watch as the adults around them seek cosmetic changes. A survey of readers of a magazine aimed at preadolescent girls asked for reader input on the topic of makeovers and managed to capture the confusion that many kids feel. One twelve-year-old wrote, “Aren’t adults always saying that ‘All that counts is on the inside’?”

Periodically, there is a mea culpa maneuver by the beauty industry to expand its imagery; for example, a decade or so ago magazines started to use more ethnic models. In mid-2005, magazines such as Seventeen, Teen People, CosmoGirl! and Teen Vogue claimed that they would be including more typically shaped girls in their pages.2 It remains to be seen how extensive this trend will be or how long it will last.

Specific Cosmetic Procedures for Children and Teens

Breast Surgery

For both girls and boys breast development during adolescence can be the source of considerable trauma. Girls are self-conscious about their budding breasts at any age, but a girl whose breasts do not develop in a way that she thinks is desirable may develop a variety of undesirable responses, including social withdrawal, posture problems, and even eating disorders. Certain breast confi gurations are the result of congenital deformities, such as Poland syndrome in which one breast, and sometimes the pectoral muscle and upper extremity on the same side, does not develop normally. Other potentially stressful breast configurations include lesser asymmetries, macromastia (a typical example of which is a twelve- or thirteenyear- old wearing a DD bra cup), hypomastia (minimal breast development), and in boys any degree of breast enlargement. These conditions are almost always within the range of what is considered normal, yet they can create great embarrassment for a teenager. Whereas timing is an important consideration for every teen who wants breast surgery, few cosmetic surgeons would debate the appropriateness of surgery for the problems just mentioned. In some cases the procedures may even be covered by health insurance. However, before agreeing to purely aesthetic requests—that is, for surgery on breasts that are developmentally within the normal or typical range and therefore should not be causing undo psychological distress—most surgeons feel that the patient should possess an additional level of maturity. The ASPS does not recommend purely aesthetic breast augmentation for girls under the age of eighteen. Hormone-induced pubertal gynecomastia in boys often subsides as the young men mature, but in some cases the breast tissue remains enlarged and will turn an outgoing, sports-minded boy into a hunch-shouldered adolescent who won’t take his shirt off in public. Breast surgery for gynecomastia in boys is sometimes, but not predictably, covered by insurance plans.

Several general rules apply to adolescents who wish to have breast surgery: (1) Pubertal growth should be complete and stable for at least one and preferably two years before surgery is performed. (2) Persis tent breast enlargement in boys and massive breast enlargement in girls warrant a hormone evaluation, usually by an endocrinologist, although most of the time the results of these evaluations will be normal. (3) Massive enlargement or severe psychological distress may warrant earlier surgical intervention, but patients and their families need to understand that early surgery includes the increased risk that a second operation may be required for the same problem in the future.

Ear Surgery

Surgery for prominent ears (otoplasty, ear pinning) can be performed with local or general anesthesia. After surgery the patient will have a head dressing for a few days and will likely have to wear ear protection twenty-four hours a day for several weeks and at night for months. Bruising and swelling are common, and final ear shape takes months to appear. Normally patients can resume full activities within a few weeks as long as the ears can be protected against injury. Boys are discouraged from future wrestling because even with headgear, ear injuries are very common in that sport. Scars are usually well hidden although occasionally will be problematic. Major complications are uncommon; irregularities, asymmetries, recurrent prominence, and need for additional surgery are quite common. Liposuction

Liposuction should not be offered to teens as an alternative to good eating and exercise habits, nor should it be used as a treatment for the residual and generally temporary fat distribution patterns of childhood.

Rhinoplasty

The shape of one’s nose changes dramatically during adolescence and can be the cause of considerable dismay for some. Rhinoplasty for adolescents is fairly common, and the results are usually quite successfully incorporated into both male and female teenagers’ evolving body images. This is a particularly important point for boys, who as teenagers tend to adjust much better to rhinoplasty than do their adult counterparts. All teenagers should defer nose reshaping surgery until facial bone growth is complete. This usually means delaying surgery until at least age fourteen or fifteen for girls and sixteen for boys. Decision Making for the Parents of Teens Making the decision to allow your teen to undergo a cosmetic intervention can be difficult, and in most cases it should be. Wanting to do it because “everybody else has done it” is not the decision of a mature individual and is not sufficient grounds to proceed. The ASPS has no formal policy on plastic surgery for teenagers but stresses that a patient should be physically and emotionally mature before undergoing a cosmetic procedure. The society reports that the most rewarding outcomes are likely to occur under the following circumstances:

• The teenager initiates the request.

• The teenager has realistic goals.

• The teenager has sufficient emotional maturity. In partic ular the teen must be able to handle temporary pain and disfigurement. Surgery is not recommended for teens prone to mood swings or erratic behavior, drug or alcohol use, depression, or other mental illness.

ELDERLY—OVER SEVENTY-FIVE

Elderly people—those over seventy- five years of age, say—do undergo cosmetic procedures, although as the available statistics do not stratify groups over age sixty- five, the numbers may not be large. Unfortunately, even the elderly cannot escape the buzzwords and images designed to convince them to buy cosmetic products and services. (My personal favorite absurdity: skin creams with calcium in them.) Several points regarding cosmetic procedures on elderly patients are worth mentioning:

• Elderly patients, properly selected, can undergo conservative cosmetic procedures safely, but one must always take into consideration their reduced physiologic reserve compared with younger patients.

• Older skin has less elasticity and less fat. Dramatic changes should not be expected, and overcorrection can lead to a very unappealing result.

• Bruising can be quite pronounced and prolonged.

• Long operations should be avoided to minimize risks of hypothermia, blood clots, excessive anesthesia, and joint stiffness leading to pain and immobility after surgery.

• A healthy person age seventy-five may have no higher risk than a person age sixty with multiple medical conditions.

• Cardiovascular disease is common in the older population and significantly adds to the risk of surgery for any patient.

 • Drugs, including painkillers, anesthetics, and sedatives, must be used carefully and in lower doses in older patients.

• Nutrition should be emphasized before and after surgery and supplemented if necessary.

• Procedures should be performed in a fully equipped, accredited ambulatory facility or a hospital rather than in an offi ce setting so that sufficient resources are available in case of emergency

. Any high-risk patient should have surgery only in a hospital.

• Extra attention should be paid to ensure that an elderly patient will have adequate care and means of transportation for as long as necessary after discharge from the medical facility.

It is 7:30 on a weeknight. Your boss made you work late and you are rushing home, hoping there will be enough leftovers in the fridge for your supper. You hate to admit it, but you are addicted to reality TV. Tonight your favorite show is on, you don’t have Tivo, and you never did figure out how to program your VCR. The dramatic theme music is just starting, and the television screen flashes pictures of the three or four chosen ones. Each was destined to be unattractive and undesirable but now is about to be made queen (or king) for a day or perhaps even forever.

Welcome to cosmetic surgery reality television.

We are living in an age of fantasy presented as reality staged as fantasy. Even though reality television is a global phenomenon, perhaps no country has managed to produce it in such excess as has the United States. This country is the land of self-invention and reinvention, home of gargantuan stores devoted to do- it- yourself home improvement projects and more than 3,000 self-proclaimed cosmetic surgeons in the state of California alone. Surgery has been a popular topic in visual media for decades, but in the early years of television most stories were serious documenta ries about heart surgery, reconstructive plastic surgery, and other medical subjects that appealed to the public’s curiosity. Then in 1984 actress Jeanne Cooper had her facelift filmed, and clips of the operation were incorporated into her story line on the soap opera The Young and the Restless. The airing of that surgery opened the media floodgates. The event received tremendous attention—it not only put cosmetic surgery squarely within the sights of the average viewer, it succeeded in pandering to the voyeur in us all. (It also became arguably the defining moment of Ms. Cooper’s career. CBS now refers to it as “the first daytime broadcast of an extreme makeover.”) Since then press coverage of cosmetic surgery and related topics has steadily increased, culminating in today’s seemingly limitless public appetite for makeover stories.

One author likened the pro cess of undergoing cosmetic surgery to that of joining a religious cult—one must undergo a period of intense self- scrutiny that leads to self- mortification. In the pro cess the individual must relinquish control to others and endure a certain amount of physical pain. Ultimately, one is reborn to much rejoicing. 1 Whether or not this fairly characterizes all cosmetic interventions, it certainly fits the portrayals of participants on Extreme Make over, one of the most popular cosmetic surgery reality shows. Fans of cinematic and televised fiction know that the sequence of mutilation or surgery, cocooning, and unveiling never fails to delight. In the 1947 fi lm Dark Passage, Lauren Bacall unwraps Humphrey Bogart’s face after his plastic surgery, undertaken to deceive law enforcement officers. Similarly, John Randolph’s character undergoes plastic surgery and his new visage “revealed” (now played by Rock Hudson) in the 1966 thriller Seconds. In one of the most popular episodes of Rod Serling’s The Twilight Zone called “The Eye of the Beholder,” a doctor repeatedly treats a horribly ugly woman in an attempt to salvage her appearance. As her bandages are unwrapped for the last time the audience holds its breath. The results are shocking: The doctor and the nurses are repulsed by her per sistent ugliness; members of the television audience for the first time see the patient’s beautiful (to them) face and the grotesque, piglike faces of the medical team.

So it is with every unveiling; the audience is titillated with the possibility of the results being either spectacularly good or spectacularly bad. The only way that a show’s producers can lose is if there is only moderate change, in other words, more like typical real-life results. That would not garner big ratings.

Yet none of this is new. History is full of public demonstrations of cosmetic surgery and other dramatic treatments, going back for centuries. Beauty doctors of the early 1900s had no qualms about staging dramatic self-promotional events, and the press was eager to write about them. In fact, many of the stories about cosmetic surgery to which the American public was treated in the 1920s and 1930s smelled suspiciously like publicity stunts. Outlaws and other celebrities underwent cosmetic surgery that was gleefully reported in the press. One of the most notorious events was the 1923 rhinoplasty of famous vaudeville actress Fanny Brice, performed in a hotel room by a surgeon of ill repute who eventually went to prison for fraud. The next year the New York Daily Mirror sponsored a “Homely Girl Contest,” in which the winner received an offer of free cosmetic surgery. Her outcome was not reported.

Then, in 1931, one might say that the cosmetic surgery reality show was born. In that year Dr. J. Howard Crum was invited to perform a public face-lift before a large crowd at the Beauty Shop Owners Convention in the Grand Ballroom of the Pennsylvania Hotel in New York City. The patient, a sixty-year-old actress, had a relatively limited amount of excess skin removed from her face, far less surgery than would be performed during a conventional modern facelift. Nonetheless, the event was deemed a success and duly reported in the newspapers. Dr. Crum, who rapidly developed a reputation as a huckster and was disavowed by mainstream medicine, went on to orchestrate numerous highly publicized cosmetic surgery performances, sometimes doing multiple operations at the same event accompanied by music. He seemed to be fond of “type-changing” nose operations and probably appreciated the extra press he got when members of his audience fainted during the “show.” Dr. Crum was hardly the last person of his generation to stage public cosmetic surgery events. The tradition continues today, and not only with reality television. The notorious French performance artist Orlan, whose motto is “My body is my art,” has filmed her on going series of cosmetic surgeries, by which she has requested that her surgeon give her the facial features of ancient female icons. Her procedures, also set to music, take place in an operating room decorated with props, male strippers, and a surgical team dressed in costumes. Orlan insists on local anesthesia so that she can talk, joke, read aloud, and direct the entire performance. Later, she incorporates footage from these fi lms into her lectures and from her studio sells bits of her tissue to the highest bidder.

In recent years more intimate versions of these events occur regularly in hotel rooms, spas, and private homes. People gather with friends, or even strangers, to undergo a variety of not-so-private treatments in a party atmosphere.

PRIVATE ALTERATIONS: THE QUEST FOR BEAUTY, YOUTH, SEX, AND TRANSFORMATION

Among the many aliens invented by Gene Roddenberry and his creative progeny for the Star Trek universe, arguably the most intriguing were those species that existed without concrete form— disembodied intelligence communicating through invisible mental links with corporeal humans. We can no more imagine existing without a physical body than we can envision time travel. Defi ning the physical body seems to be an intrinsically human preoccupation, the manifestations of which are determined by time and culture. We mark, adorn, and otherwise manipulate our physical containers in order to announce our acquired or desired social affi liations, values, and beliefs. This process of self-definition repeats itself endlessly with each human being born. Physical alteration thus has many purposes beyond vanity and the search for beauty.

Nevertheless, for centuries the quest for beauty, or at least the quest to become less unbeautiful, has motivated individuals to alter their appearance. The cultural implications of this quest have been debated by many, from feminists to economists, resulting in a number of interesting but so far unanswered questions about cosmetic medical care. For example, is cosmetic surgery a good thing or a bad thing? Are women cultural lemmings, hapless victims of marketing Svengalis, or are they exercising their rights to make decisions about their own bodies? What role do the media play in soliciting patients for cosmetic procedures? Are the media whores for advertisers, or is there really such a thing as independent content? How can a potential patient distinguish between hype and reality? What is the proper role of doctors on the pathway to cosmetic interventions? What risks should a person reasonably take to alter her or his appearance? Can beauty be defined?

A prospective cosmetic medical patient must be able to articulate a personal definition of beauty because patients and providers need to agree on aesthetic goals before determining if those goals can be achieved. Western ideals of beauty have traditionally been based on rules of proportion and balance developed by the Greek philosopher Plato and his followers, and from these rules artists and plastic surgeons developed aesthetic norms that are often used to determine ideal facial ratios for patients undergoing reconstructive or cosmetic operations. Yet when anthropologists measure faces generally considered to be beautiful, these beauties often do not “measure up.”

Their proportions fall outside the established ideals. Nonetheless, surgeons continue to use aesthetic norms when designing operations, and some still claim the classic Western proportions as the ideal. Only fairly recently have some cosmetic surgeons understood that all those brow-lift patients with the surprised appearance look that way because their eyebrows are simply up too far, partly as a result of surgeons using “ideal” measurements defined in the academic literature. By the same token, it certainly does not make sense for a patient to request cosmetic surgery to look like, say, Brad Pitt, because it is impossible to re-create all of the physical nuances that in toto are recognized as Brad Pitt’s face.

Throughout human history, manifestations of beauty have often been interpreted as good and ugliness as representing inferiority, or evil. Philosophy, literature, and myths frequently reflect this bias. Keats wrote, “Beauty is truth, truth beauty.” During the Victorian era, women of good breeding were expected to maintain beauty in the home and to take responsibility for exposing children to the arts. Some felt that women were also obligated to enhance their physical beauty in order to fulfill their role as the keepers of all that was beautiful and good; others felt that true beauty was an inner quality and that artificial physical enhancement was immoral. In terms of social engineering (if it was intended as such), those who promoted the inner beauty philosophy were not particularly successful. Women who could afford it had elaborate garments made and servants or slaves to maintain their elaborate hairstyles; those who could not afford such expense enlisted family members to help when it was time to be seen in public.

Religion has often had a practical impact on how physical beauty and adornment are judged. For example, the Puritans tried to enforce sumptuary laws that prohibited citizens from purchasing fancy apparel. Still, despite the limited influence of the Puritans’ asceticism and moral repressiveness, many people alive today were raised by parents and grandparents whose moral foundations were established around a framework of similar conservative values and whose influence feeds an undercurrent of discomfort with the present popularity of cosmetic medicine.

During the last one hundred years, given the legacy of the Puritans and the popular influence of the theories of Freudian psychoanalysis with their focus on body functions and shame, our society has been destined to argue about bodies, nudity, sex, vanity, and cosmetic interventions, even as all of those once covert subjects have gained exposure in everyday life. Recent polls indicate that vanity, at least, is no longer a cause for alarm. It appears that Americans consider vanity to be a minor sin at worst, and most people deny committing it. Certainly the popularity of cosmetic medicine today indicates that few people worry about being labeled vain. Social attempts to define physical beauty can lead to ugly consequences, and this fact perhaps more than any other formed the historical foundation of today’s cosmetic medical business. There is a long, and at times unsavory, human tradition of efforts to classify beauty and other human attributes according to measur able physical characteristics. Visual categorization of certain features, such as noses, ears, and breasts, has often led to bias based on a person’s presumed ethnic or racial origins. Phrenology and physiognomy are two examples of ideas once popular, in which an “expert” supposedly could determine an individual’s nature based on an analysis of that person’s skull and facial features. A nose shape, for example, might indicate strength, refinement, commercialism, or weakness, and partic ular shapes were usually and unsubtly labeled to correspond with par tic u lar ethnic groups.

Someone during the early twentieth century even dreamed up the idea that providing cosmetic surgery to criminals would completely alter their personalities to the degree that they would “go straight.” As unlikely as this might seem today, the theory was so persistent that the authors of a textbook on plastic surgery of the nose published in 1951 actually felt compelled to address the topic: “There has been much overemphasis on the restoration of facial contour for the relief of character and personality defects, and it has been extended even to the attempted reclamation of criminals. Anyone who has seen the courage and splendid adjustments of . . . thousands of maimed soldiers . . . will fi nd it almost impossible to believe that facial or nasal deformity in itself creates criminals.”

These theories of “anatomic predestination” influenced early cosmetic surgeons. In a paper published in 1887 and widely acknowledged, Dr. John Roe listed categories of noses: “Considered from the profile point of view alone, noses are classified according to their shape by students of physiognomy into fi ve main classes: the Roman noses; the Greek noses; the Jewish noses; the Snub or Pug noses; and the Celestial noses. These classes of noses, considered in the light of the characteristics of the race or class to which they are peculiar, are observed to indicate prominent traits of character . . .”

Physiognomy’s emphasis on the superiority of small, delicate features undoubtedly influenced the approach of many surgeons to rhinoplasty. It was decades before surgeons finally realized that a blueprint operation would not do and that the nose had to be harmonious with the face to which it was attached. It was in fact revolutionary when some of the most accomplished surgeons started to teach others that it was often necessary to add tissue in a cosmetic rhinoplasty rather than simply to reduce and narrow the nose. On a broader scale physical beauty becomes social and economic currency. Physical attractiveness enhances a person’s appeal in all kinds of social relationships. In historical and present-day cultures where women are dependent on men for economic survival, a woman’s beauty enhances her value in the marriage market.

Physical beauty and fashion used to be concerns mainly of the upper classes. A servant who was caught trying to look fashionable might be punished for overstepping her “place” or perhaps for appearing to mock her superiors. The industrialization and social forces that swept America at the turn of the twentieth century changed the social hierarchy of beauty. Widespread dissemination of images of beauty and feminine ideals ultimately democratized beauty and brought hairstyling and makeup advice to the masses. The “beauty parlor” era had begun. Beauty shops sprang up in back rooms and tiny storefronts everywhere; these small businesses brought women of all ages out of their homes to a place where anyone could get a professional manicure or “hairdo.” Fabrics became affordable, pattern companies published the latest styles, and women could make fashionable clothes that previously would have been affordable only to the rich. Women could even consider cosmetic surgery. No longer was beauty and glamour the privilege only of the wealthy. Anyone could get a makeover.

The Body in the Eyes of Those around Us

Humans (and many animal species) size each other up by appearances. The way we groom ourselves, the way we dress, and the expression on our faces convey loads of information to an observer. At the most basic level for many species, beauty and health are synonymous and indicate fertility: The search for beauty, health, youth, and sex are thus intertwined. Humans have exploited these instincts in various ways at various times in history. For example, in the flapper era of the early twentieth century, outdoor exercise became suddenly popular and was proclaimed to be the key to attracting a member of the opposite sex, even though members of earlier generations who had the luxury to do so had avoided sun and exertion. Today’s consumer, frustrated with the limits of or unwilling to meet the demands of a body-contouring exercise regimen, is enticed by the quicker gratification implied in the cosmetic medical/surgical package for the “new you.”

Most people know that appearances can also be deceiving. It is easy to make assumptions about a stranger based on what she is wearing, but in reality you have no idea who she is, where she has been, and where she is going. By the same token one can easily look at a person with a crease between his eyes and wonder why he is angry, when in fact he is not angry at all, merely thoughtful and wearing his familial furrowed brow.

A friend of mine went for her annual physical exam not too long ago, and because it was a beautiful day she was in an upbeat mood. When her physician entered the exam room, he exclaimed, “How are you feeling? You look exhausted.” She was astonished and assured him that she felt fine. Her physical exam showed her to be in good health, but the minute she got home she went to the mirror and inspected her face. What she saw were the usual puffy lower eyelids that she saw every day and that ran in her family. She assumed that the harsh overhead lighting in the doctor’s offi ce had accentuated them, and from that day forward she felt self-conscious about looking tired and, even worse, older. Eventually, she had cosmetic surgery to remove the protruding fat that was the cause of the puffi ness.

However we might wish to deny it, how we look matters. Attractive people are just that: They attract others and often become leaders by unspoken consensus. Attractive people are treated differently, especially in white-collar jobs; they are paid better; they get more promotions, better grades, and stronger performance evaluations; they garner more attention and get more respect, even without earning it. Any average- or less-than-average-looking person can relate a tale about being passed over in favor of a better-looking competitor, whether it be on the dating scene, in the job market, or on the playground. A busy, well-respected physician friend remembers her training days, when she was one of several dozen residents, mostly men. “There were several guys who had the ‘look’—they were tall, goodlooking, preppy. We used to call them the golden boys. They were no better or worse than the other residents, but they defi nitely were treated better by the attendings [teaching surgeons]. They never got yelled at and could slide through a little if they chose to. To their credit, they were decent guys and most of them did not consciously take advantage of the situation, but they certainly worked in a more pleasant atmosphere than the rest of us did.”

Attractive children enjoy the same advantages as do attractive adults. Pretty babies get more attention and cute kindergartners aquire more friends. Good-looking children and adults receive more lenient punishment for mistakes, perhaps because of the almost mystical belief that beauty cannot be bad. With all of that positive feedback it is not surprising that attractive people are more likely than less attractive people to be extroverted. It is also no wonder that adolescents agonize over their physical changes because they do not know if they will wake up the next morning as someone their peers will like, let alone someone whom they recognize in the mirror. Marked unattractiveness has an even stronger social impact and has been shown to put the affected individual at a defi nite disadvantage and subject to discrimination. In the United States, public fi gures, especially women, are castigated if they appear in public not fully put together. (Remember when early in her Senate career Hillary Clinton was caught making a quick run to Senate chambers to cast a vote sans makeup and hair not perfectly coiffed? The press had a field day.) Reporters seem to be unable even now to write about Eleanor Roo sevelt, to use a well-known example, without mentioning her lack of beauty, even though similarly plain men rarely draw comments on their dearth of physical charms. (One exception to this seems to be criticism of men’s hair: think Lyle Lovett, Donald Trump, and Ted Koppel.)

The reaction of others to one’s appearance has a critical effect on one’s self-esteem and particularly on the psychological construct that we call body image.

The Body in the Mind’s Eye

Body Image and Transformation Few psychological concepts have received so much press in recent years as has body image. Thousands of articles, books, and dissertations have been written on the subject in both the popular press and academic literature, provoked in part by the rising rates of eating disorders, cosmetic surgery, and other increasingly risky ways by which Americans strive to alter their bodies. In the past fi ve years alone, more than one hundred books have been published on the subject of body image. The endless appeal of anything to do with cosmetic body alterations has encouraged reporters and scholars to ruminate on its implications and the evolution of our cultural norms for the ideal body.

Psychologist Nancy Etcoff describes how complex our relationships with our bodies can be. She writes, “We view the body as a temple, a prison, a dwelling for the immortal soul, a tormentor, a garden of earthly delights, a biological envelope, a machine, a home.”5 Psychologists know that one’s body image may bear little resemblance to one’s physical reality, and individuals with body image disturbances are not unfamiliar to cosmetic surgeons.

Most people have fairly stable core body images that develop in childhood and adolescence and are maintained for long periods. Psychologically healthy young adults have mature body images, and if they choose to undergo cosmetic interventions, it is usually to change features with which they have been dissatisfied since adolescence. With the onset of middle age most people develop a new set of anxieties. Many feel that they cannot compete with a youthoriented society unless they look younger than their biological age. Women in partic ular start to feel invisible and their body images blur as the men around them gravitate toward younger, more energetic females.

Like skin color, body contours are largely hereditary and can also be strongly associated with cultural identity. Therefore, certain procedures not only profoundly affect a person’s appearance but can carry significant body image and cultural consequences. Body image is such a powerful psychic force that transformation myths and stories permeate all cultures. Forget about Cinderella: She just got a new hairstyle, fancy clothes, and transportation. How about all of the former and soon-to-be frogs, snakes, fish, and werewolves in fairy tales and adult literature? In many of these tales, transformation is punishment or reward doled out by a powerful force to a mere mortal, perhaps instigated by the human’s behavior or sometimes just for kicks. The transformations may be reversible but in many cases are permanent or carry the threat of permanence (Alice in Wonderland, Pinocchio). Even beyond mythology, serious and comic adult literature such as Franz Kafka’s Metamorphosis and Helen Fielding’s Bridget Jones’s Diary, to name just two well-known examples, is loaded with physical and psychic personal transformation themes. Outside literature, philosophers have long contemplated whether or not identity is even within one’s control. Certain schools of feminist thought, meanwhile, consider it a cultural imperative for women to redefine themselves within contemporary society.

With all of this psychic baggage imbedded in our culture, it is no wonder that the practice of temporary transformation (for example, cosmetics, hair color, new clothes) is so appealing, whereas the idea of permanent transformation is more controversial and loaded with potential psychological dangers. “Transformation” remains a powerful buzzword for makeover shows, or perhaps businesses aiming to restructure. (Recently, a local medical organization was so taken with the term that it organized a conference entitled “Transformation of Practice and Patients” that covered a range of topics from body-contouring cosmetic surgery to electronic medical records.)