The Democratization of Beauty

Mention plastic surgery and the more judgmental among us immediately rattle off a list of traits its devotees probably share: vanity, frivolousness, narcissism, low self-esteem. We imagine shallow socialites or vain movie stars desperately trying to forestall the ravages of time. But in fact, cosmetic surgery is not an industry built on vanity alone, but also on two much more powerful emotions: denial and envy. Cosmetic surgery thrives on our collective denial of aging and on our refusal to accept physiological limits. It feeds our envy of those who embody nature’s most powerful but fleeting charms — youth, strength, beauty, and fertility. Its supporters praise its ability to change lives and its critics denounce it as the expression of our society’s worst impulses. It is a useful fathometer for assessing the state of our democracy and a Rorschach test for people’s views about much broader social currents: the glorification of youth, the tenor of popular culture, the peculiar but strenuous American anxiety about identity. It is also a wildly successful industry — one based on ingenuity and an array of constantly evolving techniques and products, overseen by an army of trained professionals eager to protect and enhance their market prestige.

In recent years, a peculiar species of thought has emerged — call it Vanitus Democratus — that doesn’t merely tolerate, but embraces cosmetic surgery as evidence of our country’s commitment to equality, prosperity, and individual autonomy. “Envy is the basis of democracy,” as Bertrand Russell observed, but since beauty is a valuable commodity that is unfairly distributed (what political theorists call “the injustice of the given”) it can prompt extremes of envy about its undemocratic effects. Americans loathe such unfairness, but ours is not a society that would tolerate — à la “Harrison Bergeron” — a beauty handicapper who would force-feed the svelte and inflict male pattern baldness on those with thick tresses. Our solution is to democratize beauty, to make it something that, fueled by envy and with enough money and effort, anyone can attain. This blunts its force as an instrument of inequality.

We have succeeded in crafting a narrative of cosmetic surgery as a modern democratic solution (in that it endorses the free market, personal fulfillment, and individual autonomy) to a most undemocratic problem. As cultural historian Sander Gilman has noted, “In a world in which we are judged by how we appear, the belief that we can change our appearance is liberating. We are what we seem to be and we seem to be what we are!” This narrative also feeds into the longstanding American belief in individual transformation and the reinvention of self: unmoored from the traditional hierarchies, we are free to pursue our bliss.

And pursue it we do. Cosmetic surgery is becoming increasingly popular and increasingly democratic. Today it is not only the haut monde getting nipped and tucked, but also the average American. Ten years ago, if you shouted “nasolabial folds” at a crowd of middle-class, middle-aged women, they’d return baffled glances. Today they would nod knowingly, instantly begin trading tips on Botox injections and facelifts, and offer their informed reviews of the latest plastic surgery reality television show. People who used to cower in Greta Garbo-like seclusion until their stitches healed now proudly display their post-operative scars at dinner parties. Shame over such surgeries has given way to celebration. Television personality Greta Van Susteren was hailed as a pathbreaker for speaking openly about her facelift, which gave her a tighter, slightly Martian appearance for her new role as a permanent Fox News pundette. Last fall, as the New York Times reported, a cosmetic surgeon rented a Long Island banquet hall to showcase his handiwork: “With music throbbing and her proud family looking on, Amanda Draizin, 16, strutted down a runway, wearing a little black dress and her brand new nose,” the story noted. Other participants flaunted new breasts and tightened eyelids, while the good doctor basked in the exuberant praise of his invited guests.

In a mere decade (between 1982 and 1992), according to the American Academy of Cosmetic Surgery, the number of people surveyed who said they approved of cosmetic surgery increased by 50 percent, and the number who disapproved declined by 66 percent. Consumer demand for surgery has skyrocketed alongside this evaporation of disapproval. As Alex Kuczynski wrote recently in the New York Times, “The American Society of Aesthetic Plastic Surgery reports that the overall number of cosmetic procedures has increased 228 percent since 1997. The numbers are likely to rise as the population ages, prices drop, younger patients seek out surgery, technology and genetic engineering generate new techniques, and more doctors from various fields offer cosmetic surgical procedures.” At the very moment in history when we are living longer and healthier lives than any society before us, we want to stop aging. We want to live longer, but only if we can remain frozen in appearance as a rather distinguished but active 35 years for men or a still youthful and vivacious 25 for women.

But cosmetic surgery is not without potential harms — both to individuals and to society as a whole. Since cosmetic surgery is, as historians David and Sheila Rothman have noted, “enhancement at its most pure,” it is a troubling case study of how American culture grapples with techniques designed for therapy that can be used to fulfill our personal desires. Buried in the logic of cosmetic surgery are some disturbing truths about what our culture believes: that it is acceptable to be satisfied by the external markers of success; that the pursuit of such markers is, in and of itself, a useful and psychologically healthy goal for people; that what used to be encouraged — a lifelong process of moral education — is less useful, in the long term, than the appearance of success, health, and beauty; and that if we can overcome the limits nature places on our physical bodies, we should. “One way to deny our dependence on nature,” Christopher Lasch wrote many years ago in The Culture of Narcissism, “is to invent technologies designed to make ourselves masters of nature.” This is what cosmetic surgery promises to do.

There is a deeply human intuition about beauty — perhaps, as evolutionary psychologists suggest, because it used to delineate the healthy from the diseased and thus offered signposts to choosing the most appropriate and most fertile sexual partner. Culture has also long linked physical appearance to moral worth. Children’s stories are filled with characters — beautiful princesses and ugly witches — whose outward appearance speaks to their inner goodness or wickedness. Other classic tales endorse the notion of physical transformation as the route to happiness — the Ugly Duckling, Pygmalion, and Cinderella. And the power of beauty has long been recognized, in figures such as Helen of Troy and Dante’s Beatrice, if not always universally admired. In the nineteenth century, phrenologists, early criminologists, and, later, eugenicists all accepted the notion that outward physical appearance marked internal worth, and they used particular aesthetic standards (such as the slope of the nose and the size and shape of the head) as justification for ranking people of different ethnic and racial groups.

The plasticity of the body is also hardly a modern discovery, as such traditional (and multicultural) practices as foot binding, corseting, the use of arsenic powders to whiten skin, and plates placed in the lips to extend them can attest. In Europe in the sixteenth century, physicians began making early, surgical attempts to alter physical appearance, largely to mask evidence of syphilis, which was spreading rapidly throughout the continent at the time and which produced marked disfigurements in its victims, particularly to their noses. It was not until World War I, however, that reconstructive surgery became a permanent part of medical practice. Trench warfare maimed a generation of young men, and early reconstructive surgeons devised techniques for patching them back together. After the war, reconstructive surgery gained a permanent, if initially small, perch in surgical medicine.

What began as an effort to mask genuine disfigurement eventually became a way to conceal more modern woes, such as aging; a “medical response to the medical emergency of modern warfare,” as one historian described it, became a medical response to modern notions of beauty and perfectibility. Sifting through stories from these early days of cosmetic surgery is like entering the sawdust-choked confines of a sideshow tent — new horrors behind every curtain! Here you will find quack physicians injecting paraffin wax (sometimes spiked with Vaseline) into women’s lips, cheeks, and breasts; men and women enduring botched nose jobs and crude fat removal procedures; and terrifying characters such as the notorious “beauty doctor” Gertrude Steele, who, as historian Elizabeth Haiken noted, was forced to flee the United States in 1925 “after autopsies on two of the patients whose faces she had peeled revealed traces of phenol poisoning in the brain.” This is not what the average American consumer saw, of course. They saw glamour. In the 1920s, advertisements for beauty products and cosmetic procedures often featured images of elegant women staring rapturously into the mirror with captions such as, “Your masterpiece — Yourself!”

As decades passed, techniques improved, and patients began demanding more control over the kind of cosmetic procedures they were purchasing. As historians David and Sheila Rothman note, surgical work in the 1960s was often so homogeneous that “when a slide of a sixty-year-old woman who had her nose reshaped appears [at medical conferences] plastic surgeons will jocularly call out ‘Long Island 1965’ or ‘the Joseph Nose.’” But that would change as Americans took the final steps on their journey to becoming consumers of cosmetic surgery, not traditional patients.

Cosmetic surgery is one of the only surgical procedures that eagerly embraces the practice of self-diagnosis. Patients are not physically sick, nor do they suffer from a diagnosable disease, nevertheless they come to a surgeon with their etiologies clearly worked out: one person feels her nose is misshapen, another thinks her thighs are too large, still another is unhappy with the bags under his eyes. It is difficult to imagine traditional physicians taking seriously a person who walks into their office, states with absolute certainty a complete diagnosis, and demands a specific cure. What explains cosmetic surgery’s unusual reliance on this practice?

The greatest boon to modern cosmetic surgery was not the development of any particular technique or the creation of a miracle product. It was an import from psychology: the inferiority complex. Popularized by Viennese psychologist Alfred Adler in the early twentieth century, it reached an eager audience in the United States. The inferiority complex provided a crucial link: it joined individual mental health with physical appearance and thus psychologized cosmetic surgery. People suffering from an inferiority complex because their breasts were small or their chins droopy were ill; they required medical intervention to alleviate their psychological suffering. As Haiken notes, by the 1920s and 1930s, Americans had made this link between physical appearance and mental health permanent; as a result “their demands for surgical attention became more insistent at the same time as the new language of psychology made these demands more persuasive.” By 1940, Good Housekeeping magazine was asking, “why should anyone suffer under the handicap of a conspicuously ugly feature? Why not let modern science give him a normal face and an equal chance with other people?”

The practice continues today. If you accept the World Health Organization’s current definition of health — “a state of complete physical, mental, and social well-being” — then cosmetic surgery is an encouraging health trend. The psychologizing of cosmetic surgery has allowed cosmetic surgeons to feel certain that they are treating their patients’ deepest concerns; it releases them from the difficult responsibility of determining whether someone really should be having surgery or not. Since the experience of living with one’s given physical traits is entirely relative, and the standards for assessing the impact of an ugly nose or a chubby thigh on any one individual are virtually nonexistent, surgeons need only affirm their patients’ concerns and fix them.

“We have embraced plastic surgery as a legitimate way to relieve people’s suffering regarding their appearance,” says Dr. George Weston, a plastic surgeon with a reassuring, southern-inflected voice and eighteen years experience at the Austin-Weston Center for Cosmetic Surgery in Reston, Virginia. “Cosmetic surgery is designed to get your attention off of your appearance,” he says. “It sounds odd to put so much attention on your appearance to get it off of it, but the real secret of cosmetic surgery is what happens inside: a new contentment. We have to transcend our appearance at some point,” he said. “Cosmetic surgery helps with that.” Dr. Weston told me that he has operated on a number of psychiatrists; he asked one of them why she was getting surgery instead of therapy. The response? “Why spend years talking to a therapist about my self-esteem when I can spend two hours on your operating table and eliminate the issue altogether?” Dr. Weston chuckled, “It’s psychiatry with a ten-cent knife blade!”

The desire for cosmetic surgery is not fueled only by irrational fears and low self-esteem, however. There are apparently real economic harms and benefits tied to personal appearance. A 1993 study conducted by economists Daniel Hamermesh and Jeff Biddle and published by the National Bureau of Economic Research found that “holding constant demographic and labor-market characteristics, plain people earn less than people of average looks, who earn less than the good-looking. The penalty for plainness is 5 to 10 percent, slightly larger than the premium for beauty. The effects are slightly larger for men than women; but unattractive women are less likely than others to participate in the labor force and are more likely to be married to men with unexpectedly low human capital.” One of the earliest students of this economic lesson was well-known stage actress Fanny Brice, who in 1923 submitted to a nose job — and an onslaught of publicity — in the hope that she would no longer be typecast in “ethnic” (read: Jewish) roles. Her adventures in rhinoplasty prompted Dorothy Parker’s withering assessment that Brice had “cut off her nose to spite her race.”

Nancy Etcoff, in her book Survival of the Prettiest, has noted other examples of the unjust benefits that accrue to beauty: One psychological study asked college-age men, if given a choice between an attractive and an unattractive woman, for whom would they do the following: “help move furniture, loan money, donate blood, donate a kidney, swim one mile to rescue her, save her from a burning building, and even jump on a terrorist hand grenade.” With the exception of loaning money, the men were more likely to do all of these for the more attractive woman. Other studies, involving leaving a dime in a phone booth and stranding two women next to a broken-down car by the side of the road, yielded similar results: “87 percent of people return the dime to the good-looking woman, but only 64 percent return the dime to the ugly woman.” And the beautiful woman is, of course, offered roadside assistance first.

Youthfulness is a similarly desirable commodity, as Americans in the corporate world are learning. A February 2004 report in the Wall Street Journal described a recent survey by ExecuNet that asked senior-level corporate executives about attitudes toward aging. The result found that “82 percent consider age bias a ‘serious problem,’ up from 78 percent three years ago. And 94 percent of these respondents, who were mostly in their 40s and 50s, said they thought age had cost them a shot at a particular job.” Many of these executives — male and female — are turning to cosmetic surgery to help them stay competitive. “Youth in this country gets the rewards,” Dr. Weston told me matter-of-factly. “I see older people competing with younger people out there, and what happens, as we get older, is that we no longer look as sharp and effective. Men get loose necks, their faces look like they are not as sharp and competent.” As a result, he says, “Your face can send a false message.” Cosmetic surgery helps “eliminate that misrepresentation.”

Critics of cosmetic surgery argue that it is not your face that betrays you, but society’s unrealistic expectations. Many of these critics are avowedly feminist in their outlook, and decry the “beauty myth” that targets women in particular with its pernicious message that your value is tied to your youth and sexual attractiveness. But this insight no longer has any practical resonance, if it ever did. Thoroughly routing the idea of a woman-only “beauty myth” is the very real fact that men are a rapidly growing consumer niche in cosmetic surgery. They are getting procedures such as Botox and chemical peels, although they are not yet as willing to admit their cosmetic habits as women. One New York plastic surgeon told the Wall Street Journal that “17 percent of his patients undergoing eyelid surgery and about 11 percent choosing facelifts are male, double the percentage of ten years ago.” According to the American Academy of Cosmetic Surgery, the most popular procedures for men are Botox injections, hair transplantation, chemical peels, microdermabrasion, and liposuction. But more than ten thousand men have also had cosmetic surgery to lengthen or widen their penises, as well as calf and pectoral implants to upsize their musculature.

But for now, women are still the major consumers of cosmetic procedures. And it is one of the great ironies of contemporary feminism that the rhetoric about control over one’s body (“my body, my choice”) became a rallying cry for women’s “right” to reshape their noses, breasts, and thighs through cosmetic surgery. Part of what was supposedly useful and liberating about the feminist message was its insistence that women’s value was not linked inextricably to appearance or reproductive powers. But eventually, most women make the fertility link themselves (how else would we have a sense of something like a biological clock?). And eventually, all women must face the realities of aging.

Even former feminist stalwarts implicitly recognize this fact. Perusing a listing of upcoming lectures at the 92nd Street Y in Manhattan, I stumbled across an announcement for a panel discussion featuring Letty Cottin Pogrebin, one of the original founders of Ms. magazine. The topic: “Juicy Living After 50!” — including tips on maintaining your sexual allure during your “crone years.” This is the same avid denial of aging that fuels the cosmetic surgery industry. By the time we reach middle age, women — and increasingly, men — must confront our successes and failures in arenas where we might not feel we exercise as much control as we once did — careers, relationships, perhaps even in our family lives. Cosmetic surgery offers us control over one thing: our physical appearance. The few avowedly feminist supporters of plastic surgery endorse this insight. Kathy Davis, who teaches in the Netherlands, has argued for the merits of plastic surgery in the feminist journal Hypatia, noting that, for many women, deciding to have cosmetic surgery is “about taking one’s life into one’s own hands.”

Feminist critics are correct that the demand for cosmetic surgery is closely linked to a society’s cultural norms regarding aging, especially for women. Plastic surgery is less popular in France, where a cultural appreciation of a “femme d’un certain age” — an older woman who looks her age, but whom the process of growing older has marked with wisdom and (daresay!) a certain kind of sexual allure — exists. American culture yields little on this score: when older women who look their age are paired with younger men, they are often depicted as harridans or voracious man-eaters — such as Mrs. Robinson in the 1967 film, The Graduate (though it is worth noting that when the movie was made, Dustin Hoffman, who played the young, puzzled, and sexually awkward Benjamin Braddock, was thirty-one years old; his erstwhile seductress, Anne Bancroft, was thirty-six). In our youth-oriented, image-driven democratic culture, visible signs of aging, particularly for women, will soon be markers of declining status.

The contemporary cosmetic surgery industry is a lavish smorgasbord of options for the American consumer. A partial list of the procedures available include: Cheek implants, mentoplasty (chin augmentation), collagen and fat injections, otoplasty (pinning back the ears), blepharoplasty (eyelid tightening), rhytidectomy (facelift), forehead lifts, hair transplantation (using scalp reduction, strip grafts, and plugs), rhinoplasty (nose job), brachioplasty (arm lift), breast augmentation, mastopexy (breast tightening), breast reduction, buttock lift, thigh lift, calf implants, pectoral implants, abdominoplasty (tummy tuck), penile enlargements and implants, and the ever-popular Botox (where diluted doses of the botulinum toxin are injected into wrinkles) and liposuction (the removal of deposits of fat using a suction cannula).

According to the American Academy of Cosmetic Surgery, approximately 860,000 cosmetic surgery procedures were performed in 2002, mostly on women, although men accounted for 150,000 procedures. One-third of cosmetic surgery patients are between the ages of 35 and 50; another 22 percent are between the ages of 26 and 34. And 18 percent of people getting cosmetic surgery are under the age of 25. Instead of the smoke and mirrors of the old freak show, we now have, online, hundreds of “before and after” pictures of cosmetic surgery patients — all of them encouraging a belief in the surgeon’s power of total transformation.

Aging is not the only problem cosmetic surgery seeks to solve — it also offers a solution to the American obsession with our waistlines. In his book Battleground of Desire: The Struggle for Self-Control in Modern America, Peter Stearns notes how, as early as 1916, popular magazines were equating control of one’s weight with the health of one’s character. The first diet cookbook, published in 1900, stated matter-of-factly in its preface, “An excess of flesh is looked upon as one of the most objectionable forms of disease.” Liposuction, a technique for removing deposits of fat using a tool called a suction cannula, was developed by French surgeon Yves-Gerard Illouz in the 1970s, and it is the most popular invasive cosmetic surgery procedure: 74,000 people had liposuction in 2002 alone.

The language of artistic achievement suffuses the industry: surgeons describe their work as “body sculpting” or “body contouring,” and liposuction is known as “blind subcutaneous sculpturing.” But the anodyne terms mask physically brutal procedures. The trauma of this kind of surgery can be considerable. As Ryan Murphy, the creator of the FX network’s plastic surgery drama Nip/Tuck told the New York Times jocularly, “one plastic surgeon told me that getting your face done is basically the equivalent of going through a car window at 70 miles an hour and surviving.” His show is one that revels in gory details. “I think the public thinks that this is delicate surgery, and these surgeons treat the face as if it were porcelain,” he said. “And in fact they treat it like it was sirloin.”

The faces and bodies of many celebrities testify to the unhealthy lure of excessive physical transformation: Michael Jackson’s many surgeries have left him nearly unrecognizable, and Jocelyn Wildenstein, a terrifying spectacle of a socialite, has had multiple surgeries, including an enormous chin implant, lip implants, facelifts, and eyelifts so that her face would have the features of a large cat. Respectable surgeons do try to vet candidates for surgery to avoid encouraging the activities of these “scalpel slaves.” “I wish we had a questionnaire that could warn us,” Dr. Weston said. “We sit down with patients in consultation, but we’re both interviewing each other.” Weston concedes that if he refuses to operate on someone who is obviously mentally unstable or who has unreasonable expectations for surgery, “they’ll eventually find someone else to operate on them.”

More mundane dangers exist for people who undergo cosmetic surgery. One study, conducted by a plastic surgeon in 2000 and described by David and Sheila Rothman, found that “the rounded mortality rate for liposuction surgery in the late 1990s hovers near 20 per 100,000.” Compare that to the 3 per 100,000 rate for hernia operations. In the space of only a few months this year, several widely publicized cosmetic surgery deaths — notably that of 54-year-old novelist Olivia Goldsmith, who had checked into an Upper East Side hospital for a chin tuck — have prompted halfhearted handwringing in the media, but no discernible slackening of interest among consumers. “We educate our patients about the risks,” says Dr. Weston, “and you’re safer in my operating room than you are driving on the Capitol Beltway.” But it is still surgery. Complications can arise from inappropriate use of anesthesia, heart attacks, and post-surgical blood clots.

As with any lucrative enterprise, cosmetic surgery also has its share of fringe practitioners — men and women who lack board certification (or, in some cases, even medical training) who advertise their services, often targeting lower-income groups with lower prices than legitimate surgeons. Earlier this spring, Dean Faiello, who in 2002 had pled guilty to practicing medicine without a license, was arrested in Costa Rica and charged with murder after the body of investment banker Maria Cruz was found, encased in concrete, at Faiello’s former Newark, New Jersey home. Ms. Cruz had gone to Faiello’s makeshift clinic in Manhattan for a cosmetic laser procedure to remove a growth from her tongue and died, likely as a result of the anesthesia Faiello administered.

Despite the risks, demand grows — and continues to trickle down the social scale. Cosmetic surgery, once the province of celebrities, has in the last several decades begun to appeal to other public figures, including politicians. Former Senate Majority Leader Bob Dole’s post-retirement facelift led to lucrative advertising work for Pepsi and Viagra, and his new, tensile look is not the only one inside the Beltway. House Minority Leader Nancy Pelosi’s official website unwittingly features two images that represent commendable examples of human achievement in architecture: the Golden Gate Bridge in her home state of California, and Ms. Pelosi’s own stretched, lifted, and resculpted visage. Beltway observers have also remarked on Senator Joseph Biden’s flourishing hairplugs. Commenting on the American scene recently, a reporter for an Australian newspaper noted, “It’s hardly surprising that while Bill Clinton’s presidential campaign of the 1990s was haunted by whispers of infidelity, the first rumor to dog the campaign of … Senator John Kerry was that he had had Botox injections in his patrician forehead.” Today, after setting aside his plough, Cincinnatus would have to get a quick mini-lift and chemical peel before returning to rule Rome.

Our vices are also reflected in new cosmetic treatments. Surgery to cure bunions and other foot ailments is increasing, and women are even having their toes shortened (at a cost of $2,500 per toe) and feet injected with collagen so that they can wear the high-heeled, pointy-toed shoes now in fashion — despite the real risks such surgeries carry, including permanent nerve damage.

The latest trend is “Age Dropping,” with increasingly younger men and women its target market. Like the fable of the grasshopper and the ant, women in particular are being warned that, like the industrious ant, they should shore up their supply of youth and beauty by having an increasing number of carefully calibrated nips, tucks, and peels performed in their thirties so that they don’t end up, like the hapless grasshopper, without an adequate supply in their winter years. Writing recently in the New York Times Magazine, beauty editor Mary Tannen confessed to pangs of doubt about her own decision to resist plastic surgery. “Perhaps I am deluded in thinking that my jowls are an advertisement for courage, proclaiming that I’m not afraid of growing old,” she writes. “Maybe they are shrieking that I am a clueless loser who doesn’t have the wherewithal to have my chin taken care of.” In certain social milieus such as hers, she notes, “the lifted face has started to seem normal, leaving the unlifted one looking, well, strange.”

When I asked Dr. Weston what he would recommend as a preventative, “age-dropping” measure for a thirty-year-old female of average height and weight (which I happen to be), he hesitated, noting, “everybody’s face is different,” but quickly told me not to smoke and to stay out of the sun. He added that there were a lot of procedures that could be performed in one’s thirties to forestall the worst effects of aging. Another surgeon, Dr. Gerald Imber, is more forthright in his support of preventive measures — so much so that he wrote an entire book, The Youth Corridor, outlining the best methods of age dropping. “My philosophy,” Imber writes in the introduction, “advocates preventing wrinkles, rather than curing them, and smaller procedures and earlier surgery for generally younger patients, in order to maintain one’s appearance throughout the adult years in what I call the Youth Corridor.” The book includes dramatic pencil sketches of a woman’s face becoming progressively more haggard, like Dorian Gray’s portrait, because she failed to follow Dr. Imber’s multi-point strategy for wrinkle-free golden years.

What “age dropping” and other trends suggest is a diminishing tolerance for imperfection and aging. Writing in The New Yorker in 2001, Malcolm Gladwell noted that “we have come to prefer a world where the distractible take Ritalin, the depressed take Prozac, and the unattractive get cosmetic surgery to a world ruled, arbitrarily, by those fortunate few who were born focused, happy, and beautiful. Cosmetic surgery is not ‘earned’ beauty, but then natural beauty isn’t earned, either. One of the principal contributions of the late twentieth century was the moral deregulation of social competition — the insistence that advantages derived from artificial and extraordinary intervention are no less legitimate than the advantages of nature.” The inevitable result is a sense that, in certain settings such as the corporate boardroom or Capitol Hill, cosmetic surgery is beginning to be considered a career necessity.

Meanwhile, democratization sends this message ever further down the income scale. The average cosmetic surgery patient is not rich. As historian Haiken notes, “only 23 percent of patients come from families earning more than $50,000 per year. Families with incomes under $25,000 account for 30 percent of patients, while those earning between $25,000 and $50,000 account for another 35 percent.” “The worst perception of cosmetic surgery is that it’s for the rich, vain, and foolish,” Dr. Weston told me. “The reality is that most people are middle class and most people save their money for it. You can have almost anything done for the price of a used car. It’s considered a tremendous value.”

The future of cosmetic surgery is a story of continual expansion and increased consumer demand. In the years to come, “there will be more cosmetic surgery done than all surgical procedures combined,” predicts Dr. Weston. Techniques are improving, and the surgeon’s work is becoming more difficult to spot. “If cosmetic surgery looks like cosmetic surgery, it’s not good cosmetic surgery,” he says. “You don’t want someone to say ‘nice facelift.’ … You want to hear, ‘Gosh, you look good, did you lose weight?’ or ideally, ‘My God, are you in love?’ Then you know it’s really good cosmetic surgery.”

Non-surgical treatments are expected to continue to increase in popularity as well. New injectable gel-like substances with names such as CosmoDerm, Hylaform, and Juvederm are hitting the market as wrinkle fillers. The New York Times reported last year that “it’s not unusual for women in New York to spend $2,000 every few months on fillers, which run about $500 a treatment and last around six months.” New treatments for hair loss are also coming down the cosmetic pipeline, such as “follicular unit transplantation,” a procedure that purports to be a vast improvement over the crop-rotation-like aesthetic of first-generation hair plugs. Overall, industry projections are rosy: as Medical Devices & Surgical Technology Week recently reported, “demand for materials and equipment used in cosmetic surgery procedures will advance over 11 percent annually to $1.8 billion in 2007.”

Cosmetic surgery is even going global. The Washington Post recently reported on the increasing acceptance of such practices in China, particularly a procedure to create creases in women’s eyelids to give the eyes a rounder, more Westernized look. Breast implants are also popular, “a status symbol, an indication of an ability to afford the accouterments of a wealthy life.” Hardly the great leap forward Chairman Mao had in mind, but further evidence of the cross-cultural lure of physical perfection.

The democratizing trend in cosmetic surgery is nowhere more evident than with liposuction and breast implants, which speak to two American obsessions: weight and sex. Liposuction is the most popular invasive cosmetic procedure, but it is not a permanent weight-loss solution. People who regain weight after liposuction look as if they never had the procedure to begin with; indeed, some patients report looking worse, because the new fat deposits itself in strangely misshapen ways on their previously vacuumed hips and thighs. Still, websites like liposite.com offer galleries of anonymous before and after liposuction pictures, and it is not unusual to find images of 19-year-old women who are by no means overweight but seem intent on resculpting their bodies to suit the reigning slim-hipped, thin-thighed ideal.

With breast implants, the democratic message has flowed down to meet a demand that originally traveled from the bottom of the respectable social scale up: once the province of strippers and porn actresses, breast implants eventually became popular among Hollywood celebrities. Today, it is middle class American women who scrimp and save to achieve the figures they’ve always wanted. According to a recent industry newsletter, “breast implants are the most significant single product type in the cosmetic-surgery market, alone accounting for 20 percent of demand, and will continue to be among the highest profile products.” In 2002 alone, nearly 34,000 women had breast implants. Although liposuction is the most popular invasive cosmetic procedure, accounting for 74 percent of all such procedures performed in 2003, the demand for breast augmentation has increased at a faster pace. It is also the procedure (after rhinoplasty and otoplasty) with the youngest average age for patients — 33 years old.

Breast implants are a good example of some of the ironies of our pragmatic, democratic approach to cosmetic surgery. Women who get them to feel more sexually attractive are making a strange bargain. In the process of looking more sexually appealing, they rob themselves of several uniquely female experiences. Women with breast implants frequently report a loss of sensation in their breasts, eliminating a site of natural sexual pleasure. They cannot breastfeed their children, eliminating both the bonding and health benefits of this practice. They must, on average, have their implants replaced or adjusted every ten years, and rippling, hardening, and significant movement of the implant and surrounding tissue are common. And popular culture, always a fickle beast, suggests that a quiet backlash against implants is building, with purveyors of pornography increasingly touting their “all natural” performers.

It is not clear if this shift from artificial to natural (like the trend in popular “natural foods” sales) will make a permanent mark. Beauty standards change as often as the seasons. But lately, popular culture has offered more insight into our collective embrace of cosmetic surgery. Alongside our paeans to the transformative power of plastic surgery rests a fascinated disgust with its extremes. There is a lurid subculture devoted to documenting the cosmetic surgery of celebrities, for example, who often deny having altered their appearance. Websites such as www.awfulplasticsurgery.com adopt a “gotcha!” tone and feature galleries of pictures documenting starlets’ shrinking noses and ballooning bustlines — a concours d’elegance of the human body.

Televised burlesques satisfy a similar impulse, one not far removed from the freak shows of carnivals past. Programs such as Extreme Makeover, which deploys radical plastic surgery to transform unattractive women into glamorous sirens, and Nip/Tuck, a plastic surgery drama told through the somewhat jaundiced eyes of two Miami plastic surgeons, have proven wildly popular. The latest show in the plastic surgery oeuvre is Fox’s The Swan, which “takes women described as ugly ducklings and puts them under the cosmetic surgery knife, fixes their teeth, lets them see a shrink, makes them work out, styles their hair, does their makeup” and turns them into “swans,” according to the San Francisco Chronicle. There is a twist, of course. The women are not allowed to look in a mirror for three months, after which time they see themselves briefly before being shuttled off to a beauty contest where they face savage competition from other former ducklings. The show so pushes the limits of taste that it drove the cheeky but reliable television critic for Salon.com nearly apoplectic: “The Swan is bad for you. It’s bad for me,” she wrote, after watching the premier episode. “Openly reject those who discuss this show. Go ahead. Ostracize them. Limit their freedom of speech. Let the FCC roll its cannons onto this battlefield.”

Employing a more documentary style, MTV’s I Want a Famous Face tracks men and women (and even a pre-op transsexual) who are so enamored of modern celebrities that they endure major plastic surgery to look more like them. A recent episode chronicled the misadventures of Sha, a 19-year-old woman from Texas whose ambition in life is to become a Playboy centerfold. To further her aim, she receives enormous breast implants, lip implants, and chin liposuction in an effort to ape the appearance of former Playmate Pamela Anderson. The show shows only brief snippets of the actual surgery — zooming in on Sha’s anesthetized face as her surgeon crams the huge lip implants into place with a large, metal, chopstick-like tool. As he sews up her newly enhanced chest, the surgeon quips, “This ought to satisfy Playboy!” The camera then lingers over Sha one day later, mummified in bandages and weeping in agony.

Unlike Extreme Makeover, MTV gives a nod to surgeries gone bad; they interview another former aspiring Playmate who endured a similarly challenging transformation, but who, several years later and with enormous breast implants beginning to ripple and relocate on her chest, has had little luck finding work. This cautionary tale fails to dissuade Sha; even the recommendation of a Playboy scout, who gently tells her that the magazine is opting for a more “natural” look these days, fails to prompt second thoughts. By the end of that week’s episode, Sha, recovered from surgery, is proudly posing for a special issue of Playboy called “Voluptuous Vixens” and is by her own account very happy with her surgery. “I want to be somebody,” she says, tossing a marabou boa over her shoulder as she preens for the camera. “I want to be famous.” It is not difficult to imagine, a few decades hence, a “where are they now?” show that tracks down these carved up exhibitionists to see how they are holding up.

All of these shows are far more extreme expressions of older cultural tropes. In 1924, the New York Daily Mirror sponsored a “Homely Girl contest,” with an advertisement that read: “Who is the homeliest girl in New York? Daily Mirror wants to find her — for a great opportunity awaits her.” The paper promised the winner the full surgical services of Dr. W. A. Pratt and an opera audition; the winner was a sweatshop worker named Rosa Travers, according to historian Haiken. Less than twenty years later, Good Housekeeping featured the fairy-tale transformation of a “dowdy” and “rather untidy” girl with a big nose who, thanks to “a brief five days in the hospital” and the “skilled surgical hands” of an unnamed doctor, now had a nose of “pleasant proportions” which she accessorized with “a brand-new pompadour” and “a touching new-born vanity.”

Popular culture has produced a few critiques of plastic surgery, too. The Twilight Zone tackled the topic on a few episodes in the 1960s, and in 1996, John Carpenter produced a critically panned movie called Escape from L.A., which touched on the West Coast’s obsessive commitment to appearance and cosmetic surgery. In this futuristic action flick, the city of Los Angeles has become a depraved penal colony, with Beverly Hills a neighborhood inhabited by polysurgical addicts who capture newcomers and harvest their body parts, all under the watchful rule of the Surgeon General of Beverly Hills, whose hands are made of scalpels. The social message of the film is somewhat undermined by inadvertent moments of high camp, such as a scene where a doctor, examining the breasts of a recently-captured woman, exclaims in horror, “My God, they’re real!”

Popular culture currently rewards (with fifteen minutes of fame and free surgeries) a clatch of Americans who are clearly eager to have their worth judged by the fickle democratic masses. The viewing audience might observe this circus from an ironic distance, but it is clear that the impulse to measure success by outward appearance has more adherents than merely the contestants on reality television shows. Cosmetic surgery — better, cheaper, more widespread — encourages this kind of measurement. What it doesn’t offer is a solution to an intransigent fact: no matter how much surgery a person has, there will always be someone younger, more naturally beautiful and outwardly appealing. And democratic culture, which tends to cater to the well-being of the body more than the well-being of the soul, will continue to seek out and reward those younger, more beautiful people. The ultimate futility of cosmetic surgery is perhaps the least remarked upon of its features.

In the end, cosmetic surgery is in some sense self-defeating, since it cannot permanently stop the process of aging. And yet, many of us know formerly dewlapped matrons and love-handled forty-something rogues who are objectively much happier after their surgeries; indeed, some people experience more satisfaction from a “marriage abdominoplasty” (combination lipo and tummy tuck) than they do in their own marriages. In a free society, why should anyone stand in the way of another person’s transformation from tatterdemalion to goddess? Isn’t this simply the laudable and democratic pursuit of happiness?

If opponents of cosmetic surgery are too quick to dismiss those who claim great psychological benefits, boosters are far too willing to dismiss those who raise concerns. Cosmetic surgery might make individual people happier, but in the aggregate it makes life worse for everyone. By defining beauty up — fifty is literally the new forty if a critical mass of people are getting face-lifted and Botoxed — the pressure to conform to these elevated standards increases. So, too, does the amount of time and money we spend on what is ultimately a futile goal: cheating time. Even for men and women who have objectively achieved success — the award-winning novelist, the highflying CEO — the refusal to meet these beauty standards will brand you as uncompetitive, evidence to the contrary notwithstanding.

The risk is not a society of beautiful but homogeneous mannequins. “Most of my patients want to look more like themselves than they’ve looked in a long time,” Dr. Weston told me. “They don’t want to look like someone else.” The danger is a growing intolerance for what we would naturally look like without constant nipping, tucking, peeling, and liposuctioning. In the process, it contributes to that “philosophy of fatigue” and “disappointment with achievements” that Paul Nystrom, an early and astute critic of modern marketing techniques, argued led to society’s embrace of “more superficial things in which fashion reigns.”

In part, the discomfort some people have with cosmetic surgery is a discomfort about the particular form of denial it represents: a denial of bodily limits. The language of cosmetic surgery does everything to obscure this. Something “cosmetic” is not supposed to be a permanent alteration, as plastic surgery is. And humans are not “plastic,” but beings embodied in tissue, flesh, and bone that will, at a certain point, resist our efforts to remold it. But the freedom to do what we will with ourselves, which is the model for cosmetic surgery, presents a real challenge when we start thinking about permanent alterations to the human body. As a case study for how we might act in the genetic future, cosmetic surgery — which is individualistic, consumer-oriented, largely unregulated, and invokes the therapeutic language so popular today — is hardly a reassuring model.

In the 1990s, a French performance artist named Orlan embarked on a multi-stage cosmetic surgery art installment that involved having surgery performed that would give her the chin of the Venus de Milo, Mona Lisa’s forehead, and Psyche’s nose, among other things. Pictures of one of her “performances” show a partially anesthetized Orlan reclining on an operating room table, draped in a surreal, mirrored gown and speaking into a cordless microphone. Buzzing about are surgeons and nurses decked out in scrubs designed by Issey Miyake and Paco Rabanne. But Orlan has other enthusiasms. As the New York Times noted, she “grandly proclaims her work to be ‘a fight against nature and the idea of God’ and also a way to prepare the world for widespread genetic engineering.” Orlan offers us a disturbing peek into our future.

In the end, the questions raised by cosmetic surgery pose a special challenge for conservatives. Conservatives advocate free markets and individual autonomy (albeit linked to personal responsibility), but profess horror at the logical excesses of this view. We cringe when commercial culture throws up a Michael Jackson or an Extreme Makeover, but on what grounds do we argue for their end? Like our new reproductive technologies, cosmetic surgery collides with intimate, personal choices about the kind of lives we want to lead. And it becomes difficult to argue against the exercise of choice either legally or politically.

Perhaps this is the point at which culture becomes more important than policy, and the direct engagement with our cultural extremes a way of helping us find a more rational center. In the end, democratic culture seeks authenticity, but it doesn’t always find it in the old forms where conservatives tend to feel more comfortable. And so we need to ask less threatening but no less fundamental questions — questions about the excesses of individualism and the extremes of democracy, questions about what are and what are not genuine social goods, and questions about how we measure success and failure.

We are not yet a nation of Narcissi, content to stare happily into the pool, our surgically enhanced self-esteem intact but our character irrevocably compromised. But we would do well to be more engaged in the culture that is encouraging us to move in that direction. “There are no grades of vanity, there are only grades of ability in concealing it,” Mark Twain purportedly wrote. Concealing our desire for physical perfection behind a mask of democratic or therapeutic rhetoric will ultimately do us no good. We should, instead, bring cosmetic surgery out into the open, not merely to please our taste for voyeurism, but to understand how we might handle new and increasingly sophisticated techniques for empowering our vanity — techniques which stand to make that vanity much harder to conceal and to control.