Lidlift Kenneth D. Steinsapir, M.D.
Cosmetic, Facial & Eye Plastic Surgery

As a cosmetic surgeon devoted to aesthetic and aesthetic reconstructive surgery, I often find myself analyzing what motivates my patients to desire and ultimately have cosmetic surgery. In this “Makeover” world we now inhabit, it is easy to suggest that the reason men and women get cosmetic surgery is to increase self-esteem. This fits the American story line of hard work and self-improvement. However, accepting this explanation pushes aside important questions that commonly get overlooked – Why is it that the overwhelming majority of people having cosmetic surgery are women? Do surgeons really understand why people seek cosmetic surgery? How do surgical paradigms affect the outcome of a surgery? How do neuroeconomics play a role in influencing decisions to have cosmetic surgery? In the following article, I present some important psychological and cultural aspects related to why we seek cosmetic surgery.

FLESH WOUNDS

According to the American Society of Plastic Surgeons (ASPS), over 12 million cosmetic procedures were performed in the United States last year. This represents an increase of 40% over the number of procedures done in 2000, despite the economic recession. One of the reasons why cosmetic surgery has become so popular is in part because it provides an accessible if not always affordable mean to reinvent one’s self. To use the term coined by author Virginia Blum (Flesh Wounds: The Culture of Cosmetic Surgery), we are all “surgical”-potential consumers of cosmetic surgery. Blum suggests that all features become categorized into those that need and don’t need surgical work.

One important fact to note from the ASPS statistics is that 91% of the total cosmetic surgeries in 2008 were performed on women. It is interesting to know that there exists a reverse gender imbalance in the world of cosmetic surgery, where men make up for 91% of the cosmetic surgeons and women make up 91% of patients undergoing cosmetic surgery.

GIRL POWER

The feminist drive for equality and empowerment has somehow gotten translated into “girl power” where equality is transformed into sexual aggressiveness in the media. It is difficult to argue that shaving one’s genitals, having breast implants, and pole dancing represents equality and empowerment. Yet for girls and young women this is the message from mainstream media. Female agency is co-opted by commercial representations where sex is used to power consumer demand. Consider the 145 million Bratz dolls that have been sold to preteen girls. These skanky dolls are marketed to six year olds and the junior version, Bratz babyz, to 3 year olds. They make Barbie with her anorectic proportions look down right wholesome. This isn’t just a method of imposing heternormativity on our children. No, this “sexualized too soon” message, what Sociologist Brian McNair describes as the “pornographication” of everyday life sells.

Kids in the United States are exposed to 8 hours of media each day. It is no wonder that girls as young as 6 ask their parents if they are too fat and complain that they are not sexy enough. This demonstrates how this phenomena compresses into childhood. Teachers report an increasing intensity of gender separation between young boys and girls with girls focused on princess culture and femininity and boy on fighting and violence.

Rosalind Gill, a lecturer in gender and media studies at the London School of Economics, has analyzed the way a woman’s sexuality is manipulated in contemporary advertising. Advertisements today represent the empowerment of women by showcasing assertive women who make a statement with their sexual power. Gill argues that we are witnessing a shift from sexual objectification to sexual subjectification, where women today are being presented as knowing and active sexual subjects. To deal with the fierce feminist attitude observed in young women who oppose being portrayed as sexual objects, the advertising world has stealthily constructed a new femininity, which is built around sexual confidence and autonomy. This new construct “girl power” lures those same young women to accept themselves as sexual subjects. The contemporary sexualized representations of women in media and popular culture, unlike in the past, does not depict women as passive objects but as desiring and glorified sexual subjects, so that that activities such as cleaning a toilet with a disposable brush, buying yogurt, and wearing stiletto heels are portrayed by media as self-actualizing personal choices. So instead of the lean, well dressed, apron clad homemaker greeting her suburban husband at the door with a home cooked dinner on the table, advertisements are now assembling the young, narcissistic, sexually assertive, “always up for it”, lean, tattooed, pierced woman who plays with her sexual power. Gill suggests that these images represent a shift from the objectification of women by the male gaze to the subjectification of women.

UNTOUCHABLE

Sandra Bartky, Professor of Philosophy and Gender Studies at the University of Illinois at Chicago has said “Feminine bodily discipline has this dual character: on the one hand, no one is marched off for electrolysis at the end of a rifle, nor can we fail to appreciate the initiative and ingenuity displayed by countless women in an attempt to master the rituals of beauty.” However, the standards for feminine appearance are becoming increasingly unattainable. For example the singers Christina Aguilera and Britney Spears during their pregnancies were featured on the covers of Marie Claire and Harper’s Bazaar respectively -literally and figuratively as new Madonnas. No woman could hope to emulate the perfection Photoshopped into these magazine covers.

Please watch the movie at: http://www.youtube.com/watch?v=hibyAJOSW8U

In return for access to celebrities, fashion magazines now routinely turn over complete control of the photography to the celebrity who employs design staff for the purpose of adjusting the images to their liking in the photographic manipulation program Photoshop as illustrated in this Dove Self-Esteem Campaign movie. Not only are the celebrities and models attractive in their own right, their photographs are retouched and their features enhanced. Yet their published images define sociocultural standards for appearance that many women feel they need to attain. This is also occurring with male models and celebrities but the social pressure is less intense for men.

This is what Naomi Wolf described as the “beauty system.” Second wave feminists have referred to women who attempt to discipline themselves to comply with the social norms of femininity portrayed in the media as “cultural dopes.” While it seems innocuous when a mother takes her daughter to have an ethnic nose refined by rhinoplasty at age 16, it is much more troubling when a mother takes her daughter of the same age to the plastic surgeon for breast augmentation or female genital cosmetic surgery. The American Society for Plastic Surgery reported that 18 and 19 year olds made up 3 % of all breast augmentation surgeries last year. Cosmetic surgery on children under 18 years of age constituted 5% of all cosmetic procedures in 2008.

EXTREME MAKEOVER

Wheeler Dixion writing last year in the Quarterly Review of Film and Video argues that the perfect body and face “is becoming the ultimate status acquisition of the 21st century.” One might ask if shows like I Want a Famous Face, The Swan, and Extreme Makerover have increased consumer demand for cosmetic surgery. Anecdotally, surgeons feel that they have. However, objective studies are harder to come by. Robin Nabi reported her study this year in the journal, Human Communication Research, that these shows, with the exception of I Want a Famous Face, are associated with a small increased interest in cosmetic surgery. I Want a Famous Face highlighted the risks associated with cosmetic surgery and viewing this show was associated in this study with an increased perceived risk of having surgery. Meredith Jones observes that these shows pull back the curtain on the “during” that is normally removed from before and after pictures.

Feminists have increasingly accepted that cosmetic surgery is not going away. Quoting Kathy Davis, a medical sociologist, who studies cosmetic surgery: “It opens the possibilities for biographical reconstruction and opportunities for women to redefine their sense of self.” Susan Paulson and Carla Willig writing last year in the Journal of Health Psychology found that the concerns of women ages 58 to 80 regarding their appearance are related to loss of social relevance and fears of disappearing. In contrast men of a similar age are more concerned with how they function. These women operate with a frame of mind that the aging body represents a mask over the inner younger identity. Some older women reject cosmetic surgery as too radical or dangerous. Screenwriter Nora Ephron in her collection of essays “I feel bad about my neck,” summarizes her concern about being overdone by plastic surgery writing: “ I learned the hard way that just because a doctor was a famous surgeon didn’t mean he had any gift for sewing people up.”

THE NEW NEW FACE

As boomers age, marketers have found glamorous aging celebrities to take up the cause of maintaining appearance. Actresses such as Diane Keton and Susan Sarandon were chosen for the L’Oreal Age Perfect campaign because it could be plausibly implied that they have maintained their appearance without cosmetic surgery. Whether they have or have not had surgery is irrelevant. Who needs surgery when a little Photoshop magic can make you look thirty year younger as can be seen when comparing magazine cover images of Sarandon with images taken at the same time without the benefit of Photoshop.

Meredith Jones in her article “Mutton cut up as lamb” notes that the emphasis on youth culture means a decline in the value of the elderly. In this formula, youth equates to beauty and aging to ugliness. She describes cosmetic surgery as an increasingly essential “toolkit” to maintain a stretched middle age or “agelessness.” This is what I call designer aging, a process eloquently described by Jonathan Van Meter in his August 2008 New York Magazine article where he define the “New New Face.”

Jones contends that women have only two choices: actual youthful beauty or youthful verisimilitude. Trying to appear youthful is almost as important as being youthful perhaps justifying surgical and non-surgical treatment effects that generously are idiosyncratic in their results or less generously hideously unnatural. Jocelyn Wildenstein, the socialite, or Orlan, the body artist, come to mind. Jocelyn is reported to have spent 4 million dollars on cosmetic surgery. Her late husband Alex was quoted as saying: “She seems to think that you fix a face the same way you fix a house.”

Please watch the movie at: http://www.youtube.com/watch?v=ri61lBfMBu0&feature=related

Some of our most notable celebrities appear engaged in this exercise. This perhaps helps us understand why individuals with surgically disfigured looks defend and appear to love their faces. I would suggest that for some individuals, the extreme alteration in appearance actually meets a narcissistic need for attention. We look at these individual with disgust, but instead of experiencing shame and humiliation, they experience attention and interest, which serves to confirm that they are objects of adoration. In the case of Michael Jackson, it now appears that his addiction to cosmetic surgery was also reinforced by the exposure to drugs administered for his anesthesia, contributing to his premature death.

COSMETIC SURGERY JUNKIES

This raises one final issue I would like to discuss with you. In considering my more demanding poly-surgery patients, I would like to suggest that there is a difference between body dysmorphic disorder and what Pitts-Taylor has described as “the surgery junkie.” The line between normal enthusiasm for the benefits of cosmetic surgery and cosmetic surgery addiction is not well defined. Body dysmorphic disorder is defined in the revised DSM IV as excessive preoccupation with a specific body part that causes significant impairment in functioning.

The cosmetic surgery addicts do not restrict themselves to a particular body part. Instead, they have a global appetite for cosmetic surgery. Like the painters of the Golden Gate Bridge who begin repainting the bridge immediately upon completing the last job, cosmetic surgery addicts are never satisfied and are only constrained financially in their quest for ever more enhancement. These individuals have surgery with many doctors and may not be forthright in disclosing recent procedures. I believe that this type of individual is more a victim of the neuroeconomics of appearance rather than some deep-seated psychological problem. Unattainable standards of beauty, the fear of loss of status, and the ready availability of cosmetic surgery all contribute to the problem. As such, cosmetic surgery addiction has more in common with drug addiction and pathological gambling than with body dysmorphic disorder. Unfortunately we are all familiar with the horrible disfigurement that seems to be the final common pathway for these individuals.

When does cosmetic surgery become too much? This is a question that we currently wrestle with as individual surgeons. However, I suggest that this is a public health issue. I ask you to consider that we may already be experiencing an epidemic of adverse cosmetic surgery outcomes. If surgeons can’t address this growing problem, we can look forward to solutions by angry legislators prompted by what will be the inevitable consumer backlash.

CONCLUSION

Socio-cultural pressures have elevated the standards of appearance predominantly for women. The difference between these standards and what people see daily in the mirror creates various levels of chronic shame. More than narcissism it is low self-esteem that drives the demand for cosmetic surgery. Cosmetic surgery is used as a survival kit to mitigate these negative emotions and personal insecurities. In the future, I hope to share my insights on shame mechanisms, attachment and terror management theory, mortality salience and the role of neuroeconomics in the cosmetic surgery, which ascertain the cultural concerns discussed in this article.

This article was given as a lecture before the 40th Anniversary Fall Scientific Symposium for the American Society for Ophthalmic Plastic and Reconstructive Surgery in San Francisco, California on October 21, 2009.