The Dark Side of Plastic Surgery
Opinion
By Ann Louise Bardach
MELAINE YOUNG WAS BLOND, PRETTY AND POPULAR; HER FATHER WAS RICH, powerful and the head of a Hollywood studio. On weekends she went to parties with her parents and met the movie stars of the day. ''But whatever I had, it wasn't enough,'' says Elaine, now 53 and a partner in a successful Beverly Hills real estate firm. ''The women are so beautiful here. There's so much of everything that you get insecure no matter how good a personality you have or how many men like you. You think, 'I gotta look better.' There's so much competition.'' By the time she was in her early 20's, Elaine was a superstar realtor, finding homes for Elvis, Johnny Carson, Paul Newman, Elizabeth Taylor and scores of other celebrities, including Gig Young, to whom she was married for five years.
Her successes, however, never assuaged her feelings of emptiness and of ''not being good enough.'' In the spring of 1977, an old acquaintance walked into her office. ''She looked gorgeous, with stunning high cheekbones. She told me she had had silicone injections in her face,'' says Elaine. ''The next day, I was in her doctor's office.''
MORE THAN ONE million Americans have some kind of cosmetic surgery each year. Among the seemingly ever-inventive procedures are eyebrow lifts, nose jobs, eyelid tucks, breast implants, tummy tucks, liposuction and controversial and troubling silicone injections. Once the exclusive domain of celebrities and the very rich, such surgery and body sculpting have become commonplace for everyone from the C.E.O. to the rank-and-file union member, male as well as female.
Cosmetic surgery is clearly a flourishing business. In a recent issue of Los Angeles Magazine, more than 25 advertisements peddled the miracles of such surgery as unabashedly as if it were aluminum siding, with fees ranging from $50 to $5,000. Many surgeons have incomes in the high six figures, and lavish tens of thousands of dollars on interior decorators to replicate European settings.
Some see the boom in cosmetic surgery as a result of new, more sophisticated procedures, safer anesthetics and the desire for self-improvement. Others credit - or blame - a narcissistic culture with its craving for instant gratification, youth and perfection, and its fear of aging and death. The darkest observers see the trend as the profit quotient of human self-loathing.
FOR THE NEXT YEAR AND A HALF, DR. Jack Startz injected silicone into Elaine Young's cheeks at least once a month for the purpose of creating the look of strong, high cheekbones. Immediately following the injections, her face would swell, but ''the silicone would go down the next day and it looked good.'' Real good, Elaine thought. She sent her friends and many of her celebrity clients to Dr. Startz.
About three years later, Elaine noticed that the shape of her face was changing. The silicone seemed to be moving and growing. Initially, it was ''just around the cheekbones; then it started moving around and growing out of both sides of my face. I became ugly and grotesque. I called Startz and told him I was having problems.''
Suddenly, Dr. Startz stopped returning her calls.
In any general discussion of cosmetic surgery, it is important to point out that the vast majority of patients have a satisfactory experience. Face lifts, in which surgeons make a cut in the scalp, say, and pull and tighten facial skin, or facial injections of the natural fibrous tissue collagen, are relatively risk free.
Dr. Frank Kamer, a Beverly Hills surgeon whose celebrity clients have included Cher and Joan Rivers, says that ''good plastic surgery is quick psychotherapy,'' and there are thousands of satisfied patients who would promptly agree with him. ''Nothing makes me feel better about being a doctor than working on someone who is a good psychological and physical candidate,'' he says.
Dr. Kamer was interviewed during a break for lunch after he had spent the morning ''doing a rhinoplasty on an air controller, followed by a face lift on a movie star.'' His two-story building has a separate V.I.P. entrance and lobby, sparing celebrities even a casual brush with the common folk. He said he turns away about 40 percent of the people who come to see him, either because they have unrealistic fantasies or because they are overweight and thus for a variety of reasons may be at risk for such surgery.
Responsible cosmetic surgeons operate only on psychologically stable and medically sound candidates -people, for example, who don't have heart disease or diabetes, who are not obese, who are not heavy smokers with poor blood supply to the skin. Dr. Kamer and other proponents warn, too, that there is also the general risk of complications. ''People can die from any surgery,'' he says. ''Death is the ultimate complication.''
THROUGHOUT 1981, ELAINE Young saw a series of doctors who shrugged helplessly when they saw her face, unfamiliar with any procedures to remove silicone. She contacted an attorney to file a complaint against Dr. Startz. ''My lawyer was really excited,'' recalls Elaine. ''Then he told me there were 105 lawsuits ahead of mine.'' Helene Ballas, who worked for Dr. Startz as a technician and office manager from 1965 to 1979, says that Elaine's silicone injections were about average in quantity and number for one of Dr. Startz's patients; she estimates the number of people he injected with silicone to be around 2,000.
Eventually, Elaine was referred to Dr. Lawrence Seifert, then chairman of the plastic surgery division at Cedars-Sinai Hospital in Los Angeles. Dr. Seifert had his doubts about the success of any treatment. He said his previous experience was limited to correcting severe complications resulting from silicone injections in the breasts; these complications - rock hardness, gangrene and ulceration - usually require mastectomies.
After consulting Dr. Fred Grazer in Newport Beach, Calif.; Dr. Ernest Kaplan at Stanford, and Dr. Harvey Zarem at U.C.L.A., Dr. Seifert attempted to suction the silicone out of Elaine's face. But the silicone had become so hard that he could not remove it. He injected steroids into her face in an attempt to reduce the inflammation that was progressively distorting her features. Although it was not a cure, Elaine was pleased with the result.
Though problems with facial procedures may be more apparent, breast operations are at the top of the risk and trouble list of most plastic surgeons.
Surgeons and patients are having some success with improved breast implants placed under the muscles of the chest walls, rather than between the skin and the muscle, but many problems remain. The principal complication of breast implants is fibrous capsule contracture - the hardening of the breast when the scar tissue that inevitably forms around the implant contracts.
One successful New York fashion designer, who asked for anonymity, says she would not have been unhappy if her left breast had ''the consistency of the proverbial tennis ball, but it was concrete hard.'' Generally, a second procedure, a closed capsulotomy, in which a doctor manually breaks up scar tissue around the implant, resolves the problem. But for the fashion designer, another major surgery was needed to replace the first implant.
Some women complain that they were never told about the possibility of capsule contracture, although the designer says her surgeon did warn her. ''But I really wanted this operation, so I wasn't really listening.''
In most cases, breast augmentation is reversible simply by removing the implants. However, for women who believe that larger breasts are the sine qua non for better living, this is often unthinkable.
Dr. Sherrell Aston and other plastic surgeons say they are careful to warn patients about the risks and advise some that they are not good candidates, but that many patients, like the designer, will not heed the warnings. Dr. Howard Bellin recalls one patient on whom he had attempted two capsulotomies. He said he ultimately decided she was simply not a good candidate for breast augmentation and was willing to admit failure. ''She was sitting on the table, naked from the waist up. I was at wit's end and told her I thought we should remove the implants,'' he says. ''She went 'Aaah!' grasped both breasts with the palms of her hands, looked at me with astonishment, put her clothes on, and I never saw her again. If I had tried to take those out, she would have attacked me.''
Nevertheless, Paul Tilton, of the Food and Drug Administration's Center for Devices and Radiological Health, says it is his belief that many women across the country are clearly not being adequately prepared for the dangers and complications.
''Mammary implants are prone to failure,'' Tilton says. ''They do not last a lifetime. Plastic surgeons do not impress upon their patients that they may be subjected to repeat surgery, but in fact that is the case.'' And one of the problems, says Tilton, is that ''the manufacturer considers the user of a breast implant to be the doctor, not the patient.'' Tilton adds that another possible complication is ''bleeding'' into the breast area and other parts of the body. There have been no systematic follow-up studies on women with implants since they were first used in 1964, Tilton says, but early animal studies have shown that silicone particles can bleed through the implant membrane and become lodged in many organs of the body.
Last January, a law took effect in Maryland - it is the first law of its kind - requiring that, at least five days before undergoing breast-implant surgery, patients be given a brochure that lists the potential risks and complications.
In 1976, Congress passed a law that gave the F.D.A. the power to regulate all medical devices, but the agency has still not fully exercised that right with regard to breast implants. The F.D.A. has never approved them, but neither has it prohibited their use.
The agency does require, however, that a second breast-implant operation, if it is due to failure of a medical device, be reported. According to Brian Kunst, who monitors general and plastic surgery devices for the F.D.A.'s Division of Product Surveillance, the failure rate on breast implants is one of the highest in his division.
Within the near future, according to Tilton, the F.D.A. will designate all mammary implants as Class 3 surgical devices, which means insufficient evidence now exists reasonably to assure their safety and effectiveness and that, before their use will be allowed, manufacturers will have to prove them effective and safe.
Breast lift and reduction procedures can also be especially troublesome. David Taback, a New York attorney, tells of a young client whose operation was a failure: ''Her breasts were uneven - different sizes, different shapes, one was square-shaped -and she had half-inch-thick, red, unsightly scarring so substantial that it deformed the whole contour of her breasts.'' She sued her surgeon for malpractice and for not adequately explaining the risks of the operation to her.
However, Taback makes it clear that pursuing courtroom justice in a cosmetic surgery case is expensive and grueling. ''Juries are not generally receptive to people who are not satisfied with what God gave them,'' he says. Inasmuch as the young woman's doctor was - and still is - regarded as a superstar in his field, no Manhattan surgeon was willing to testify in her behalf. ''They will not testify against their buddies,'' says Taback, who said he eventually found a doctor in Brooklyn who had had no dealings with the plaintiff and was willing to testify.
Just prior to summation, the case was settled out of court when the plastic surgeon's insurance carrier agreed to pay the young woman $50,000.
OVER THE NEXT FOUR years, Dr. Seifert was able to stem the ravages of the silicone for Elaine Young. He gave her three or four steroid injections as a ''temporizing procedure.'' Nevertheless, her face again began to become hideously distorted. She was terrified by the rapid change. ''I couldn't sleep on either side of my face. The pain was excruciating. The silicone was growing up into my eye.''
At about the same time, she learned that Dr. Startz had committed suicide, his practice and reputation in shambles.
It is not uncommon to hear people talk about pressure from friends to have some kind of surgery that will make them look more attractive or about their own desires to look younger.
Joie Davidow, 41, publisher of L. A. Style magazine, says that her friends, professional women in their 30's and 40's, are ''panicked about aging'' and that most of them have had liposuction. ''It's a very social thing. They call me and say, 'What are you doing Thanksgiving weekend? I'm having a little work done on my thighs. Why don't you come with me and have your stomach done?' '' She says she feels both the peer pressure and her own concern about looking older than everybody her age.
Patricia Resnick, a screenwriter in her 30's, says, ''I have been friends with the same crowd for roughly 10 years. They were always eight years older than I, but now suddenly they look eight years younger.'' The comedy writer Larry Gelbart puts it differently. ''They don't look younger,'' he says, ''they look surprised.''
One 39-year-old advertising woman says she felt intimidated at having to pitch her ideas to ''20-year-old executives'' and at competing with yuppies. Consequently, she had her nose done, the bags under her eyes removed and her jaw reshaped. And she is very satisfied. She even found a surgeon who promised he could lengthen her 5-foot, 2-inch, frame by inserting six-inch steel rods in her knees. She backed out when he told her she would have to spend a year in a wheelchair recuperating.
A successful business manager in her mid-50's sings the praises of cosmetic surgery. Judging from photos, she has always been attractive. Still, as she got older she wanted to enhance and maintain what she had. In the last five years, she's had a nose job, a chemical peel, a face lift, an eye job and collagen injections every six months to smoothe her wrinkles, and she is moving toward breast surgery.
''My mother is 80 and she looks it,'' she says. ''When I'm 80, I'm not going to look it.''
But peer pressure and fear of aging are not the only motivations. Dr. John Sherman, a Manhattan plastic surgeon, tells of the patient who says, ''My life is not exciting,'' or says, ''My marriage is falling apart''; or the teen-ager who is not unhappy with the shape of her nose when she is away from her parents but seeks surgery anyway because her mother said it doesn't look good; or the young woman whose boyfriend brings her in for breast implants.
Patients wanting the impossible and patients who become helplessly addicted to cosmetic improvements are other concerns. Dr. Sherman remembers one 29-year-old woman who wanted a face lift. ''She pushed her cheeks up with her fingers and asked, 'Can you make me look like this?' I said, 'Sure, if you let me sew your fingers to your face.' ''
And Dr. Ronald Strahan, a Los Angeles surgeon, says a new breed of patient is showing up in surgeons' offices across the country - the cosmetic-surgery junkie. He recalls an attractive, slim woman in her early 30's and with a successful career, who initially saw him for a nose job. By the time he saw her again, a year later, she had had her eyes done, her chin enlarged and a breast augmentation. Dr. Strahan agreed to give her a forehead lift and a partial face lift. But when she expressed interest in liposuction, he refused to do the operation. ''I told her that she had a problem with perception and should see someone in psychology.'' But instead she went on, he learned, to have numerous liposuctions and other procedures performed by other doctors.
LIPOSUCTION, IN WHICH fat is vacuumed out of the body, has now become the most popular cosmetic procedure in America. In 1986, nearly 100,000 liposuctions were performed.
Now ''everyone wants to get into the act, and lots of doctors with absolutely no qualifications are doing it,'' says Dr. Sherman.
There are risks: disability from fat clots, blood clots or severe depletion of body fluids and pain, numbness and bruising that can linger for as long as six months. And there have been 11 deaths since the procedure was introduced from France six years ago. The mortality rate is low, .01 percent, but critics say that even 1 death out of 10,000 is too many for what amounts to a strictly cosmetic, nonmedical procedure.
Liposuction has helped renew interest in transferring fat from one part of the body to another, from fat thighs to small breasts or to the face, for example. But last September the American Society of Plastic and Reconstructive Surgeons deplored the use of this procedure for breast augmentation since fat moved to the breast can dissolve, leaving in its wake calcium deposits that resemble cancers, impeding cancer detection and resulting in unnecessary biopsies.
LIQUID SILICONE LIKE that injected into the face of Elaine Young has been given to thousands of people during the past three decades or so, though, like breast implants, its use in plastic surgery has never been approved by the F.D.A.
Among the leading proponents of liquid silicone is Dr. Norman Orentreich, a New York dermatologist who says he has been injecting it with great success and safety for 35 years. Dr. Orentreich believes that silicone casualties are caused by ''improper technique'' (large single injections) and ''impure silicone'' - a reference to the so-called sakurai formula, which contains 1 percent oil. Dr. Orentreich says he uses ''medical-grade, purified, sterilized silicone,'' which he says he obtains from four sources or manufactures himself. He has also used a ''microvolume, multiple-injection technique'' with syringes of his own design that deposit no more than ''a 50th of a milliliter'' as opposed to ''the 3, 4, 5 milliliters'' of the single-injection method.
Other doctors believe the potential dangers of liquid silicone far outweigh its possible value.
Dr. Kurt Wagner, a Los Angeles surgeon, says he has seen at least a dozen patients with their faces now disfigured. He describes one who, prior to her silicone injections, was ''as beautiful as Cyd Charisse,'' and he has now operated on her 17 times, trying to remove the silicone. He expects to do still more surgery as the remaining silicone migrates. Wagner says he also performed a mastectomy on each of her silicone-injected breasts. The doctor who did her initial facial-silicone work - not Dr. Startz -also committed suicide, Dr. Wagner says. Coincidentally, Dr. Wagner knew Dr. Startz and adds, ''He did the right thing when he killed himself. He was a scoundrel.'' Dr. Sherman says he sees two or three patients a year who have been disfigured by silicone injections. Last November, he says, he examined a woman who had been injected with medical-grade silicone in microvolume levels over a period of five years by a New York doctor. ''She had gross deformity of both cheeks, which were rock hard, and ulceration with draining on one side of her face.''
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UNBELIEVABLY, HE says, the doctor who first injected her proposed additional silicone injections as a remedy. Dr. Sherman advocates banning liquid silicone injections.
Dr. Ernest Kaplan, a plastic surgeon associated with Stanford Medical School and co-author of a paper on injectable silicone, says he still sees one or two people a year with serious inflammation from silicone injections. A good result is possible but ''the risk factors I have seen are so significant that I have to discourage its use.''
Some observers continue to be less troubled by the actual risks of cosmetic surgery than by the social and cultural issues. There is concern that it has become one of the many ways in which rich ethnic diversity is broken down. Will the surgeon's scalpel help create one homogenized standard of beauty? Should one be troubled that so many Asian women have opted to have their eyes ''Westernized,'' that many Iranian-American women in the Los Angeles area have traded their strong unarched noses for small pert ones, that stunning teen-age models have had their breasts enlarged to keep up with the current fashion?
According to Dr. Bellin, the singer Michael Jackson has had 10 surgical procedures. Dr. Bellin bases his analysis on photographs of the superstar, listing three rhinoplasties (nose jobs); a chemical face peel or other skin-lightening procedure; cheekbone implants; two operations on his chin, including one to create a cleft; possibly, fat suction from his cheeks; a procedure to make his upper lip thinner, and a blepharoplasty (the removal of skin from his lower eyelids). A spokesman for Jackson says he has had only two surgical procedures.
Cosmetic surgery clearly necessitates a special artistry, since the surgeon must have something of the sculptor's skill. But is there something disturbing about the sense of esthetics at work here? Or, perhaps, the lack of esthetics?
IN JUNE 1987, WITH HER face hardening into an ever-growing painful mass of disfigurement, Elaine Young implored a reluctant Dr. Seifert to operate to try to remove the silicone. He was wary and warned her of three nonexclusive possibilities: a long slash of a scar across her cheeks; large depressions in her cheeks from the sagging skin after the silicone was removed, and paralysis of her facial muscles and part of her mouth because the silicone could migrate toward it.
It was a grueling five-hour procedure, during which Dr. Seifert slowly chipped away at the mass of hardened silicone on the right side of her face. Transplants of fascia from her skull to her face were necessary to support the skin. He repeated the operation on the left side to extract what he believes to be most of the silicone injected into Elaine Young's face.
Miraculously, she seems to have been spared any major disfigurement for the time being, except for a slight paralysis of the left side of her mouth, which she says is improving. She has also had two operations on her eye to strengthen the silicone-weakened eyelid muscles.
''I can't believe I did it,'' Elaine says softly. ''All because someone told me they could make me beautiful.'' COSMETIC SPECIALTIES
IN THE UNITED STATES, A LICENSED PHYSICIAN is allowed to perform any medical procedure, including cosmetic surgery. Physicians who have undergone an accepted training program in a medical specialty are known as ''board certified'' in that specialty. The American Board of Plastic Surgery, for example, certifies that a doctor is ''boarded'' to perform all types of plastic surgery. Otolaryngologists (ear-nose-throat doctors) and some other specialists are certified to operate only above the collarbone, and their training now includes cosmetic procedures.
Both the American Board of Plastic Surgery and the American Board of Otolaryngology are recognized by the American Board of Medical Specialties. But any group can call itself a ''board.'' According to Dr. Donald Langsley, the executive vice president of the American Board of Medical Specialties, there are about 70 self-designated boards, such as the American Board of Cosmetic Surgery, that are not recognized by the American Board of Medical Specialties. Patients can call 312-491-9091 to find out whether a particular physician is board certified in a specialty.
Going through the lists of the two largest plastic surgery societies represented in the American Medical Association - the American Society of Plastic and Reconstructive Surgeons and the American Academy of Facial Plastic and Reconstructive Surgery - can also give a degree of protection to a patient. The 3,000 members of the A.S.P.R.S. are all board certified to perform plastic surgery from head to toe, and patients can call 800-635-0635 to determine who is a member.
There is considerable divisiveness within the medical community about who should perform which cosmetic procedures. Dr. Frank Kamer, president-elect of the A.A.F.P.R.S., believes that ''doctors should only do the work they are boarded in,'' and strongly disapproves of facial surgeons working below the collarbone. The A.A.F.P.R.S. information number is 800-332-3223.
But these Scar Wars, as they are called, have yet to produce much in the way of the watchdog committees and Government regulation many believe are needed. And even a surgeon who has impeccable credentials, including multiple board certifications, can botch an operation. EQUAL OPPORTUNITY
NOT SO LONG AGO, MOST MEN, IF THEY THOUGHT about enhancing their appearance at all, might have been content to comb a little color through their hair. But increasingly, society is accepting cosmetic surgery as appropriate for anyone who wants it, and men are going in for longer-lasting, more obvious improvements in their looks.
According to the American Society of Plastic and Reconstructive Surgeons, 12 percent of all cosmetic surgery procedures are now performed on men. Another group, the American Academy of Facial Plastic and Reconstructive Surgery, says that men account for slightly more than 33 percent of all new facial cosmetic surgery patients. Men want many of the procedures their wives and mothers have been comfortable with for years. Most commonly, men have their noses reshaped; surgery to tighten sagging flesh around the eyes is next in popularity.
Dr. John Sherman, a Manhattan plastic surgeon, says that in the last three years his practice has changed, and now 25 percent of his patients are men. They seek ''liposuction under the chin and on the flanks, or what you'd refer to as love handles, and on the abdomen, too.'' He says husbands and wives commonly come to his office together to consult with him. ''Nowadays,'' says Dr. Sherman, ''there's almost an indistinguishable difference between the goals and the psychological effects of surgery on men and women.''
''I'm seeing a thousand percent more men now than I did 10 years ago,'' says Dr. Toby Mayer, of Beverly Hills, Calif., who chalks it up to the critical importance of looking good in today's society, speculating that ''the general public began to ask, 'What can I spend money on that is nonspiritual that will give me that kind of satisfaction?' '' Dr. Mayer points to his own eyes. ''I've had surgery done on myself,'' he says, showing off the work of his partner, Dr. Richard Fleming.
Dr. Sharon Romm, a Washington, D.C., plastic surgeon, medical historian and writer, says that older men are now going through what older women used to experience: they are concerned about their looks and trying to appear younger than they really are. Oddly enough, she sees a trend away from hair transplants for men. Baldness is now considered sexy, she says. ''Baldness is related to the male hormone testosterone, and there's at least a folk belief that bald men have more of it.'' PROCEDURES, COSTS AND RISKS Hair replacement surgery
Large sections of hair and scalp are moved from the lower back part of the head to bald areas. Possible complications: those normally associated with surgery and anesthesia, such as bleeding and infection; headaches for 2-3 days. (Clumps of single hair follicles can also be transplanted. This simpler procedure costs from $250 to $4,000.) Face lifts
The procedure generally lasts between 2 and 10 years, but aging starts to show again after 2. Risks include bleeding that can lead to hematomas; difficulty closing eyes; nerve damage resulting in a crooked smile. Nose jobs
Recovery time, 1 week, during which some breathing difficulty occurs. Procedure is relatively risk-free. Eyelid tucks
Complications: difficulty closing eyes; in rare cases, dry eyes. Breast augmentation
Procedure takes about 2 hours; recovery time, 1 week. Risks: implant contracts and hardens, requiring second surgery; implantsmay obscure breast tissue on mammogram, making cancer detection difficult. Breast reduction
Procedure takes about 3 hours; recovery time, 2 weeks. Hazards include irregular breasts and diminished nipple sensation. Breasts can enlarge again from such influences as weight gain or birth control pills. Tummy tucks
Can result in misplaced belly button. Liposuction (thighs, abdomen, buttocks)
Complications: the risks associated with all surgery and general anesthesia, such as infection or heart stoppage; permanent bruises or swelling; nerve damage; skin discoloration; uneven contours.
Ann Louise Bardach is a journalist and screenwriter based in Los Angeles.
