Before & After


Attempts at social engineering may have been minor and sporadic, but the potential for individual self-improvement was enormous. Spurred by Alfred Adler’s formulation of the inferiority complex, a less sexually determined and more user-friendly theory than Freud”s, Americans set out not only to look inside themselves for feelings of inadequacy, as an ad for Adler’s Understanding Human Nature promised the book would enable them to do, but also to correct the causes of these feelings. Plastic surgeons rushed to record changes in character resulting from the upgrading of features, and the question of who would draw the line between mere imperfection and true deformity became moot. It no longer mattered if the nose looked straight to the physician, or the body weight appropriate. If the patient thought the nose was malformed or the body obese, surgery was the only hope for a good prognosis. The shift in responsibility, however, could spell trouble down the road. Knowledgeable surgeons lived in dread, and naive ones learned the peril of operating on individuals who suffered from delusional disorders, for whom the surgery was never a success, and litigation was a likely aftereffect.

The surprise, however, is not that the fix frequently did not work but that it sometimes did. In 1961 a study of 53 male salespeople and sales managers in their fifties and sixties found that their incomes had increased by an average of $1,300 during the year following their face-lifts. Whether the gain was the result of the operation or the economy is not clear. Another survey found that all but two women who underwent Ivalon sponge implants in their breasts were “extremely pleased,” and many swore that the implants had “changed [their] entire life.” Moreover, the results held up over time, or at least until the implants began to cause physical problems.

Now Jewish girls opted for the tiny turned-up nose the Irish had once suffered to have made larger.

As the century progressed and individuals’ quests for self-realization triumphed over society’s strictures against vanity and self-indulgence, procedures proliferated. Tummy tucks, liposuction, hair transplants, foreskin reconstitution, collagen and Botox injections, pectoral implants, and buttock lifts, to name only a few, joined the old standbys like rhinoplasty, face-lifts, and breast surgery. The market for these uninsured procedures was surprisingly egalitarian. By 1994, 65 percent of the patients undergoing them had annual incomes of less than $50,000.


The rate of breakthroughs continues to accelerate. Researching this article, I left a plastic surgeon’s office with a stack of brochures devoted to a variety of procedures, including endoscopic plastic surgery, which promises smaller scars and a “minimizing” of after-effects, and grafts that take tissue from human cadavers and implant it “at affordable prices” on scarred patients. Marketing methods have kept pace with medical advances. Hardly a week goes by when I do not get an e-mail hawking penile enlargement. (Strangely enough, I receive no electronic importunings for breast augmentation, though it is easy enough to find online.)

The gender issue in plastic surgery is confused and constantly changing. Since 1997 the number of procedures on males has tripled, though they still account for only 15 percent of operations. While men were once suspect as patients—in the 1920s a team of Johns Hopkins specialists warned of “insatiable” male cosmetic surgery patients—many surgeons now prefer operating on men, whose expectations, they say, are more realistic and satisfaction more likely. In the 1970s feminists viewed plastic surgery as one more weapon in patriarchal society’s war against women, but by 1988 Ms. magazine was hailing Cher for reinventing herself surgically. And while the battle over the safety of breast implants is medically grounded, it is also politically charged. During the 2003 hearings on whether to return silicone implants to the market, conservatives accused the National Organization of Women of defending women’s right to control their bodies, except their breasts.

Medical progress has altered our expectations. According to Dr. Michael Schwartz, a Pasadena, California, surgeon, “Surgical advances, improved technology, and developments in anesthesiology, which make cosmetic surgery safer and more affordable to the general public, also make it more socially acceptable. Patients no longer have to go into postoperative hibernation for a month. Now they return to work and resume their lives almost immediately, in some cases as if nothing has happened, in others eager to proselytize about what has.”