Commentary Magazine

Prozac, with Knife

Imagine Tyler and Kelly Tucker—as I like to think of them—on the first night of their honeymoon, in a glow of happy confidence that sets a mood for postcoital intimacies. Tyler opens by confessing to his bride that his thick hair is the result, partly, of hair plugs, implanted three years before he met her. Kelly admits in turn that her high cheekbones, which Tyler has so often remarked upon, are the consequence of silicone injections. He allows that, at age sixteen, he rid himself, through surgery, of the aquiline Tucker nose. She confides that her once weak chin has been augmented, her front teeth are capped, and six of her back teeth are implants. Finally he shares the news of his penile enlargement. Her breasts, she whispers back, have likewise been enlarged, her thighs and bottom reduced through liposuction. In a swoon of candor they embrace—though Tyler, a former fat boy, has still to divulge his tummy tuck.

“Beauty fades,” says the character played by Albert Brooks in I’ll Do Anything, bemoaning his weakness for knock-out young women. Then he adds, “but it fades so slowly.” Not slowly enough, apparently, for the Americans, Europeans, Latin Americans, and Israelis who have been going in for plastic surgery in continually larger numbers. The statistics on these procedures—also known as cosmetic surgery, less frequently as aesthetic surgery—show them to comprise a flourishing business. In Making the Body Beautiful1 Sander L. Gilman, a professor at the University of Chicago, reports that from 1981 to 1984, the number of such surgeries in the United States rose from 296,000 to 477,700. By 1995, 825,000 operations were being performed on the face alone—quite apart from procedures to lift the skin of the upper arm; breast work (implantations, reductions, removal of earlier, faulty implants); buttock and thigh lifts; tummy tucks; liposuctions of various sorts; calf and other implants; foreskin reconstitutions; penile enlargements and implantations; and—the ultimate surgical alteration—sex-change operations.

Plastic surgery—from the Greek plastikos, meaning “fit for molding”—has, we learn from Gilman, a long history. The 7th-century Alexandrian physician Paulus of Aegina thought that the growth of breasts in men was something to be dealt with surgically. Later, surgery was called upon to camouflage wounds incurred in dueling or warfare, or to hide the depredations of advanced syphilis on facial bones, particularly the loss of cartilage in the nose. Surgeons also did their best through the centuries to undo nature’s dirty tricks—repairing cleft palates, constructing missing body parts, reducing hideously outsized organs and appendages. But it was during and after World War I, when physicians worked to reconstruct faces destroyed in combat, that plastic surgery obtained its best press. This may also have been the last time it was not bogged down in the swamps of controversy.

The first of these controversies had to do with whether plastic surgery strictly qualifies as medicine, especially when its intentions are purely cosmetic. If the patient seeks the treatment, decides what is needed, and then is the chief judge of its success, is this really medicine? Plastic surgeons themselves used to worry over such questions, and in the first decades of the 20th century many refused to take on cases that they deemed trivial or requests for reasons that went no deeper than vanity.

But help was at hand by the 1920’s with the widespread publicity given to the psychiatrist Alfred Adler’s notion of the inferiority complex. The important word here is “complex,” implying that feelings of inferiority are unnatural, an aberration, needing to be altered, cured, or . . . cut away. (The alternative, of convincing individuals that they really are inferior, and hence relieving them of the burden of carrying around a complex, has apparently never been tried.) Thus, cosmetic surgeons soon found themselves able to say that they were not only performing surgery but supplying therapy. With a cut here, a bob there, they combined the work of a sawbones with that of a shrink, turning a sad person—a person with too large a nose, a weak chin, big ears, a squint—into a happy person. In effect, they were supplying Prozac, but with a knife.

Leaving aside the recent scandal over the possible consequences of silicone breast implants, physicians doing cosmetic surgery probably feel rather better about their work today than ever before. Cosmetic surgery is even creeping into other branches of medicine: dermatologists, for example, have begun doing skin peels, collagen injections, and liposuctions. A physician I see told me recently that if he had his medical career to plan over again, he would be a cosmetic surgeon. The work requires artistry, it makes most clients quite happy, and it is profitable: an eastside Manhattan facelift from a swank practitioner might run, with all the extras—consultation fee, nursing, anesthesia, recovery hotel—somewhere near $20,000.

The profit most often comes in the form of cash on the barrelhead. Since insurance companies reimburse only that portion of the surgery that is truly reconstructive or directly related to health, much of the usual bureaucratic-financial headache connected with the practice of medicine is eliminated. Fees are paid up front, which does away with bill collecting and also prevents unsatisfied customers from withholding payment (though a few have returned to murder their surgeons, causing many nowadays to screen for potential maniacs). As for patients who go to law to complain about the quality of the surgery they have received, juries tend to be most unsympathetic, viewing them as members of two vaguely but genuinely despised groups: the pathetically vain and the antipathetically wealthy.



Vanity aside, what is cosmetic surgery really about? In my high school in Chicago—this is going back 40 years or more—a small but not negligible number of girls had already begun to have their noses done. “Done” invariably meant shortened, often made retroussé, or slightly upturned. Different surgeons conferred different looks: I seem to remember something called a Becker nose being popular in Chicago; in New York during those same years, Long Island girls went to a cosmetic surgeon named Howard Diamond to acquire a Diamond. A few among these girls claimed they needed to have an operation because a “deviated septum” was giving them trouble breathing. Most, of course, simply disliked the shape of their noses sufficiently to undergo the pain and general unpleasantness—they would show up at school with blackened eyes and vast quantities of tape across the middle of their faces—required to change it.

The younger sister of a close friend of mine in those days had a distinctly non-Beckerian nose. Like her mother’s, it was slightly aquiline and with flared nostrils—clearly, as the old anti-Semites had it, one of the chosen noses. She also had an attractive shyness, a slight holding-back of herself that I found winning but that may well have been traceable in part to her unhappiness with her looks. At fifteen, she had her nose fixed. The operation was an almost unqualified success, definitively solving the problem of both aquilinity and—as writers on the subject call it—nostrility. Now altered by the knife, my friend’s sister descended into the great adolescent female herd of the merely cute, losing, so far as I could determine, all distinctiveness whatsoever. Yet, I have no doubt, she was happier.

What this suggests is that cosmetic surgery is “about” the specific form of happiness that can accompany passing: becoming invisible by melting into the mass. Not that passing is necessarily the same thing as hiding out altogether. My friend’s sister, for example, certainly did not want to de-Judaize herself—her name was Jewish, she went on to marry a Jewish man and bring up her children as Jews. She only wanted a face that more closely conformed to the then-prevailing American standard of beauty. In the 1960’s, the ideal American nose was said to belong to Jacqueline Bouvier Kennedy Onassis. Study of that famous appendage—small, short, just slightly upturned—reveals no oddity or distinction of any kind. And that is just the point: it was a nose that gave no clues to origin, no hostages to ethnic identity.

Passing can take many forms. Some people wish to escape or elide their ethnic or even racial heritage: Asian girls, for example, who want western eyes. Others (John Dillinger is the famous example here) may wish to avoid detection by the cops. Some wish to add to their erotic cargo, which is what breast implants are about. Others—these days, they are the majority—wish to seem younger than they are. And some, as with the singer Michael Jackson’s estimated 31 operations, may not be quite sure what they are after but are confident that, in one way or another, cosmetic surgery will alter their lives for the better.

And it may well do so. Most studies report that handsome or beautiful men and women tend to do better in the job market and also—golly, Mom, wouldya believe it?—tend more easily to find partners for sex. Beauty is a quality, noted Montaigne in the 16th century, “that gives power and advantage”; to Aristotle, it was “a greater recommendation than any letter of introduction.” True, in certain circles beauty can come under suspicion: I once heard two great scholars—the historian Arnaldo Momigliano and the social scientist Edward Shils—discuss in perfect earnestness how a graduate student’s handsomeness seemed to suggest an incapacity for serious scholarship. Still, given the choice, most of us would undoubtedly prefer to come into the world beautiful, and most of us are also likely to have at least one unbeautiful physical quality that we feel may have held us back from the greater triumphs that were surely meant to be ours. Are not such flaws more costly to us than the price of eliminating them through cosmetic surgery?

Not that most people who enter into such surgery do so wholly without trepidation. A piece of flesh, after all, is hardly a piece of cake, and the literature is strewn if not with corpses then with post-operatively misshapen or malfunctioning body parts. There are women whose skin becomes stretched so tight from facelifts that they cannot close their eyes at night, or from whose faces the makeup slides off. There are women with silicone inserted in their cheeks in the hope of attaining the look of Audrey Hepburn who, when the silicone falls, end up looking more like Alvin the chipmunk. There are the noses that emerge snouty, the lips that curl or fall to one side, the scarring, the infections, the long-term slippage that, over time, needs to be redone, the occasional death.

Consider lipoplasty, better known as liposuction and employed to bring about what were once called “contour improvements” by vacuuming or sucking out fat from the face and neck, abdomen and flanks, thighs, hips, knees, calves. Because Licensing laws are unclear in some states, and nonexistent in others, incompetent practitioners—not to say outright quacks—can never be ruled out. But even under good conditions, and in good hands, serious screw-ups can occur. In The Unofficial Guide to Cosmetic Surgery, E. Bingo Wyer notes that “In all forms of lipoplasty, . . . too great a loss of fat can result in a rumpled or unbalanced appearance, which can be difficult to correct.” She then adds a brief but horrific list of possible side effects, including pain, bleeding, temporary numbness, excessive fluid buildup, clots that block the flow of blood, infection, shock. In Lift, an account of her own “brow lift, nose nip, secondary facelift, and lip peel,” the journalist Joan Kron mentions matter-of-factly the post-operative removal of “fifteen or twenty annoying metal staples used to close the incision in the back of my head.” A routine matter, this—and yet, one cannot help thinking, maybe it isn’t merely not nice but not too smart to try to fool Mother Nature.



But people do continue to try. For one thing, new techniques keep being invented and put into practice. For another, fashions change. Rhinoplasty (nose jobs) has dropped off in recent years—although some people, no longer shamed by their ethnicity, are going back to their cosmetic surgeons to have their old bumps or beakishness returned. The notion of “passing” has itself passed from the wish to seem normal, or invisible, or WASPish, to the wish, mainly, to seem young. Facelifts, along with eye- and brow-lifts and various skin peels (collagen and Botox injections, dermabrasion, laser resurfacing), lead all other forms of cosmetic surgery today.

And what is wrong with the wish to remain youthful-looking? Medical technology has given us a great gift, one that enables us to fight off, for as long as possible, nature’s slow, inexorable onslaught, to cheat that great sculptor, Time. If we want to make ourselves seem younger and therefore (by our own lights) happier, and can afford the cost, why not?

One answer is that heredity and time—or, if one prefers, the heavens and fate—deal us a much more interesting hand than doctors can ever hope to do. Think, in all its immense variety, of the nose: from Gogol’s long sharp proboscis to Tolstoy’s potato nose to W. C. Fields’s empurpled lighthouse nose to Jimmy Durante’s two-pound cucumber nose to Igor Stravinsky’s isosceles-triangle nose to Bob Hope’s ski-jump nose to Barbra Streisand’s grand depressed-tip, sloping-septum nose. Interesting faces, oddly beautiful faces, are not created by surgeons, no matter how skillful, but by the years, working in conjunction with character. Who would have wished to subject the rhino-hide face of the older W. H. Auden to a face-lift, or to change in any way the countenance of the novelist Marguerite Yourcenar, with its strong lines, shadows, dark nostrils, sagging eyelids, and more than a hint of a mustache?

Novelists have long depended on the relation of physiognomy to character; Balzac speaks with pity of people who have not yet learned to read moral character in a face. And if beauty, as the cliché has it, is in the eye of the beholder, here is the twenty-six-year-old Henry James, the subtlest of beholders, writing home to his father after meeting the English novelist George Eliot:

To begin with she is magnificently ugly—deliciously hideous. She has a low forehead, a dull gray eye, a vast pendulous nose, a huge mouth, full of uneven teeth and a chin and jaw-bone qui n’en finnnissent pas. . . . Now in this vast ugliness resides a most powerful beauty which, in a very few minutes, steals forth and charms the mind, so that you end as I ended, in falling in love with her. Yes behold me literally in love with this great horse-faced blue-stocking. I don’t know in what the charm lies, but it is thoroughly potent.

This suggests a philosophical question for cosmetic surgeons: does a change in one’s body bring about a corresponding change in one’s moral character? And if so, can we be sure it is for the better? In his introduction to a 1937 book titled New Faces, New Futures: Rebuilding Character with Plastic Surgery, Alfred Adler answered in the affirmative: after such surgery, “the personality relaxes into naturalness and character is transformed.” But one may be permitted to doubt this. Even, it turns out, radical feminists do. Fifty years after Adler, a writer in Ms. confessed, “Before the operation I rationalized how I wanted my face-lift so my exterior would match my interior. . . . I realize now I was lying to myself. I just wanted to look younger and prettier.”

I am not sure that George Orwell was correct when he claimed that at fifty a man gets the face he deserves, but at sixty, I can attest, he tends to get reconciled to it. I look in the mirror and consider my ample, stick-out ears; my mottled complexion, with a beard that confers a five o’clock shadow sometime past noon; the impressive bags—two-suiters—under my eyes, which go so nicely with the sag that has shown up in my right eyelid; the slightly off-center circumflexes that my eyebrows have begun to form; the strong downward lines running from alongside the bridge of my nose to the top of my upper lip; the fairly recent addition of two further lines, running from the corners of my lower lip down to my jaw, giving my mouth the look of a ventriloquist’s dummy and a not-so-gentle hint of pervasive depression. A face, clearly, begging for the knife. Yet, just as clearly, it is not going to get it: for I have grown accustomed to this face, a poor thing but mine own.

From both limited personal acquaintance and photographs in various books on the subject, I have noticed that cosmetic surgeons are not themselves a notably handsome bunch; yet most do not seem to have done anything about it. Why not, when the remedy is so obviously and easily and literally at hand? An old joke about psychoanalysts is that, after conferences in Vienna, they get drunk together and sing, “I want a girl/just like the girl/that married dear old dad.” Can it be that cosmetic surgeons begin each day by crooning into their mirrors: “But don’t change a hair for me/Not if you care for me/Stay, little Valentine, stay”? I would like to think so, at least for a few happily cynical souls among them.



1 Princeton, 544 pp., $29.95.


About the Author

Joseph Epstein is a regular contributor to COMMENTARY.

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