Our Quest To Be Perfect

Ten years ago, when she was only 25, Holly Lagalante shelled out $2,500 for an eyelid lift. The tab nearly maxed out her credit card, but the results--more bright-eyed, less droopy--left her absolutely giddy. Two years later, Lagalante, a petite blonde from suburban Chicago, was back for liposuction on her thighs ("I'd love to have Heather Locklear's body," she says). Then varicose-vein removal. And, later, a forehead peel. Last year she had $7,000 left to pay off when she lost her $9-an-hour job managing a health-food store, moved in with her mother and filed for bankruptcy. Still, she claims she's happier and more self-confident since her body overhaul and has no regrets. She now has a new job as a salesclerk at a local mall and says that when she finishes paying off her debt she'd like to reward herself--with a forehead lift or maybe liposuction to fix her saggy knees. "It's been tough on me financially, but it's worth every penny," she says. "It's life-changing."

Not so long ago aspiring starlets and women "of a certain age" were pretty much the only patients who went under the knife--and they did so in secret. But now the image-conscious of all ages--and genders--quest for perfection. "The person we see today," says Dr. John Tebbetts, a plastic surgeon in Dallas, "is your sister, your next-door neighbor, the lady in the grocery store." Teen girls beg their parents for liposuction and breast augmentation, prompting a heated debate over how early is too early to perform elective surgery. Twenty- and thirtysomethings go in for cosmetic "maintenance": a chemical peel here, a little microsuction (liposuction for the face) there. Record numbers of baby boomers get their fat sucked out and "rejuvenate" their cheeks and eyelids. Any stigma has melted away as quickly as fat cells during liposuction. Dr. Stephen Perkins of Indianapolis says his patients used to flee when they saw him at parties for fear they'd be found out. Now, he says, "they come up grabbing their friends" to introduce potential new customers.

This boom is fueled in part by doctors frustrated with managed care and dwindling reimbursements in the last few years. Insurers won't cover procedures that are purely esthetic, so patients must pay the full cost (which can easily run upwards of $3,000) for what one doctor calls "happy surgery'' out of pocket. To draw in business, physicians are advertising like mad in newspapers, magazines and even on TV. But as more jump in, there's concern about safety and oversight. Board-certified plastic surgeons spend years in specialized training, but anybody with a medical degree can perform cosmetic procedures. Just last week, as 500 plastic surgeons debuted a nationwide television and radio campaign promoting breast augmentation, Florida's state medical board--a national leader in regulating office surgery--debated tough new rules.

Advanced techniques, promising less-invasive procedures and swifter recoveries (the famed "weekend face-lift") make surgery seem less scary to first-timers. High-beam computer-controlled lasers blast away fine lines and wrinkles. Endoscopes, pencil-like tubes with cameras on the end, allow doctors to make small incisions rather than drastic cuts. While the number of reconstructive surgeries (fixing burns or lacerations, for example) have stayed fairly stable this decade, cosmetic enhancements have steadily gone up. The bottom line, according to a new report by the American Society of Plastic and Reconstructive Surgeons (ASPRS): a 153 percent increase in the number of cosmetic procedures performed by plastic surgeons since 1992, to more than 1 million last year. And that number is considered highly conservative, since it excludes work done by noncertified specialists, such as dermatologists, dentists--even gynecologists.

Many of these patients struggle to cover the cost. Two thirds report family incomes under $50,000 a year. "They pay you by credit card or check and you have no idea whether it will take them one month or 10 years to pay it off," says Dr. Albert Dabbah, a Florida plastic surgeon. "If they want it badly enough, they'll treat it like any other commodity." Some are choosing lifts and tucks over vacations and even down payments on first homes. Not to worry if you have no such savings. Loan companies now offer monthly payment plans for body work.

Earlier this summer, Erica Barrow, a 24-year-old Chicago waitress, took full advantage. She was desperate to blast away minuscule acne marks and a small scar on her face, but she didn't have $4,425 for laser resurfacing. Her surgeon happily hooked her up with a local cosmetic loan company, Unicorn Financial, which helped her work out a plan. Barrow used $500 she earned in tips as a down payment, then took out the rest in a $178-per-month loan.

For some patients, cosmetic surgery has become about as routine as an annual checkup. Dr. Gerald Imber, a New York plastic surgeon, recommends that his patients begin small "maintenance" procedures--removing fat in the neck, eliminating worry lines--somewhere between 35 and 45 before sags and wrinkles make major headway. Forget the face-lift at 50. "The idea of waiting until one needs a heroic transformation is silly," says Imber. "You've wasted 20 great years of life and you've allowed things to get out of hand."

Kelly Sue Evans, just 24, has already gotten that message. She's taking full advantage of the Cosmetic Surgery and Laser Center where she works as an administrative assistant at a strip mall in suburban Boston. She's had collagen injections to pump up her lips, liposuction to attack "diet-resistant fat" and dermabrasion "power peels" that blast away old skin with tiny bits of silica. "People tell me, 'You're too young, you don't need it'," says Evans. "But I don't want to have that leathery look when I get older."

For baby boomers, who account for more than 40 percent of the market, liposuction and eye lifts have become accepted as a generational rite of passage. They want to live to 100--but refuse to age past 35. Last year, Mary DiPirro, 40, of suburban Chicago paid $2,500 for what she calls an "insurance policy" against the ravages of time. Her secret weapon: a jar of fat cells sucked from her very own thighs and tummy, which now sits in her dermatologist's office freezer. Every two months or so, during her lunch break from her job as a nanny, DiPirro sneaks out for a dose--two to three teaspoons injected into her cheeks to plump them back to youth. "It's so easy," she says. "It's like a trip to the dentist."

Many boomers say they feel pressure to keep up appearances to keep their jobs. Mary Bentley, 43, a global-marketing manager at IBM in Dallas, was just a size 6 when she decided to have liposuction on the back of her thighs about a year ago. "People judge you by the way you look, dress and talk," she says. When Bentley noticed fine lines forming on her face, she marched back to her doctor for a shot of Botox, a toxin that temporarily paralyzes frown muscles. Now, Bentley says she feels "more competitive in the job market... If I get to the point where I want to get a face-lift, you bet I'll do it."

Women aren't the only ones worried about the future. Last year more than 99,000 men signed up for liposuction, eyelid surgery and face-lifts (among other procedures), compared with fewer than 55,000 in 1992, the first year the ASPRS began keeping national statistics. "Nine years ago I'd see fewer than five [men] in a year," says Dr. Cristina Keusch, a plastic surgeon in Boca Raton, Fla. "Now I see five in a month." Some want to stay competitive with twentysomethings at work; others are divorces beginning to date again. Or, like many women patients, they're motivated by simple vanity. Kevin Callahan, a 31-year-old creative director in Florida, makes no excuses for the silicone rubber implants inserted under his pectoral muscles. "I wanted the biggest pecs I could get without looking like a steroid monkey," he says. "I wanted to look buff." Lean and muscular, Callahan plays tennis and works out at the gym twice a week. But he's still not satisfied with his body. His next surgery: buttocks implants. "I've done all the squats and lunges I can do, but it's just not in the genes," he says. "So I'm going to let the doctor do some sculpting for me."

The most controversial category of new patients is teens. Last year, 1,645 patients 18 and younger had liposuction, and 1,840 had their breasts enlarged--twice as many as in 1992. In California, which leads the nation in "augs," as they're known in the business, the procedure has an air of being "pretty common" to girls like Amber Reeves, soon to be a junior at Huntington Beach High School. "A lot of seniors at my school get breast augmentation as a graduation present," she says. "I know at least four girls who had it done last year." Last month, at just 16, she joined the crowd, boosting herself from a B cup to a C "basically to even everything out," she says. "I realized my hips weren't going to get any smaller, no matter how much I dieted." Her goal is to be "thin but healthy in a toned sort of way. Kind of like Madonna."

Such material-girl aspirations have ignited a debate among surgeons. Some say they won't do breast enlargements on anyone under 18. "It seems to me that someone we don't consider old enough to order a drink shouldn't be considering plastic surgery," says Imber. The ASPRS, which represents the country's 5,000 board-certified plastic surgeons, has no official position. It's "a judgment call that should be made between the surgeon, the family and the patient," says the group's president, Dr. Paul Schnur. Some believe teen surgery can be appropriate under the right circumstances--if a girl is physically developed and mature enough to understand the risks. "The key here is not chronological age," says Dr. Fritz Barton, president of the American Society for Aesthetic Plastic Surgery, "but the age of development."

As the client pool expands, so does the number of providers--but they come with vastly different credentials. The gold standard in plastic surgery is certification by the American Board of Plastic Surgery, which requires a minimum three years of training in general surgery and two in plastic surgery. But many of the estimated 50,000 other doctors practicing in the field learned their skills in short courses or apprenticeships. "Anyone with an M.D. can call themselves a plastic surgeon," says Dr. David Ross, an ASPRS member since the 1970s. "That is why we have catastrophic liposuctions--this is not a business people can jump into with a weekend course." Dermatologists like Chicago's Dr. Gary Barsky charge that such an attitude is elitist. "It's a turf war," Barsky says. "It seems they don't want anyone else doing this, no matter how good." For doctors in his specialty, he says, procedures like laser resurfacing and liposuction are a "natural evolution."

Most cosmetic procedures are performed safely and patients are satisfied. Still, many specialists are troubled by those who come in seeking help after botched jobs. There are no national statistics, but Dr. Gerald Pitman of New York, considered one of the top liposuctionists in the country, estimates that the revision rate for all cosmetic surgery could be as high as one in 10. Landa Pappas, a 51-year-old DJ in Boston, had her "lopsided lips" augmented with an implant five years ago. But the Gore-Tex fibers used to build them up began poking out like bedsprings from an old mattress. The surgeon who performed the procedure tried twice to fix her lips, but after repeated infections, Pappas turned to Dr. Michael Kaminer of Beth Israel Hospital in Boston for a $2,500 redo. "It's kind of a barbaric procedure," says Kaminer, who had to spear Pappas's lips from end to end and dig through scar tissue to implant a new device. "The patient has to really trust she'll look better when it's all over."

Many of the newest techniques are also controversial. A few doctors offer penile augmentation, removing fat from the thighs or buttocks and grafting it onto the penis. Critics call the surgery unsafe and unethical since it can result in permanent dysfunction. For many other patients, live-fat-cell injections are a welcome alternative to Gore-Tex or to collagen, which can cause allergic reactions. But frozen cells like DiPirro's are much more fragile. Many doctors say they're probably dead by the time they're injected and are ineffective because they simply dissolve into the patient's body.

Laser resurfacing, which is edging out chemical peels and dermabrasion, works by vaporizing the skin. It can cause oozing and crusting, and lingering redness can last months. Some doctors say there's still not enough evidence that the $2,000 procedure does that much to help long-term. Botox, the wrinkle remover, is approved by the Food and Drug Administration only for rare eye muscle disorders. Doctors are allowed to use the drug "off-label," but slip-ups could cause temporary paralysis in eyelids. Only a few physicians offer pec implants because of problems with infection and slippage.

Liposuction, the most popular procedure for both men and women, can be especially risky in the wrong hands. In traditional liposuction, patients have been known to lose too much fluid during the suctioning process, sending them into shock. In the newer "tumescent" method, doctors inject a medicated solution into the fatty tissue to reduce bleeding, but in rare cases, it can cause fluid buildup in the lungs and fatal blood clots. A recent study in New York cited these problems in the deaths of five patients from 1993 to 1998.

Many procedures are increasingly performed in doctors' offices rather than hospitals--and that itself can increase the risk. Hospital operating rooms must meet strict equipment and personnel guidelines that generally don't apply to in-office surgical units. In 1997, Judy Loveless, a 49-year-old flight attendant, died while having eyelid surgery at an office suite in Atlanta (following story). The office was not equipped with a crash cart, routine in hospitals, that could have helped save her life.

Medical experts are also worried about a growing trend in multiple procedures; combining a face-lift and eyebrow lift with liposuction, for example. Some doctors will offer discounts if patients opt for several fixes at once. But loading up can keep patients on the surgical table too long, putting them at greater risk for complications. Certain states, including California and Florida, have taken the lead with stiffer regulations for in-office surgeries. There's similar legislation in the works in other states.

After all the incisions, the blasting, the snipping and sewing, the loans and lost vacations, consider this: most plastic surgery is temporary. Botox and collagen have to be re-administered every few months. Face-lifts last about a decade. The earlier you begin many procedures, the more often you'll need them done. And though liposuction can shrink problem areas, it doesn't keep you thin. "[Patients] can eat faster than I can suck," says Pitman. "That can ruin the effect of surgery."

Who will be deterred? Certainly not Lisa King, a 31-year-old mortgage-loan officer in Atlanta. After having two kids, King says she wanted to firm up her abdomen and perk up her breasts. "I was doing sit-ups and all kinds of Nautilus, but that loose skin and fat was just not going to go away," she says. She made her decision after a self-conscious walk on the beach and last February spent her $10,000 bonus on a "tummy tuck and a boob job." The results--displayed soon afterward on vacation in Aruba--so impressed her mother, Ann Alford, 51, that she, too, had a tummy tuck. Since then, King has referred four other people to her surgeon. "Perfection," it seems, is contagious.