the Body and the Brain


“I showed up to a place I’d never been and there was a guy with a drafting board …”

So begins “Dove Real Beauty Sketches,” the documentary-style online ad campaign that went viral this spring. The guy with the drafting board—a forensic artist hidden behind a curtain—asks a woman to describe her face and sketches her portrait based on her description. Then he draws her again—based on a description provided by a complete stranger. 

For all seven women in the ad, the results are shockingly similar: Their self-portraits are less attractive than the stranger-generated portraits. Much less attractive.

Why? “Women are their own worst beauty critics,” Dove tells us. According to its research, only 4 percent of women around the world consider themselves beautiful. Dove wants the other 96 percent to know that their problem isn’t physical—a big nose, a weak chin, a too-round face—but emotional. “We spend a lot of time as women analyzing and trying to fix the things that aren’t quite right [about our appearance],” says one of the women in the video. “And we should spend more time appreciating the things we do like.”

In the words of the campaign tagline, “You are more beautiful than you think.” (And buy Dove products.)

Also this spring, researchers in Germany announced the results of the world’s largest study of cosmetic surgery patients. What they discovered, as published in the March 2013 edition of the journal Clinical Psychological Science (which did not go viral), is that “patients demonstrate more enjoyment of life, satisfaction and self-esteem after their physical appearance is surgically altered.” In other words, the more than 8 million cosmetic surgery procedures performed each year make people happier.

Taken together, these two phenomena illustrate our current cultural ambivalence about cosmetic surgery. On the one hand, we know we can be happier if we empower ourselves to believe we already are beautiful—or at least quit focusing on the things we dislike about our appearance. On the other hand, we also know it makes us happy to fix those very things—and every day there are new procedures that allow us to do just that.

So, which is it?

Dr. Patrick ByrneBoth, says Dr. Patrick Byrne, director of the Johns Hopkins Center for Facial Plastic and Reconstructive Surgery in Greenspring Station. When a patient comes to him complaining about a certain feature of her face, he sometimes wants to tell her, “Just don’t focus on it.”

Pretty easy for a man who’s a dead ringer for actor Rob Lowe to say. But in his 12 years performing procedures both at the surgery center and at Hopkins hospital, where he is director of the
Division of Facial Plastic and Reconstructive Surgery, Byrne has come to understand that what people focus on—and what they don’t—is integral to his work. For some people, says Byrne, a physical flaw or less-than-perfect aspect of their appearance dominates their life while others aren’t bothered. “There’s the objective physical feature and there’s how people experience it,” he says. “They’re not inextricably linked.”

A common type of patient, he says, is a woman with a minuscule bump on her nose who wants it fixed. “You have a nice nose,” he’ll tell her. “Just be happy with it.” But when she can’t be convinced, he’s sympathetic. After all, he says, the desire to improve one’s appearance is less a function of cultural norms or individual vanity than of evolutionary pressure. “We know all the details and measurements that will create the most ‘objectively beautiful’ face,” says Byrne, who notes that the definition of a “beautiful face” is fairly stable from culture to culture. “If I move my patients toward those measurements, a majority of people they encounter will think they’re more attractive. From an evolutionary sense, it means they’re better mates, which means they’ll have a better chance of reproducing and surviving.”
The reason cosmetic surgery is so effective at making people feel better, Byrne believes, is that it typically moves people closer to the universal ideal of beauty, particulary the youth part of that ideal. “Given the evolutionary pressure, which is particularly strong for the face, wanting to look younger is predictable,” he says—especially for women, who undergo 87 percent of cosmetic surgery procedures and 92 percent of “minimally invasive” cosmetic procedures like injections and laser resurfacing, according to the American Society of Plastic Surgeons.

Janet Paulsen, the fit and healthy 54-year-old general manager of the Green Spring Racquet Club, underwent a face and neck lift last year in order to look as young as she feels in her body and mind. Before her surgery, “I had all this energy, but everyone kept telling me I looked tired,” she says. These days, “People tell me I look bright and refreshed, which is what I wanted. Not, ‘You look different.’”
Paulsen isn’t ashamed to be public about the “work” she had done. “Some people think it’s a stigma,” she says. “I don’t. Sometimes you need a little enhancement. My persona is that I want to look healthy and fit. Besides, [local fitness impresario] Lynne Brick rents from me at the racquet club. I have to look good!”

Byrne is satisfied with Paulsen’s results, but most importantly he’s happy that she’s happy. After all, cosmetic surgery is unique from every other field of medicine in that instead of trying to heal sickness, aesthetic surgeons put “well” people under the knife to make them feel better. And, just as the patient’s particular perspective motivates the surgery, it’s the patient who decides if it’s a success.

Still, like a perfect foil to the scientist in Nathaniel Hawthorne’s short story, “The Birthmark,” who obsesses about the small birthmark on his wife’s otherwise lovely face, Byrne is surprisingly reluctant for his loved ones to go under the knife. For years, Byrne’s wife asked him to analyze her face and he always managed to put her off. Finally, one day she cornered him and he rattled off a dozen or so things that are “objectively imperfect” about her face. And yet he’s adamantly against her getting surgery.

“Technically, her face could look better,” says Byrne. “But I don’t want her to change. She’s beautiful as she is.” More beautiful than she thinks.

Larry LicksteinLike Byrne, when aesthetic surgeon Dr. Larry Lickstein of the Cosmetic Surgery Center of Maryland is at a cocktail party and people ask, “What would you change about my face?” he dodges the question. “Our role is not to tell someone what they need but to listen to them express their needs. The older generation of plastic surgeons diagnosed flaws,” he says. “I don’t want to impose my view on someone. If an 80-year-old woman comes in and wants a tighter neck, I say, ‘You’ll need some work on your jowls, too, to look natural.’ But if she’s not bothered by her heavy eyelids, then I’m not either. If they’re not bothered by something, I can’t fix it.”

Dr. Michael Cohen, Lickstein’s colleague at CSCMD, learned that lesson the hard way early in his career. “A woman came in wanting liposuction for her knees,” he says. “I didn’t think the procedure would get the results she wanted so I turned her down. But I suggested we could do something about her heavy eyelids. She cried. She’d never thought they were a problem.” (But she did ultimately get eyelid surgery from Cohen.)

Lickstein and Cohen, like all of the plastic surgeons interviewed for this article, say the majority of their patients seek cosmetic surgery for some variation on the following: “I look in the mirror and don’t like what I see.” “I want to look as good as I feel.” “I’ve never liked my nose.” Or, in the case of the “Mommy Makeover,” “I’ve had two kids and I don’t like what it did to my breasts and stomach.” There are also some patients who are trying save a marriage—or preparing themselves to go back “on the market” in anticipation of a divorce.

Most patients are realistic and goal-oriented, the doctors say. They’ve identified a problem and are taking a proactive response to solving it, one that takes guts and a willingness to undergo discomfort. As one handout from CSCMD says, “Anyone who has cosmetic surgery has shown they are a person of courage and they may now demand great deeds from themselves. They have given up the excuse called, ‘I’d be afraid to do that.’”

Actually, says Cohen, it’s not fear of going under the knife that keeps people from signing up for cosmetic procedures—it’s the cost. Sure, some injectables can cost less than $1,000—but the results will be relatively minor compared to a face, neck and eyelid lift that runs $15,000.“Some patients have the funds and the interest, and they like an improvement project,” says Cohen. “It’s like if you have a home and you start by redoing one room. And then you get more funds and redo another.”

This was the case for John (not his real name) who lives in Green Spring Valley and says he’s a “frequent shopper” at the offices of plastic surgeon Dr. Ronald Schuster. John is in his 70s and has a “considerably younger” wife, he says. During the past three years, he’s undergone an eyelid lift, a neck lift and a CoolSculpting treatment, a procedure that targets fat in localized areas. For John, it was worth the $15,000 price tag to feel better about his appearance. But, he says, it was not a “game-changer” in the sense that his appearance comprises only one aspect of his happiness.

For Amanda Rice, 32, a parole and probation agent supervising sexual offenders in Baltimore City, cosmetic surgery was a game-changer. In March 2008, she underwent bariatric surgery, shrinking from roughly 300 pounds to 152. The surgery helped her weight-related health problems but left her with loose skin that hung around her midsection, masking the weight loss. So, in 2010 she paid $17,000 to have Cohen perform a “body lift”: a tummy tuck, breast lift and breast implants. “It’s almost like Humpty Dumpty,” she says. “He put me back together again.” Rice says the body lift gave her even more confidence than the bariatric surgery. “I went out and bought a whole bunch of string bikinis and had a good time,” she says. “Even now, I’ve put back on some of the weight, but I still feel confident.”

Some folks are so delighted to be undergoing a tummy tuck that they ask Cohen to take a picture of the skin and fat cut off during the procedure. Then they put the photograph on their refrigerator, a symbol of their “old self.” “I did reconstructive surgery for a long time and now, doing cosmetic surgery, I’ve often asked myself, ‘What are you doing to contribute?’” says Cohen. “But I see every day that if you can make people feel good about themselves, it has a ripple effect on their marriage, their job, their relationships. It has a long-lasting effect. That’s why I’m in this field.”

But there’s a percentage of cosmetic surgery patients who will never be happy. Sometimes it’s because their expectations are unrealistic, like the 70-year-old woman who once showed Lickstein a picture of Nicole Kidman and said, “I want to look like this.” Much to her disappointment, he told her it was impossible. “Some patients think we have magic wands, not scalpels,” he says.

For just that reason, Schuster says he appreciates it when patients bring in photographs. “It lets me really get into their head and see what they want,” says Schuster. “But it’s not just that. If they have an image of a result they want, but their body isn’t going to get there, there’s a disconnect. Then I have to educate them that they’re not going to get that result and instead say, ‘Let’s think about how we can help you.’”

By educate, many doctors mean re-educate. Dr. Randolph Capone, director of the Baltimore Center for Plastic Surgery at Greater Baltimore Medical Center, requires all rhinoplasty patients to attend two hour-long consultation sessions before he schedules them for surgery. The first session involves a discussion, exam and the taking of “before” pictures. At the second session, Capone uses digital imaging to show prospective patients how their “after” pictures are likely to look. “During that session, that’s where I can get a sense about their level of acceptance of improvement versus perfection,” says Capone. “If I can’t get them happy in that session, we’re not going to have a surgical episode together.”

Though many patients arrive with a vision of perfection in mind, says Capone, he’s able to persuade most to have more realistic expectations through the two consultation sessions, and they move on to surgery. Nearly 10 percent of patients aren’t ready to let go of their hopes for perfection, so he sends them away. (Often, he says, they come back in a year or two with more realistic goals.)

Beyond patients with unreal expectations, there are those who present with a defect that doesn’t actually exist. Schuster recently saw a woman who’d had her eyelids done by another local surgeon. “She was bothered by her results and had gone back to him and he’d done a touch-up. She came to see me really being upset at how she looks. She was crying, saying she’s too upset to leave her house,” he says. “When I examined her, she looked good. That tells me her concerns are out of proportion with reality. It’s a difficult situation because you want to help people but you have to recognize that some people you can’t help and you might make it worse.”

Schuster estimates he turns down 2 percent of patients who seek procedures from him. “You have to recognize the red flags and be disciplined about saying no,” he says.

Indeed, if a patient has body dysmorphic disorder (BDD)—a mental illness that affects roughly 1 percent of the population in which a person is obsessed by a perceived defect that doesn’t exist or is unhealthily focused on a minor physical flaw—operating can feed the illness, not cure it.

In April, Capone had what he calls the most difficult consultation of his 15-year career. “This young man who came into my office had had a face-lift at 22. He’d had two rhinoplasties before that. And he had seven silicone implants in his face. He felt like his face-lift wasn’t good and needed revision,” says Capone. “There was no perceptible problem I could see other than an operated-on appearance. My recommendation was he do nothing. But he wouldn’t take that as an answer.”

Capone says the psychological aspect of plastic surgery is what makes it at once so unique and so challenging. “I could do the Michelangelo of rhinoplasty procedures, but it doesn’t matter if the person isn’t going to be happy,” he says. “If you’re a general surgeon and you’re doing an appendectomy, you don’t have to worry about that.”

In the end, maybe the question isn’t whether we should change our bodies to change our minds—as cosmetic surgery does—or focus on changing our minds so we can think we’re beautiful as we already are.

Maybe the real question is why two people with the same nose—or wrinkles, or breasts or eyelids—can feel so differently about them. For one woman, it’s a curse, a defect, a problem to solve. For another, it’s just her nose or skin or eyes.

If we’re being honest, we all want to be that second woman. But, with apologies to the folks at Dove, many of us can’t simply empower ourselves to feel beautiful. So we rely on the knife—to cut and carve—and the injection—to plump and erase—and the laser and the fat-melter and the cellulite destroyer and whatever else gets invented next. Sure, it’s the second best thing. But it works.

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