Lesson 16 The Price of BeautyThe government’s sudden decision to ask for a halt to breast-enlargement operations because they might be unsafe has terrified 2m women who have had them. Is America’s obsession with looking good unhealthy?11. “Get in shape” orders the cover of the latest issue of Los Angeles magazine. Alongside articles detailing where Madonna works out and recommending “apres-shop spas2” are familiar advertisements offering a quicker route to beauty through “facial sculpture”, liposuction and breast enhancement3. Cosmetic operations, once closely kept secrets, now appear as prizes in southern Californian charity raffles4. Meanwhile morticians complain that silicone implants, which do not burn, are clogging up their crematoriums.52. Los Angeles, a desert city which made up for its lack of natural endowments by stealing other people’s water and building its own port, is an appropriate capital for America’s $3 billion cosmetic-surgery industry. Nearly half the world’ s cosmetic surgeons live in America; a third of those work in California. Cosmetic surgery arguably began in San Francisco in 1964 when a topless dancer, Carol Doda, caused a national sensation by increasing her appeal with the help of 20 silicone injections.3. Until recently the most remarkable thing about cosmetic surgery in America, was how unremarkable it was. There were probably 2m cosmetic “procedures” in 1991-six times the total in 1981. It is no longer news that stars such as Michael Jackson, Liz Taylor and Cher have “gon e under the knife”; one talk-show hostess, Joan Rivers, talks about her body’s ebbs and flows as if they were as natural as the tides.64. Now those “effortless’ good looks seem a little more risky. Allegedly, the silicone implants can leak and interfere with the body’s immune system. There have been over 2,000 complaints, particularly about implants which predate 1985-although cosmetic surgeons blame zealous lawyers for manufacturing concerns.7 The Food and Drug Administration (FDA) announced an inquiry last year, but initially said it would not ask for the operations to stop before it reported. It changed its mind on January 6th, reportedly because of evidence coming out in court cases. In December, for example, a woman who suffered from a ruptured implant8 was awarded $7.34m from the biggest maker of implants, Dow Corning.5. The announcement has caused more panic among American women than any medical decision since a contraceptive device9, the Dalkon Shield, was removed from the market in 1974. Some 2m women have had implants, 80% of them for cosmetic reasons; the rest had “reconstructive” medical surgery following cancer treatment. The waiting list for implants by one Californian doctor used to be six months; it is now less than one month. Shares in implant makers have slumped.106. Such second thoughts are overdue.” For all its glittering advocates, cosmetic surgery is the only type of medicine where a perfectly healthy patient is cut up. (This, of course, omits reconstructive operations to repair burns or replace missing breasts.) Eight out of ten cosmetic operations are performed outside proper hospitals-some in operating rooms that look more like offices. Warnings of side-effects rarely appear in advertisements; nor do the records of the eager surgeons. Since it is “elective” surgery, not covered by insurance, few of the normal rules apply.7. Inside the industry rumours of malpractice are rife12. One senior plastic surgeon says that hehas a list of peers who he “wouldn’t let touch my dog’s haemorrhoids”.13 The American Medical Association seldom intervenes; neither, until recently, did the FDA. The cosmetic industry itself is split into several warring associations, who refuse to co-operate even on statistics, let alone standards and certification14.Bigger and bigger8. New rules may discipline the industry, but they are unlikely to stop it growing unless the American obsession with physical beauty sours. So far, surgeons say the recession has done more harm to their business than the bad publicity about breast implants; hence their confidence that trade will pick up. That still leaves two questions unanswered: why is cosmetic surgery so popular in America; and, even if it is safe, is it a good thing?9. A string of global industries-fashion, cosmetics, fitness-show that it is not just Americans who want to look good. A few countries, notably Brazil and Japan, have fast-growing cosmetic-surgery businesses. But America stands out as the only country where cosmetic surgery carries virtually no stigma. That is partly the result of good marketing. As many as 15,000 doctors now rely on cosmetic surgery for a fair chunk of their income-and they are allowed to advertise aggressively.10. However, on the whole, America’ s cosmetic-surgery business has been built on demand rather than supply. That demand comes from Americans of all ages, classes and races. One recent survey found that nearly one in three patients had an income below $25,000 a year-not much when most operations cost over $3,000.11. According to the American Academy of Cosmetic Surgery, breast enlargement, which costs between $2,000 and $4,000, was only the tenth most popular cosmetic procedure in 1990. Topping the wish list was sclerotherapy (the removal of spider veins15 in the legs), followed by collagen injections to get rid of facial lines, then nose-jobs, lip-jobs and liposuction (fat removal). But among clients of the rival American Society of Plastic and Reconstructive Surgeons, breast enlargement, collagen injections and eyelid surgery were roughly equal as the three most popular operations.12. When pushed to defend their trade, cosmetic surgeons argue that “vanity surgery” is often just an extension of reconstructive surgery. For example, redesigning the nose of a young boy, perpetually :eased because of his prominent conk16, can turn a problem teenager into a well-adjusted man. Cosmetic survey follows two great American traditions: a refusal to surrender to an environment and a willingness to give people a second chance. What is the difference, some ask, between removing excess fat in an hour on the operating table and three months in the gym? “I don’t intend to grow old gracefully,17” says a woman in a television advertisement for an ambitious skin cream, “I intend to fight it every step of the way.”13. Many, however, admit that there is a darker side. Psychologists point out that many operations are not to get rid of deformity18, but to make perfectly good looks even better. The Los Angeles Times recently reported that the beginning of the swimsuit season prompts a rush of breast implants; school reunions are good for the face-lift business.Growing old gracelessly14. Such competitive narcissism19 stretches into employment too. Larry Schoenrock of the University of California at San Francisco points out that good-looking people are more likely to get jobs. Most are women aiming to please prospective male bosses; but many male patients citetheir careers as the chief reason for going under the scalpel20.15. For ethnic minorities, the most popular operations are ones that change their racial characteristics. Asians want wider eyes; blacks want thinner lips. Critics say this is surrendering their identities to the white stereotypes that appear on the media. Surgeons say the point is more subtle: minorities want to de-emphasise rather than eradicate their looks21. For example, one Californian surgeon says that many blacks specifically ask that, after their operations, they should not look like Michael Jackson, who now has a “white” nose and “white” skin.16. Some trend-spotters22 detect the beginnings of a reaction against the knife. Non-surgical methods to reduce wrinkles, such as electronic massage machines, are selling fast. Last year the number of face-lifts completed increased by less than 1%. Cosmetic surgery can only hold back age; it cannot defeat it.23 Mr. Jackson, who has been described as the Peter Pan24 of the music industry, might reflect on Maurice Chevalier’s sanguine attitude25 to the appearance of a few wrinkles. “I prefer old age to the alternative,” he said.From The Economist, January llth, 1992。