Skin Deep

Don't like your face? Your breasts? Your tummy? Get yourself new ones. Plastic surgeon Ernest DiGeronimo makes the kindest cuts.

Two weeks later, John is experiencing a normal amount of stuffiness and swelling, but otherwise he's quite pleased. "I think it looks much better," he says. "My nose is thinner, my ears are pinned back. It was just something that bothered me."

John is something of an anomaly. Only about fifteen percent of all plastic surgeries performed in the U.S. are done on men, according to the American Society of Plastic and Reconstructive Surgeons, but here in Florida some surgeons report 25 percent male patients. DiGeronimo says a mere five or ten percent of his patients are men. And while appearance matters to men, it doesn't play the overwhelmingly central role it does in women's lives.

The women who come to see DiGeronimo apparently feel driven to look younger and sexier by any means necessary. Breast surgery is particularly popular among younger women, even in the wake of class-action suits against manufacturers of silicone implants and growing medical concerns about the effects on the immune system of saline implants. All the controversy, in fact, ultimately boosted DiGeronimo's business, because it raised awareness about breast surgery and led to an upsurge in women seeking replacements for their silicone gels. And in the doctor's view, the need for his women patients to have bigger and better breasts is perfectly understandable: "When you're a female with small breasts, you want to have bigger breasts. They feel it gives them an advantage in a competitive world."

A few days before her scheduled breast surgery, a 30-year-old mother of two, Juanita, is getting a final checkup and talking about breasts with a woman who had her breast job a week earlier. Amy, a perky young blonde, is proud of her new breasts, pointing out she was only slightly flat-chested before the operation, and yet insisting, as almost all of the women coming to the office for cosmetic surgery insist, that she's not really doing it to attract new men into her life. "It just looks more appealing in bathing suits," she explains. "You feel more confident because you look better."

As for Juanita, she didn't like the way her breasts shrank after she stopped nursing her last child, and these days she's too ashamed to take off her shirt when she makes love to her current boyfriend. "I feel bad about my breasts," she allows, but, typically, she claims, "I'm doing this for me."

Not quite, if certain experts are to be believed. Charles Carver, a professor of psychology at the University of Miami, cites genetically coded evolutionary pressures as the hidden engine behind cosmetic surgery. "The vast majority of cosmetic surgery is done on women," Carver explains, "and this is consistent with the evolutionary goal of a female to attract suitors and to give every appearance of being young and fertile in order to be a good breeding partner." Even if reproduction isn't part of a woman's conscious reason for seeking cosmetic surgery, Carver adds, "The desire to be attractive is one that never goes away," no matter if a woman already has a mate.

The same principles of evolutionary psychology apply equally to older women, argues Robert Wright, author of The Moral Animal. "Plastic surgery is a way of fooling the age-detection mechanisms of men, who are designed to prefer younger women," he theorizes. "These women are playing a game shaped by evolutionary logic."

Female therapists, on the other hand, point to a range of social -- not genetic -- pressures on women that help goad them toward plastic surgery. "Women keep getting messages from the culture to look younger and thinner," notes Adrienne Ressler, a therapist who specializes in body-image issues at the Renfrew Center, a women's mental health clinic in Coconut Creek. "It leads to the relentless pursuit of perfection. They're buying a mythical product -- physical perfection -- that doesn't exist." Up to a third of the Broward County center's patients, who are treated for eating disorders, sexual abuse, and depression, also have submitted to plastic surgery, far higher than the average in the general populace. Ressler believes that many women's reliance on plastic surgery is similar to the impulse behind excessive dieting. "It's really sad," she says. "It's all part of a movement to deny being human."

Whatever drives women to indulge in cosmetic surgery, there's little doubt that many of them want to change as much as they can about themselves. For instance, over the last year, 45-year-old Maria has had a tummy tuck (a horizontal incision in the skin covering the abdomen that permits the tightening of skin and the removal of fat), liposuction, and a nose job at DiGeronimo's office. Now she boasts that her husband calls her "the teenage mom." (She's so proud of the changes that she asks the doctor to show off her "before" pictures: a flabby woman with folds of flesh on her abdomen, thighs, and buttocks, all marked up with blue pencil lines like a butcher's diagram of the parts of a cow.)

These days women are seeking cosmetic surgery at earlier ages than ever before. At least one Dade County plastic surgeon, Dr. Carlos Wolf, has said that several women under the age of 30 have clamored for face-lifts. Adds DiGeronimo, "Fifteen years ago, if somebody in their forties came in asking for a face-lift, you'd throw them out the door and say they're nuts." Now these baby boomers (ages 31 to 49) make up the largest segment -- 41 percent -- of cosmetic surgery patients. The national plastic surgery group, ASPRS, reports that liposuction, eyelid surgery, and collagen injections are the three most requested procedures by baby boomers, who have been shaped by the youth culture of the 1960s and are disturbed by aging, according to Marcella Bakur-Weiner, an adjunct professor of psychology at Marymount Manhattan College who has written books on aging and body image. "My generation wasn't hung up on getting older," says the 69-year-old Bakur-Weiner. (DiGeronimo's pattern of surgeries on baby boomers reflects the national trends, although he does more face-lifts for this group.) Although there are still plenty of women in their fifties and sixties who want to turn back the clock, there are increasing numbers of women in their early forties -- or younger -- who tell DiGeronimo "I want to stay young and look more refreshed," he points out.

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