November 1, 2014
Unhappy with their Facebook photos, more, and ever younger, Americans are taking action and altering their appearance with cosmetic surgery. Teenage patients are particularly susceptible to the rising pressure.
By Katja Ridderbusch, Atlanta
The thought of her wedding pictures kept Carilee Dahl up at night for many years. The pictures haven’t been taken though, and it may be a while until that happens. Carilee is 17, and she hasn’t had a boyfriend yet. Carilee was convinced that her nose was the cause of all of the misery. It was really wide, she says. “I knew that whenever I’d see the pictures of my wedding day, my nose would have been the one thing that would bother me for the rest of my life.“ That’s why Carilee got a nose job. Now she can look forward to her wedding day.
Carilee Dahl is a typical American teenager. Her legs crossed, she sits in the voluptuously upholstered couch in her parents’ house in a Dallas, Texas, suburb, where the family recently relocated from Georgia. Carilee is a pretty girl with glowing cheeks; her brown hair is held in a bird’s-nest-like bun. Mascara-saturated lashes frame her eyes. She likes to dance and play soccer. She likes to go shopping with her girlfriends, she likes her iPhone, and she likes being online.
There’s just one thing she didn’t like: “I never wanted to take a selfie,” Carilee recalls. “I used to cry when I saw myself in pictures, because of this really ugly nose.”
She never posted photos of herself online, and she used pictures of kittens instead of profile shots. “Now, I like how I look in pictures,” she says. “Some people tell me I look pretty. And definitely, more boys talk to me.” That may be because of Carilee’s new nose, or because of her joy over it.
Carilee is a typical American teenager – and her surgery also makes her a trendsetter. According to a survey conducted by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), cosmetic surgery patients in the United States are getting younger. The majority of surveyed plastic surgeons reported that they saw, over the past few years, a distinct increase in patients under 30 requesting cosmetic surgery or injectables, like Botox or fillers. The most popular procedure among the younger age group is rhinoplasty, or a nose job.
Unlike in the U.S., patients in Germany seeking cosmetic procedures have been getting older. This year, the average age for cosmetic surgery is 41, the German Society for Aesthetic Plastic Surgery (DGÄPC) recently reported.
But America, not Germany, is the world’s largest market for cosmetic surgery, and its products are under constant and critical public observation. Something that actress Renée Zellweger just experienced when, after taking a little break, she returned to the red carpet without her signature hooded eyelids and set off a storm of speculation and spite on the Internet. Zellweger is 45, which is an age when Americans statistically enter the second round of their surgical makeovers.
The survey conducted among American plastic surgeons further shows that social media, like Facebook, Instagram, Pinterest, Snapchat, or the iPhone app selfie.im – almost all image oriented – play an increasingly important role in young people’s decisions to get their appearance polished for the virtual stage – with nips, tucks, cuts and shots. Social media have become a benchmark for self- evaluation and a scale for self-perception; a criterion for comparison; and a currency calculator in the competition for beauty, youth and productivity.
Dr. Louis DeJoseph is a plastic surgeon at Premier Image, a cosmetic surgery practice in Atlanta, Ga., and the one who operated on Carilee’s nose.
“Carilee was a pretty clear-cut case,” says the 42-year-old physician, who wears small metal-rimmed glasses in a friendly face. “She knew what she wanted. She wanted a more elegant nose, but she still wanted to look like herself.”
And indeed, Carilee’s new nose looks like a grown-up version of her old one and naturally blends in with her face.
Social media are young - Facebook started in 2004. Plastic surgery has been around for thousands of years; it was performed in ancient Egypt and Rome. Modern warfare gave a boost to this medical specialty. Over the past century, surgeons learned new ways to reconstruct the faces and bodies of soldiers and civilians, burnt, shot or disfigured by shrapnel.
Cosmetic surgery is plastic surgery’s lucrative twin, and images in all of their forms have become its most powerful vehicle: moving or still; in color or sepia; from Hollywood to television to YouTube; from pin-ups to Pinterest. Images and their message have pushed the demand for the skills and tools of plastic surgeons and made them a sought-after service on the global market of vanities.
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Dr. Kenneth “Ken” Neufeld comes directly from the operating room, still in his cobalt blue scrubs, the magnifying glasses dangling on a strip around his neck. He pulls the surgical mask off his face, crumples it in his hand and throws it across the hallway into a trash can; he then sits down in his office and crosses his legs. On this particular day, he had nine surgeries on his schedule. Among his patients was a 2-year old girl whose drooping eyelid was raised with a silicon thread, so the development of her vision wasn’t obstructed.
Another was a 92-year old woman whose eye socket after a life with a prosthesis had become scarred – and was bolstered up with skin from the inside of her lips. And there was a young man whose face was crushed in a car accident; the surgeon implanted a titanium plate underneath one eyeball in order to keep it from sinking into the sinus cavity. He also performed an upper eyelid lift, as well as an endoscopic brow lift.
Neufeld – slim, big eyes and an expression both confident and skeptical – is an ophthalmologist with the sub-specialty of oculoplastics, plastic eye surgery, at the Thomas Eye Group, a large practice with a surgical center in Atlanta. While the majority of his patients seek help for reconstructive issues – trauma, deformities, and tumors – a growing number also comes in for cosmetic procedures. With a focus mainly on reconstruction, his perspective on cosmetic surgery may be slightly different, he says, more conservative, or cautious.
“In my practice, restoring function often comes first,” he says. “That doesn’t mean I give the aesthetic part less attention.”
Like his colleagues, Neufeld has observed the rising influence of social media, especially among younger patients. They compare eyes, noses, lips, skin, hair, wrinkles, their actual age, their estimated age, and the age they feel like they’re at.
“They constantly compare themselves with others, or with the images of others, on social media,” he says. “And it’s slowly diffusing into their psyche.”
Their stories are almost all the same, says the 42-year-old physician. They see themselves in pictures, and they don’t like what they’re seeing. “All of that drums up an enormous pressure, and that’s driving a lot of patients to seek some sort of relief in cosmetic procedures.”
Neufeld doesn’t judge. After all, it’s part of his business. But he says he only operates when he and the patients are on the same page, when he finds the patients’ requests reasonable and their expectations realistic. Therefore, it’s not so rare that he sends a potential patient home. Often, but not always, it is the younger ones.
“With some of them, I just don’t see what they are seeing,” he says. Eyeballs that a patient thinks are protruding, eyebrows that allegedly are asymmetrical, or bags that don’t exist. “Those patients are clear cases of ‘no surgery’ in my book.” The reason is, that he can’t deliver what they’re looking for. “There’s just no way this could turn out well,” he says. “Some of those patients need a psychiatrist more than they need a surgeon.”
At times, he concedes, the lines between medical and cosmetic procedures can become blurry. And at times, especially among teenage patients, the longing for the scalpel may only at first glance seem absurd. The survey conducted among American plastic surgeons also shows that bullying is an important motive for teenage patients who seek plastic surgery - either as a response to being bullied, or to even prevent being bullied.
Neufeld stops in the middle of his sentence, pauses for a brief moment, starts again. Of course, he says, “it would be ideal if one could teach a kid to withstand the criticism and rise above it and become stronger and more resilient.”
On the other hand, he adds, cosmetic surgery has been known to improve self-confidence – and could therefore be helpful for younger patients. “The question remains: How crooked does a nose have to be, and how droopy an eyelid, in order to make cosmetic surgery a reasonable option?” he says, wearily shrugging his shoulders. “I’m really not sure.”
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Carilee was dead sure that one day, she would get a nose job. At least since the 4th grade, she says, when her classmates started calling her “Popeye”, after the popular cartoon featuring a sailor with a prominent, bulbous nose. The other kids made fun of her, all the time, “and it was always about my nose,” Carilee recalls.
She often came home crying bitterly, adds Carilee’s mother, Sheri.
It was Sheri who decided to take her daughter to a plastic surgeon, just for consultation. Sheri, a woman in her mid-40s, blond, trim and perky, had a facelift five years ago and was looking to get a refresher. After her visit to the doctor’s office with her mother, Carilee kept talking about the operation. Her parents finally agreed. The cost of her rhinoplasty was $6,000, but DeJoseph offered a discount, since mother and daughter decided to have their surgeries done on the same day; first Carilee, then Sheri.
While the teasing bothered her a lot, it wasn’t the main reason for Carilee to push through with the surgery. “The nose job was something I mostly did for myself,” she insists. Also, she didn't have a celebrity role model, she says, as do many of her peers.
Carilee’s career as a cosmetic surgery patient has just started. The next stop is already on the horizon: Botox.
The nerve poison Botulinum toxin, which was first used in the early 1980s to treat eyelid twitches and crossed eyes, was approved for cosmetic procedures, especially to smoothen wrinkles, in 2002. Under the trade name of Botox, it quickly conquered the offices of plastic surgeons, dermatologists and dentists, and found its way into beauty parlors and wellness temples. Botox has become a buzzword and a polarizer.
Some love it - in America more than in Europe - some condemn it, and some mock it, but everyone knows it. By now, Botox injections are the most requested cosmetic procedure in the world. In the U.S. alone, the demand has risen by 111 percent since 2004.
When Ken Neufeld started out in private practice 10 years ago, Botox still had a somewhat dubious reputation. Patients rarely spoke about Botox treatments in public, and doctors were afraid to embarrass or compromise their patients by recommending it. That has changed, radically, says Neufeld. “Botox has gone from a complete taboo to an accepted cosmetic standard.”
For many people, he adds, Botox today is part of maintenance they do on their faces. “It’s almost like getting your teeth cleaned,” he says.
Botox has been a game changer for the beauty industry – and has democratized the cosmetic surgery market. Unlike with surgery, there’s no downtime and little risks; the results are temporary and the costs reasonable – between $400 and $600 per set. Neufeld says he likes to work with Botox. He finds its marketing campaign almost as intriguing as its effect. “Social media have played a huge role in pushing Botox to the public.”
Therefore, it’s no surprise that patients requesting Botox are getting younger, too. A few years ago, the toxin was known as a quick fix for women at the far foothills of youth. Today, in the United States more and more women and men in their mid-to-late-20s decide to get Botox injections – as a preventive measure. “Patients are more proactive now,” says plastic surgeon DeJoseph. “They don’t wait until the first wrinkles appear.”
Carilee thinks that’s pretty plausible and therefore wants to start using Botox in a few years, too.
Even patients under 20 are getting Botox shots these days – for cosmetic, not for medical purposes. About 18,000 teenagers per year in the United States get the injections, and the number of unreported treatments are likely to be higher.
“Too early,” says DeJoseph when asked about teens and Botox injections.
Neufeld raises his hands defensively. “Clearly: No. I can’t think of one reason to justify that.” He has two young daughters himself. “And I couldn’t imagine why I would ostracize them and make them more of a target than anything else,” he says.
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Ken Neufeld and Louis DeJoseph expect the trends to continue; that the age when patients start having cosmetic procedures will keep going down, and the power of social media will keep rising. And they also know that for every treatment at every age, there’s always a doctor who’s willing to do it.
The physicians point out, however, that most of their patients aren’t solely going for a look that’s ever more youthful and maybe, down the road, ever more uniform. Most importantly, people seeking cosmetic procedures want to look as if they were just coming back from a vacation, from fun and play, and that applies to all age groups. “Looking rested signals productivity and accomplishment,” Neufeld says – at work, in school, even in your personal life. Looking tired, on the other hand – like a surgeon after a long day in the operating room for example – can be a delicate and for the most part, unwanted thing, at least in America. Neufeld raises his eyebrows, stretching his lips into a thin half-smile. “I guess it depends on how you wear it,” he says.
Looking tired is not a concern for Carilee Dahl these days. She is only 17. And, after she’s gotten a new nose, and after her dark thoughts have been shattered to pieces, perhaps she can sleep well at night again - and even dream about wedding pictures.
This is a translation of an article that was originally published in the German daily national “Der Tagesspiegel” on Nov 1, 2014
© Katja Ridderbusch