Dr. Eskenazi, a nationally recognized expert on breast reconstruction after cancer, began her medical career believing that she would become a psychiatrist. Her interest in psychology combined with a lifelong study of art, mythology, and anthropology has given her an unusual window into the interior landscape of her patients. What she has found is that the desire for external transformation through surgery is connected to internal transformation, most particularly at key moments of transition in a woman's life. Although some eight million women a year have some sort of procedure done, cosmetic surgery is still identified with excessive vanity, narcissism, lack of authenticity, and psychological weakness with the path of least resistance being to deny having had it. By framing cosmetic surgery in a more deeply spiritual and psychological way, Eskenazi takes on this culture of shame and refutes the idea that cosmetic surgery and internal change are antithetical. Whether women decide to have cosmetic surgery or not, this book will provide them with a different vision and a context for understanding their decision.

More Than Skin Deep

HarperCollins Publishers, Inc.

Chapter One

Cosmetic Surgery and the Promise of Transformation

Some twenty-five years ago, I went to medical school to become a healer. I chose plastic surgery because the transformation it offered patients was immediate and life-changing. As a young medical student, I witnessed cleft lips made whole, birth defects rectified, and missing body parts re-created, and I fell in love with the extraordinary promise offered by the specialty. I traveled to foreign countries as part of a surgical team that in real and visible ways altered the lives of hundreds of adults and children over the course of a few weeks. I saw that each life and each surgery was unique, and I felt sure and confident that this was medicine at its finest and most personally fulfilling.

Now, having performed roughly ten thousand surgeries and undergone three procedures myself, I spend my days as the founding partner in an all-women's practice in San Francisco, where I devote half my time to breast reconstruction after cancer and half to cosmetic surgery in all its forms. I now see that the healing we offer as surgeons isn't always as clear-cut as it once appeared, and that cosmetic surgery raises questions and concerns I didn't anticipate when I was just beginning.

I've grown troubled as cosmetic surgery increasingly becomes, with each passing year, a commodity in American life, a readily available answer to dissatisfaction with all aspects of the physical self. Where it was once the province of the rich and famous, it's been fully democratized. It no longer needs to be done in Beverly Hills or Manhattan or cost a fortune, and more and more women each year from all over the country are choosing it. Information about procedures as well as local advertising from doctors offering their services are readily available on the Internet, testifying to the ubiquity of this surgery. Type in "cosmetic surgery" on Google and you'll get more than 1.5 million matches.

Each year, more and more American women elect to have cosmetic surgery, and the trend shows no sign of abating. More than 10 million surgical and nonsurgical procedures were performed on women in 2005, and by the time you read this, the number will undoubtedly be higher, as it has been with each passing year—a reflection of cosmetic surgery both as a cultural fact and a phenomenon. It has become a reliable growth business: In a single year—between 2003 and 2004—the number of abdominoplasties increased by 28 percent, the number of breast lifts 19 percent, the number of liposuctions 28 percent. In 2004 the number of breast augmentations went up 9 percent, and the abdominoplasties another 12 percent.1 This growth shows that cosmetic surgery has become just another product in our consumer society.

These are seismic changes and are having an effect on our culture and how we think about beauty, age, and our bodies. But we don't appear to have developed the philosophical tools we need to understand how these changes can help us live better and more fulfilled lives in the future or how these changes may, in the alternative, make personal happiness more elusive.

I actually had the opportunity to see how quickly attitudes toward cosmetic surgery changed when I participated in teaching a course in biomedical ethics at Stanford University in the early 1990s. I lectured undergraduates on body modification and plastic surgery for several years, and during that time, I witnessed an extraordinary shift in attitudes. The first year I taught, I asked my students if they would ever consider plastic surgery, and their answer was a resounding "No way!" They were judgmental about people who chose to alter their appearance. The second year, the answer was still a categorical no, but this time, a number of students knew someone who had had surgery and they were mildly curious about the possible benefits plastic surgery could bestow. Astonishingly, by the third year, one-half of the class answered that they would, indeed, opt for surgical improvement, although they remained troubled by how plastic surgery had the potential to install uniform standards of beauty in a culture. By the fourth year, when I asked the question, the class was solidly in favor of cosmetic surgery and said they would absolutely avail themselves of it; their only caveat was cost. In fact, by then, they thought it should be covered by health insurance. For better or worse, young people are more flexible than their elders.

For our children and their children, cosmetic surgery will actively shape how our culture defines feminine beauty, assesses physical "perfection," and responds to the process of aging. In the face of a growing demand for the improvement and refinement of the physical characteristics we're born and age with, my profession will continue to be motivated to seek out new techniques, which will, in turn, bring in more patients. In the future, we'll be seeing the patient pool—now concentrated between the ages of thirty-six and sixty-four, with the majority of women between forty-five and fifty-five—get younger as procedures are performed earlier to stave off the early signs of aging and as "proactive" surgery becomes the norm.

While this should make me feel good about a wise career choice, it gives me pause.

As a woman, a doctor, and a patient, I feel we've reached an important watershed moment. Contradictions abound when it comes to cosmetic surgery. First, for all that Americans seem fascinated by and drawn to the promise of improvement that cosmetic surgery offers, they also believe that those who choose it are weak and insecure. Even as scientific research begins to decipher the complex relationship between the mind and the body, popular culture continues to insist that the mind and the body are separate and that the "mind" is morally superior to the body. What this means in practical terms is that women who choose to have cosmetic surgery for reasons that might be healthy and self-affirming will nonetheless be stereotyped as vain or overly concerned with appearance. As a result, there's no dialogue about how changing the body can and does change the "self" or the mind—even though there is plenty of scientific evidence at hand.

Excerpted from More Than Skin Deepby Loren Eskenazi Copyright © 2007 by Loren Eskenazi. Excerpted by permission.
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