By the time she was 14, Candice (not her real name) knew breast implants were for her. She'd seen the bulging—often fake—breasts of women in porn, and they mesmerized her, creating an artificial normal of the female form. "I guess I always saw women like that and I assumed you grew up and you [got breast implants]," she says.
Last year, in January, Candice, a 23-year-old hairstylist from Arizona. finally took the plunge. The surgical procedure took her from a 32C to a D cup; eventually, they ballooned into a triple D, the biggest size you can find at a Victoria's Secret.
Within a few months she began doubting her decision. The porn mirage of giant breasts evaporated into stabbing back pain, clothing that strained to fit her disproportionate body, and a blinding self awareness of her superficial appearance. The implants were nothing like she'd expected, and they didn't make her happy like she thought they would.
So in November, after 11 months, Candice went back under the knife for explant surgery. The whole ordeal cost her $10,000 and 12 weeks off work. As she recovered from the implant removal, Candice wondered why no one had counseled her—or other patients—about the possible psychological ramifications of cosmetic surgery.
"I just wished I had talked to somebody about it and I would never have done it," she said.
The research on satisfaction with cosmetic surgery is a mixed bag: A 2005 study found that 87 percent of patients were happy with their procedures, noting an improvement in their body image. But other studies indicate that those who spring for cosmetic surgery may be more likely to suffer from depression or low self-esteem, which can lead to worse outcomes. In 2003, a study of Swedish women found suicide to be more common among those with breast implants, indicating a greater presence of pre-existing mental disorders in that population.
Pre-surgery counseling is one way to screen patients who seek the operating room as a way to deal with other mental health issues. As the number of cosmetic procedures continue to rise—there were over 15 million procedures performed in the US in 2014, a 3 percent uptick from the previous year—some counseling services have emerged to guide people through the decision to go under the knife.
"It is a physical and emotional journey for a patient, so physical and emotional practitioners are needed," said Deborah Sandler, a psychotherapist based in the United Kingdom. Her practice, Cosmetic Surgery Counseling Services, has worked with hundreds of clients considering altering their appearance through cosmetic surgery, as well as less invasive procedures like Botox and fillers.
Sandler said she provides an objective space for clients to question their own motivation for surgery: Will they be satisfied after surgery or is it a case of body dysmorphic disorder, an obsession over physical flaws that are often imaginary? Is it to win a spouse back, or are they doing it for themselves? For other clients, it might be about aligning their expectations with the reality of what a surgeon can achieve, or helping them to find the surgeon best qualified to conduct a specific procedure.
"I don't have a vested interest in whether they choose to get it done or not to get it done," Sandler said. "My vested interest is if they are comfortable with the decision they make."
"Every surgeon should know how to operate. A good surgeon knows when to operate and a great surgeon knows when not to operate." — Dr. Charles Durrant
David Song, the president of the American Society of Plastic Surgeons (ASPS), said that any decent cosmetic surgeon should conduct at least some form of psychological screening before undergoing a procedure. He estimates that for every ten patients who come to his private practice, he operates on three or four.
"If there is even a hint of someone who doesn't seem stable or has off expectations, I just simply wouldn't operate," Song told me.
But not all surgeons abide by that rule. In the US, at least, cosmetic surgery is the Wild West of the medical world—anyone with an MD and access to an operating room can dip their toes into the field without specific training. The ASPS offers voluntary guidelines, which suggest members undergo at least a three-year plastic surgery residency, operate in an accredited facility, and adhere to a strict code of conduct including how they advertise. But those guidelines aren't mandated by law, and not all surgeons are equipped to psychologically screen patients.
"Every surgeon should know how to operate. A good surgeon knows when to operate and a great surgeon knows when not to operate," said Charles Durrant, of the British Association of Aesthetic Plastic Surgeons, quoting a surgical proverb. "There is never a field where that applies more than cosmetic surgery."
Recently, there's been a push for additional counseling to be offered—or, in some cases, required—to prevent patients from undergoing "unnecessary" cosmetic surgery procedures.
Michele Garber, of San Francisco's NipTuck Coach, a cosmetic surgery counseling service, says she offers "knowledge about the surgeries, about the emotions, and I also understand how consumers think." Garber entered the cosmetic surgery industry as a PR rep for New York City surgeons. But it wasn't until she experienced a handful of botched procedures herself—an allergic reaction to fillers, a scar from a laser appointment, and a dud facelift—that she realized patients might need a hand to hold while making decisions about cosmetic surgery.
Now, she works with patients from every age group, considering every type of procedure: a 17-year-old gearing up for a nose job, her second cosmetic procedure; a ballerina seeking a facelift; a woman in her 30s trying to balance out asymmetrical breasts; a middle-aged man looking into neck contouring. Garber said she receives no kickbacks for referring clients to surgeons.
The need for counseling has been exacerbated by what plastic surgery consultant Wendy Lewis calls the "demedicalization" of cosmetic surgery. Tacky advertising, reality television, and Groupons offering huge discounts on treatments have made plastic surgery seem like casual, like deciding to buy a six-week pilates course on DVD.
Lewis, who calls herself The Knife Coach and who has worked in the New York plastic surgery industry for three decades, said episodes of shows like The Swan—a reality TV show that aired between 2004 and 2005 and had contestants compete for a "total makeover" including cosmetic surgery procedures—would cause a flood of calls to her office the following day.
"It just brought out a certain type of client with expectations that were completely unrealistic," she said. "It is not what I do, not what I want to do, and not what credible doctors would do."
Still, most plastic surgery patients don't seek outside counseling before undergoing surgery, particularly for a younger generation of patients. Why pay a few hundreds bucks to see a coach or a counselor when a Google search on rhinoplasty will respond with 1.5 million results, including surgeon reviews?
"I very rarely get millennials. They believe everything they read online," said Garber, the NipTuck Coach."I know that the millennials really need someone like me, but they don't know it."
Candice, who had her breast implants taken out after 11 months, did all her research online, took the advice of anonymous people in chatrooms, and chose her surgeon based on reviews. The tables turned when the surgeon's staff insisted she write a Yelp review a week after surgery, before she had even healed.
"I guarantee that every woman has some kind of issue going on in their head," she said. "They would probably feel a lot better about themselves if they just went to counseling."
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