The Making of theModern Face:Cosmetic Surgery /BYELIZABETHHAIKEN

n November 11, 1960, Rod Serling invited CBS viewers to joinhim in The Twilight Zone. The episode that aired that night"TheEye of the Beholder"begins as Patient 307 (later identified asMiss Janet Tyler), her head swathed in gauze, waits in her hospi-tal room. "I never really wanted to be beautiful," Tyler tells herdoctor. "I just wanted people not to scream when they looked atme." Her doctor is sympathetic and confides his confusion to anurse: "What is the dimensional difference between beauty andsomething repellent? Why shouldn't people be allowed to be dif-ferent?" But with Tyler, he is regretfully stern. She has exhaustedher state-rationed medical opportunities, he reminds her; shouldthis effort prove unsuccessful she will be "allowed" to move into aspecial area where people of her type have been "congregated."Tyler protests: "The state hasn't the right to penalize someone foran accident of birth...hasn't the right to make ugliness a crime!"The doctor shrugs helplessly, lights a cigarette, and turns away.

In true Serling style, the twist at the end is starding, if pre-dictable. In an oddly ethereal sequence, the layers of gauzeunwind to reveal the teen beauty queen face of Donna Douglas.The doctor and nurses gasp in horror, and the camera finallypulls back to reveal a society of aggressively identical pig-likebeings, which has no room for someone like Janet Tyler.

In 1960, this episode could have been interpreted in a numberof ways: as a pointed comment on the McCarthy era (the pigfaces being reminiscent of George Orwell's 1984); as a critique ofconformity (the vision is as chilling as the one Kurt Vonnegutdescribes in Harrison Bergeron, in which piercing noises stymie

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intellectual creation and weights tie dancers to the ground); as acomment on the burgeoning civil rights movement (there is nomistaking the message about the kind of society created throughpractices like segregation); even as a sally in the American Med-ical Association's campaign against "socialized medicine" (thenot-so-veiled reference to the rationing of medical care). But itwas taken as none of these. The collective memory of those whosaw this episode is that it was about beauty, and about the pecu-liarly unforgiving culture of modern America, which had set cer-tain standards and rewarded those who met themand whichhad invented cosmetic surgery for those who did not.

Cosmetic surgery is one branch of what we now call plasticsurgery (from the Greek plastikos, to shape or mold). Precedentscan be traced around the globeto India, hundreds of years B.C.,where members of a brickmaker caste tried to reconstruct nosescut off as punishment for adultery; to sixteenth century Italy,where Gasparo Tagliocozzi pioneered techniques to repair thefacial scars that resulted from frequent duels (Stark, 1975, 509-510)but the history of plastic surgery is essentially a twentieth-century story.

At the turn of the twentieth century, cosmetic surgery appearedto contradict both the traditional American injunction againstvanity and the Hippocratic injunction against doing harm andreputable surgeons, who derisively called it "beauty" surgery, gen-erally refused to perform it. Now, at the turn of the twenty-firstcentury, cosmetic surgery seems to embody the American dream,and physicians of all persuasions cannot hang out their shingles(or launch their websites) fast enough. And despite its interna-tional origins (and its apparendy increasingly internationalfuture), the story of the branch of plastic surgery we call cosmeticsurgery is essentially, and peculiarly, American.^ In the early partof the 20th century, Jacques Joseph perfected noses in Berlin,Suzanne Noel smoothed wrinkled brows in Paris, and during thefirst World War, French, British, and American surgeons workedtogether in wartime surgical services as pioneers in what was thenknown as maxillofacial surgery (Barsky, 1978, 1019). Only in the

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United States, however, did this experience translate into a post-war boom in cosmetic surgery.^

The culture that produced cosmetic surgery is the increasinglyvisual, psychologized culture of the twentieth century UnitedStates. Early in the twentieth century, the intertwined processesof industrialization, urbanization, immigration and migrationtransformed the United States (Higham, 1973; Kraut, 1994).From a predominantly rural nation, in which identity was firmlygrounded in family and region, and in which wrinkles and sag-ging breasts were simply facts of life, the United States became anincreasingly urban nation, in which identity derived from self-pre-sentation (Susman, 1984, 273-274)and in which wrinkles wereno longer facts to be accepted but "problems" to be conquered.Proponents of aesthetic surgery, who began to discuss andemiphasize the social and economic importance of externalappearance, were inspired by this new culture even as they them-selves helped to shape it. In more recent years, the extension of awestern (and by nature westernizing) visual culture around theglobe has influenced both the desire for aesthetic surgery and itspractice. Just as in the 1920s movies and fan magazines taughtyoung American women that beauty looked a certain way, todayyoung Asians and Africans cannot help but come in contact withAmerican fashion magazines and American movies, which famil-iarize them with Western ideals of beauty.^

Cosmetic surgery is one of the fastest-growing medical practicesin the world. The American Society for Aesthetic Plastic Surgeryrecendy reported that more than two million Americans electedto undergo cosmetic procedures, both surgical and non-surgical,in 1998an increase of four percent over the previous year. Andsince this organization's statistics cover only activities reported bythree specialty boards (plastic surgery, dermatology, and oto-laryngology), the number of procedures performed in NorthAmerica alone is clearly higher. Worldwide, from China to Peru,the number of people who are convinced that anatomy does notequal destiny increases each year (Hoge, 1980; Stanley, 1995;Koop, 1998; Pomfret, 1999). And while much is made over body

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sculpting, the fact that, in 1998, liposuction continued to rankfirst in popularity and breast augmentation inched back up to sec-ond should not obscure the fact that the procedures ranked num-bers three, four, and fiveeye surgery, face lifts, and chemicalpeelsall concern the face, which remains (even in these Bay-watch days), the locus of individual identity.^

The words used to describe their work have changed over time,but for those who practice cosmetic surgery, thinking about themeaning of their workits historical precedents, its cultural con-notations, its implications for the futurehas been as important(and at least as challenging) as learning to use a scalpel or a laser.

That facial surgery is grounded in complex questions of gen-der, race, culture, and personal identit)' was clear to the pioneersof this specialty. During and immediately after the First WorldWar, surgeons spoke and wrote in unselfconscious terms aboutthe fact that their goal was to recreate a face that would enable itswearer to function in a society in which the male roleideally, afamily breadwinner but at least self-supporting^was well defined.As one surgeon put it, "We know from a considerable experiencethe patient... will undergo untold hardships to be restored to thenormal..." Attempting to amplify the meaning of normal for sucha patient, the surgeon explained that the question, "What is theuse of life if he is not in a condition to seek and earn a liveli-hood...," was paramount. The goal was a masculine identity andthe means to it was an acceptably male face (The New York Times 14June 1918; Ryan, 1918, 69; Vanderbilt, 1916).

The question of facial configuration and social identity becameeven more important after the war; in fact, during the 1920s and1930s it dominated plastic surgeons' world. Surgeons' preoccu-pation with the idea of an individual identity that was also anAmerican identity is easier to understand if one considers thecontext. The second wave of immigration from Europe to theUnited States began around 1890; unlike those who rode the firstwave, who hailed largely from the British Isles, these new immi-grants came from the darker lands of southern and eastern

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Europe: Russia, Poland, Italy, Greece. Can it be a coincidence thatone of the first references in the United States to a "Jewish nose"in the context of plastic surgery dates from a text written in 1892?(Roberts, 1892, 231-233).

In 1921 and 1924, in a cultural climate permeated by "scientific"racism and eugenic thought, the U.S. passed restrictive immigra-tion laws whose goal was to reconstruct the identity of the nationby changing its face. These laws virtually ended immigration fromAsia and set strict quotas that privileged northern and westernEuropean immigrants over those from southern and easternEurope. In retrospect (and to at least some contemporaryobservers) these new restrictions signaled an attempt to turn backthe clock, to return to a time which, if not idyllic, was at least peo-pled by those perceived to be familiar, similar, easily assimilable.In 1923, when the beloved Jewish comedienne Fanny Briceexplained that she got a nose job because she wanted to play therole of Nora in Henrik Ibsen's play A Doll's Home, The New YorkTimes hailed her as "the intrepid Fannie, whose motto is 'all for artand a nose well lost'"but Dorothy Parker's quip that Brice had"cut off her nose to spite her race" was widely quoted (The New YorkTimes 15 August 1923 and 16 August 1923; Katkov, 1953, 141).

And, in fact, evidence from published studies and medicalrecords suggests that the concept of "identity" was key for Jews (asit would become later for members of other racial and ethnicgroups) in several ways. Those who sought surgery shared a beliefthat Americans "read" faces, ran them against familiar stereo-types, and from this made assumptions about identity and char-acter. Moreover, they shared a conviction that altering the termsof this exchange would liberate them to create their own individ-ual identities. As Arthur Steelman (nee Schulberger) told soci-ologist Frances Cooke Macgregor around mid-century, "I wanteda Jew to know I was a Jew...At the same time I didn't want othersto know I was a Jew. At first I was horrified when I looked like anIrishman. I was a man without a country. Now I'm beginning toget used to it" (Macgregor, 1974, 103-105).

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The question of identity is also central to the history of the face-lift. Physicians performed face-lifts as early as the 1920sper-formed, in one case:, quite literally, when an aging actress had herface lifted in front of an audience of beauty shop operators andreporters. Not until the 1960s, however, when what fashion edi-tors dubbed the "Youth Quake" rocked the nation, did surgeonsbegin to wresde en masse with the question of the effect of agingon female identity. In her 1956 Clamour Book, beauty advisor LilyDache warned women, "Today, there is no excuse for a woman togrow old, unless she is ill...If you want to keep up with this mod-ern, wonderful world, you must be young in thought, feeling, andappearance" (30-31). In the more down-to-earth McCalls, writerEugenia Harris agreed: "Up to a point, being an old hand [ir\thefashion business] gives us an advantage. But then suddenly thatpoint is passed. The very shm, very chic, but obviously maturewomen of last year suddenly remind you of the tall, gaunt, mad-women of Chaillot...It's not quite decent that they're still work-ingto say nothing of looking for jobs" (1961, 78-79).

Today, when mass-market magazines and newspapers routinelyrun cleverly designed advertisements enticing readers to changetheir lives by changing their faces and bodies, mid-twentieth cen-tury marketing efforts look pretty tame. As these two stories sug-gest, however, even when they tried to be cautionary, surgeonsoften encouraged prospective patients to think in terms of sweep-ing transformation. The first of these stories ran in AmericanWeekly, a widely distributed Sunday newspaper supplement, in1946. The caption reads "To a homely girl, life may seem an end-less succession of Embarrassments, Frustrations, and Anguishuntil she decides, one day, to ... have a plastic surgery operation.Then a remodeled nose, a rounded chin, may alter her personal-ityand her whole life." The accompanying illustration, whichdepicts, first, a disconsolate secretary sniffling and doodling cari-catures of large noses as her boss ignores her, and second, thesame secretary with a smaller nose basking in the welcome atten-tions of said boss, underscores the idea of unlimited possibility(Potter, 1946).

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The idea of transformation is equallyif perhaps unintention-allyreplicated in an Esquire article from 1965, in which a sur-geon told his interviewer, "I had a woman patient recendy; a verysmart, chic, well dressed woman...she wanted a facelift...she wasmarried to a veiy responsible man in an upper income bracket,and she wanted to look better for her husband. It soundedokay...Later on I heard she absolutely ran amokdivorced herhusband, ran ofif to Mexico, took a twenty-five year old boy as aloverthe whole route. It was dreadful." Dreadful, perhaps, forthe surgeon; probably dreadful for the unsuspecting husbandbut for the middle-aged woman sidelined by the youth culture ofthe 1960s who stumbled across this article as she waited her turnin the beauty shop, dreadful is probably not the word that cameto mind (Harris, 1965, 134-136).

.....--throughout the 1960s, when surgeons meditated on the ques-tion of aging and its effects on identity, they were clearly con-cerned only with women. When they did mention men, it wasonly in the context of comparison: whereas aging was widely per-ceived to alter female idendty in a negadve way, it brought bene-fits to men, who were perceived to become more powerful, notless, as they aged (Davis and Davis, 1975). Surgeons were doubt-less infiuenced as well by the homophobic culture of Americanmasculinity, which held that "real men" did not care about theirlooks (ergo: men who did care were suspect) (Alvarez, 1957). AsLos Angeles surgeon Michael Curtin put it, any man consideringa facelift was "either an aging actor, a homosexual, or both" {SanFrancisco Examiner 4 August 1972).

In 1961, Coronet broke new ground with a report of a study of53 West Coast menmiddle class, heterosexual commission sales-men and sales managers in their 50s and 60s^who had foundfacelifts extremely beneficial (one year later, their incomes hadincreased, on the average, by $1,300). Foreshadowing the hun-dreds of ardcles that would follow in publications ranging fromEorbes to Gentleman's Quarterly, author Marilyn Mercer explained,"We put such a premium on youth today that a more youthfulappearance may be necessary for survival" (1961)an observa-

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don that has an eerily prophetic ring to it more than thirty yearslater, when stories of down-sized, middle-aged men who resort toeye lifts, face lifts, liposuction, and hair transplants to reconstructa more masculine, more youthful, more powerful identity are socommon they seem like tropes (Kelly, 1977; Business Week, 1980;Psychology Today, 1983).

For those who perform cosmetic surgery, the relationshipbetween the physical face and the construction of individual iden-tity has always been and continues to be central. It is also some-thing of a catch-22.^

If cosmetic surgery is not about identityif, in other words, it'sonly about changing external appearancethen it's not deepand meaningful but superficial; it may not even be medicine.

This is a stance that most practitioners have rejected. Just as thefirst generation of surgeons struggled to distance themselves fromwhat they perceived as the less than honorable history of the "bar-ber-surgeon," they fought long and hard to shed the pejorativelabel of "beauty doctor." The surgeons did this, in part, by orga-nizing themselves into associations (and, a bit later, into specialtyboards), by prescribing standards in education, training, and pro-fessional behavior, and by enforcing these standards (granted,with varying degrees of success) through examinations, licensingrequirements, and self-policing (Davis, 1926, 203-210).

Just as important, they formulated an ethical and philosophicalfoundation for the practice of altering appearance throughsurgery. Medicine, they said, has evolved from a preoccupationwith curing disease to a concern with the wellness of the wholeperson. Individual well-being depends on mental as well as physi-cal health, and a mentally healthy person is one who feels com-fortable functioning in the society in which she or he lives.Medical practitioners have accepted, even embraced, the convic-tion that their mission is to repair the disjunction that candevelop between the internal and the externalto facilitate "well-ness" by facilitating the development of an identity that feelsauthentic. Thus, they argue, cosmetic surgery is properly aboutidentity.^

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Granted, if they are to maintain their status and their self-imageas responsible professionals, medical practitioners simply cannotsay, "Let's face it, it's all about what sells in the market." But toacknowledge that cosmetic surgery is about identity is to raisesome troubling questions. Within the context of the medical pro-fession, accepting this connection naturally invites the question ofwhether cosmetic surgeons (not to mention ear, nose, and throatspecialists, dermatologists, general surgeons, and others who rou-tinely perform surgical procedures that we would define as cos-metic) are the appropriate professionals to deal with this issue.The first generation of plastic surgeons argued that a mark of"progress" in twentieth century medicine was the recognition thatpsychological functioning is just as important as physical func-tioning. They congratulated themselves for recognizing this asearly as the 1920s and 1930s and for providing the services theirpatients needed (smaller noses, smoother brows) to functioneffectively in consumer society. But the relationship betweenthose who practice "physical medicine" and those who practice"mental medicine" (psychiatrists, psychologists, psychotherapists)has not been smooth. Currently, it ranges from respectful (we cancooperate and learn from each other) to dismissive (make sureyou send the prospective patient to a psychiatrist to find out ifshe's the litigious type) to competitive (we can fix this problemfaster and better than you can). Perhaps more importantly, thatsurgeons prescribe cosmetic surgery as the solution for complexproblems involving individual, social, and cultural identityreflects not only their grounding in medical culture, but the lim-itations of that culture. For much of the past century, medicinehas encouraged practitioners to search for "magic bullets" (as wellas to protect and when possible expand their specialty turf). Aface lift may indeed be a "magic bullet"i.e., the quickest, eventhe most effective, solution for an individual patient who is con-vinced that her sagging chin line is making her life miserablebut by giving and receiving the lift, the surgeon and the patientaffirm the culture that created the disjunction in the first place.

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Naturally, the relationship between medicine and culture looksdifferent depending upon where one stands. Medical practition-ers tend to situate themselves within medical culture. From thispoint of view, cosmetic surgery comes out of plastic surgery, whichcomes out of general surgery, which is a branch of medicine, andthe drive toward technical and technological advancement comesout of the recognition that functional defects are desirous ofrepair. Thus efforts to repair cleft palates and war injuries inspiresurgeons to experiment and to take risks which lead to the devel-opment of other facial surgeries; efforts to reconstruct breastspost-mastectomy lead to breast augmentation; the two World Warswere major turning points, in facial reconstruction and in burntechnique, respectively (Rank, 1968).

There is, however, another way to view the history of this phe-nomenon. As a practice, cosmetic surgery is contemporaneouswith reconstructive surgery, which means that plastic surgeryemerges out of culture, as well as medicine. The drive towardtechnical and technological advancement is given impetus byconsumer conviction that certain features are not advantageousand thus desirable of improvement, and by the whiff of money.Just as anti-Semitism and anti-immigrant sentiment inspiredprospective patients to request, and surgeons to perform, nasalsurgery beginning in the late nineteenth century, babyboomers^who grew up swearing not to trust anyone over thirtyand now find themselves uneasily some twenty years past thatwill, as both surgeons and patients, transform the way we thinkabout aging, as well as the way aging looks. From this point ofview, the two World Wars were turning points in terms of tech-nique and the supply of surgeons, but the real turning pointtheacceptance of and accommodation to a media-driven, urban, con-sumer cultureoccurs in times of relative peace and prosperity(Haiken, 1997).

In a broader sense, to acknowledge that cosmetic surgery isabout identity is to invite criticism and participation in the dis-cussion about how identities are constructed in this culture. Inmodern twentieth century United States, our attitudes toward cos-

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metic surgery have been based on a series of assumptions: thatinside every person who looks "other" is an "American" strugglingto get out; diat inside every homely girl a confident girl is tryingto emerge; that inside every middle-aged woman the "essentialself (which, for whatever reason, in this culture, is assumed to beperpetually 25) remains intact; that inside every balding, middle-aged ex-executive exists a virile power broker at the top of hisgame.

These assumptions rest on a complex web of beliefs about whatis good, desirable, and aesthetically pleasing. Methods for mea-suring and calculating objecdve standards of beauty have gone inand out of style (the science of anthropometry having replacedthe "profilometer," an early twendeth century invendon: seeFarkas and Kolar, 1987 and Straith, 1939) but the rhetoric inwhich many plastic surgeons indulge has not. Those who devotethemselves to altering the human face and body are ardsts, sculp-tors whose medium is human fiesh; it was not by accident thatmid-century surgeon Maxwell Maltz chose Dr. Pygmalion as thedde for his 1953 autobiography (and it is no coincidence that sur-geons' web pages wax euphoric about the "artistic nature of theirwork"www.bodybybloch.com offers one striking example). Thestandards of beauty that shape plastic surgeons' work (and theirpatients' faces and bodies) are informed, they say, by objectivemeasurement and educated, professional judgment of what ismost aesthetically pleasing to the human eye.

But if the phenomenon of plastic surgery is shaped by cultureas well as by medicine, it seems logical that its practitioners wouldbe as well. The vision of artisdc inspiration described above isproblematic because it obscures, even denies, the extent to whichplastic surgeons shape and are shaped by the specific culture theyinhabitin this case, the visual culture (movies, magazines, mod-els) of the United States in the twentieth century. Those surgeonswho in the 1920s and 1930s described Semitic noses as "too large"were clearly operating within the realm of a culture that haddefined certain looks as beautiful and certain others as less soan orientation suggested by their choice (in the 1930s) of the

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Venus di Milo as the central icon of their first official societal logoand today by their frequent use of the adjective "sleepy" todescribe the way Asian eyelids look before they are westernized(Kaw, 1993).

There is no question that our "ideal face" has changed some-what since the 1950s; Donna Douglas is no longer our ideal andany fashion spread of significant length shades from cream tococoa. Television commercials morph male and female faces ofvarious ethnic persuasions so convincingly as to make the UnitedColors of Benetton look tame. Yet as the "Brown Out" threatenedby actors and actresses of color in response to the snowy white Fall1999 TV lineup suggests, what we see when we look at popularculture is both more inclusive than ever before and yet frustrat-ingly narrow. And if this is not enough to convince, a quick touraround the globefrom China, where a mark of the new bour-geoisie is the "Big Nose" look to Lima, Peru, where to have a "His-panic" nose (rather than Indian) is to move up a social class ormore and cut-rate surgical clinics are springing up by the dozensto meet this new needtesdfies to the enduring power of white-ness (Koop, 1998; Pomfret, 1999).

Surgeons are quick to cite the market as something that com-pels them. "If we don't, somebody else will," they argued in the1920sand they did. They have been less inclined, however, toexamine the effect they have had on the market. In the earlytwentieth century, when medicine was a cash business and familyfunds were carefully husbanded to cover the necessities of child-birth and contagious illness, the disdnctive economics of cosmeticsurgery made it a luxury of the few. Over the course of the twen-tieth century, an increasing proportion of Americans were cov-ered either by a proprietary medical plan or by the federalgovernmentbut with the exception of some Public Health Ser-vice hospitals and military medical centers, whose coverage wasgenerous enough to spark a minor scandal in the early 1970s("Facelifts on the Taxpayer!" the San Francisco C/ironkfe exclaimedon 20 July 1971), procedures defined as aesthetic or cosmeticwere generally not covered. As a specialty defined by pre-paid

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elecdve medical procedures, cosmetic surgery remained disdnc-dve. Today, that disdncdveness remainsalthough the reasonsfor it have changed. Cosmetic surgery has begun to seem like arefuge for physicians abandoning the trenches of managed carein favor of the freedom and independence they once enjoyed (orhoped to enjoy) in medicine's free market. As a result, its eco-nomics are changing rapidly, as physicians, finance companies,and credit bureaus collaborate to extend their services to a widersector of the populadon (www.celebritydoctor.com offers a fasci-nadng example of what happens when medicine meets the mar-ket).

Similarly, while surgeons have long acknowledged the ways inwhich "culture" has shaped their specialty, they have been lessforthright aboutor perhaps simply less aware ofthe extent towhich they themselves shape culture. There can be no questionthat surgeons have played a reactive rolefiooded with requestsfor Sandra Dee noses in one decade, for Bette Davis eyes the next.Yet to think of surgeons merely as hapless carpenters buffeted bythe capricious demands of generations of fashion-consciouswomen is to do them a grave disservice. That complex web ofbeliefs, desires, and dreams we call culture is no solid thing. It iscreated each day in each surgeon's office during the series ofexchanges during which padents' requests fit, or not, with what asurgeon believes to be appropriate and desirable. Surgeons whoover the course of the century have agreed with their padents thatJewish noses should be made smaller, that Asian eyes should bemade to open wider, that lines and wrinkles are ugly and whohave then acted on those convicdons have played a role com-mensurate with the fiood of perfect images that inspired the ini-tial inquiries.

Individual identity evolves through a complex social and cul-tural process of percepdon and refiection; as writer Lucy Grealyput it in her memoir. Autobiography of a Face, "It is no mistake thatin movies and literature the dead sometimes know they are deadonly after they can no longer see themselves in mirrors" (1994;

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222). At this point in time, as the number of Americans who per-ceive their identifies as being largely defined by their faces andbodies, and who thus choose surgery as the most effecdve way toalter or enhance their idenddes, increases each year, quesdonsabout the evolving relationship between identity and cosmeticsurgery are significant. They may not, however, remain so. Imag-ine a (perhaps) not too distant future, in which babies are madeto order, down to the size of their noses and the longevity of theirhairlines, a future in which "post-birth alteradon" is rememberednostalgically as the primitive practice of well-meaning but tech-nologically handicapped medical practidoners. If the market hasits way with those accomplishments, cosmetic surgery as a way ofaltering the configuration of the face will become obsolete. Butthen, of course, we will face a new set of equally troubling ques-dons about the complex reladonship between culture, appear-ance, and human idendty.

Notes^Much of this background is drawn from my book Venus Envy: A His-

tory of Cosmetic Surgery. Baltimore: Johns Hopkins University Press, 1997.Historians, of course, do not necessarily agree; for an alternative inter-pretation, see Sander Gilman, Making the Body Beautiful: A Cultural His-tory of Aesthetic Surgery. Princeton: Princeton, NJ, 1999.

^This phenomenon is unique to the United States. British, French,and American surgeons participated equally in World War I, but at theonset of World War II Britain claimed only four plastic surgeons, andFrance, two. The United States, in contrast, had almost fifty. This pat-tern has continued in the intervening decades.

B^y this I do not mean to say that non-Western peoples are simply"cultural dopes" (or dupes), unthinkingly adopting Western standards.But it is ingenuous, I believe, to accept that young Asian women who saythey want to look "prettier" and cite westernized eyelids as a requisitestep in that direction are saying what they mean and meaning what theysay. Words like "attractive" and "pretty" accrete meaning through a com-plex process of cultural exchange and the result is that such words arenot only multilayered but infused with the past history and present real-ity of differential powercultural, social, political, and economic.

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''Together the number of operations in these categories (approximately275,000) top even liposuction (at 175,000) by quite a bit The most recentstatistics are tracked and posted periodically by the American Associationfor Aesthetic Plastic Surgery at www.surgery.org and by the American Soci-ety of Plastic and Reconstructive Surgeons at www.pljisticsurgery.org.

^Anyone who thinks this discussion is no longer current should seeEileen Ringel's "The Morality of Cosmetic Surgery for Aging" in Archivesof Dermatology 134 (1998): 427-431 and the responses to it in Archives ofDermatology 134 (1998): 1204-1206, 1293-1297.

^In this vein, the World Health Organization now defines health as"complete physical, mental, and social well-being and not merely theabsence of disease or infirmity" (Thomasma in Brock, ed., 1984, 51).

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