Ten years ago, a typical patient at my plastic surgery practice in McLean, Virginia, was 47 or 48. She (about 80 percent are women) generally wanted to look like a younger version of herself, or else she wanted the best version of her basic appearance. This might mean a face or neck lift, eyelid lifts, a brow lift, a skin-resurfacing procedure, or Botox injections. "What do you recommend?" she'd ask. This is the kind of work I got into my profession expecting to do, and these are the consultations I expected to be giving.
Today, my average patient, according to the records we keep in my office, is 38 or 39. She'll come in fixated on a specific "flaw,"and often knows exactly what procedure she wants. Her nose is crooked, she's sure, or her chin is too small (or large), or her eyebrows appear "droopy." "I need a tip-plasty," she will say - rhinoplasty for the end of the nose. And these patients are much less realistic about what I can achieve. They will ask for Kim Kardashian's nose, even if their facial structure looks nothing like hers.
There's a reason for this rapid and radical change: selfies.
The self-taken photograph is warping the confidence of many younger people in unsettling ways. They come to my offices, show me selfies and point to (say) an asymmetry in their lips - a totally normal variation. Often they will have already searched online till they've found someone with a similar "issue" who fixed it with surgery. In one informal consultation on RealSelf.com, a site that lets people ask questions of plastic surgeons, a woman asked me if plastic surgery could give her "cats' eyes" - rounded, feline eyes of the sort that some photo filters can add to selfies. I told her that wasn't a sensible goal. Once, a 20-year-old, having studied countless images of herself, said she needed a facelift; no 20-year-old needs a facelift.
A survey of members of the American Society of Plastic Surgeons last year found that social media was driving more plastic surgery requests than any other social influence: more than TV, movies or magazine photography, which were the influences I used to hear about from my patients. People are simply spending more time looking at themselves, in an online environment where invidious comparisons are inevitable. But selfies also mislead people about how they look. Smartphone cameras get better each year, but photos taken at arm's length or closer often produce a "fish eye" effect: Whatever's at the center of the photo is bigger, and things on the periphery are smaller. A study published in JAMA Facial Plastic Surgery last year found that selfies make noses look 30 percent larger than they are.
Academic psychologists - including Brian Feinstein of Northwestern University and several co-authors, who studied a sample of 268 college-age adults - have found that the more people use social media sites, the more they ruminate about their own supposed shortcomings. And a few preliminary studies have found that specifically posting self-portraits causes self-esteem to drop. (One measured self-regard in South Korean students before and after they posted a selfie to a social media site, comparing them with people who simply saved the photo to their phones.)
One of the first things I do in a consultation is take a photograph from a reasonable distance, with professional lighting. This has persuaded hundreds of my potential patients that there's no reason for surgery. One young woman, on whom I'd already performed a rhinoplasty, forwarded me a selfie, along with a note saying that her eyebrows sagged in an unflattering way. She included a photo of Kylie Jenner and said she wanted her eyebrows to look like Jenner's. But she was taking her selfie from an unusually high angle. I persuaded her to look at some standard photographs before moving forward, and she decided not to have the work done.
The media often suggests that there's been an explosion in plastic surgery in recent years, but the evidence is mixed. More than 1,800,000 surgical procedures - things like breast augmentation, nose reshaping and liposuction - were undertaken in 2018. That's up 1 percent since 2017 but down 5 percent since 2000, according to the plastic surgeons association.
Long-term growth has been more significant when it comes to minimally invasive procedures, things like soft-tissue fillers and chemical peels. Nearly 16 million such procedures were done in 2018 - up 2 percent from 2017 but more than tripled since 2000.And the data does confirm that patients are getting younger: Last year, 72 percent of members of the American Academy of Facial Plastic and Reconstructive Surgeryreported seeing an uptick in patients under 30.
People think plastic surgeons are so eager for business that we love it when patients scrutinize themselves and dislike what they see. But I reject more patients than I accept, and I’m hardly the only one of my peers to do so. On many days - as I push people to consider whether the new nose they’ve been dreaming about will really change how they feel about themselves - I feel more like a psychologist than a surgeon. These are delicate talks. You can’t seem to be minimizing someone’s concerns, or she might just end up in another doctor’s office, getting a procedure that might make her life worse.
About six months ago, a woman came to my office to ask me to fix a nose job that she thought had been botched. I asked for a photograph taken before the procedure. When I saw it, I was so shocked I had to sit down, to steady myself. The nose had been perfectly shaped before the operation. The woman had convinced herself that it was flawed and now was miserable about the outcome. I declined to do further work, because her fixation on her nose seemed excessive, and I doubted she would be content, no matter what I did.
Don't get me wrong. I'll work with people to help them look their best. Patients who looked younger from the neck up were telling me they couldn't wear V-neck shirts, because their lower neck gave away their age, so I developed a "neck tuck" procedure to help with that problem, extending the benefits of a neck lift further down. And yes, these people may look better in their selfies, a pleasant side effect.
And if you want to look a little more like a celebrity, I don't rule it out. Quite a few patients today mention Meghan Markle as an ideal. If they have a facial structure like Markle's - and if, through probing questions, I am convinced that the request isn't a result of a morbid obsession with a perceived flaw, known as dysmorphia - it might be reasonable to discuss giving her the fullness of Markle's lips or some of the contours of her nose.
It's a fine line between requests like that and requests driven by an obsession with selfies. But the truth is that selfies provide inaccurate feedback about how we look, and they're generally making people feel bad about themselves. That's nothing a plastic surgeon should cheer.