Marianne Guarena, editor of the resource guide, has undergone more than 20 major and minor cosmetic procedures.
Courtesy of Marianne Guarena
Marianne Guarena, editor of the resource guide, has undergone more than 20 major and minor cosmetic procedures in the last eight years. “The more people speak about it, the more they want it," she says.
By M. Alex Johnson Reporter
updated 8/2/2005 12:03:02 PM ET 2005-08-02T16:03:02

Time was — this was not so long ago — that cosmetic surgery was a little scandalous. If you had something nipped or tucked or lifted or vacuumed, you were just a wee bit too vain. Boy, Jessica looks great, doesn’t she? Well (sniff), she’s had work done.

Things have changed:

“I started at 25. I had a breast augmentation at 25.”

Marianne Guarena, who lives in Las Vegas, is editor-in-chief of Enhancement Media, which operates several Web sites devoted to cosmetic surgery. The marquee site, Yes They’re Fake!, draws more than a million unique visitors a month, she said.

She is 33, but she must still get carded every time she goes into a bar. This is because in the last eight years, Guarena has undergone more than 20 major and minor cosmetic procedures, all chronicled on her Web site.

On one day alone — May 5, 2004 — she had a breast implant exchange; liposuction to her flanks, hips, thighs and abdomen; a modified brow lift; lip augmentation; and a graft of fat into her cheeks.

If there used to be a stigma, it has long since been erased for people of means of Guarena’s generation.

“Before, it was, like, hush-hush, and no one really talked about it, but then the media started getting in on it and we have all these makeover shows,” she said.

“It’s become a household word, to the point it’s not embarrassing  to say that you’ve had it,” she added. “The more people speak about it, the more they, too, want something done.”

More in-your-face than ever
For many years, medical professionals have pointed to the increasing sexualization of American culture, selling the idea that Young + Slim = Beautiful. What’s new is the advent of reality TV makeover programs, which pound home the message that Young and Slim can be bought.

“Over the past five years, I have seen a community standard shift,” said Dr. Andrew Jacono, a facial plastic and reconstructive surgeon at the New York Center for Facial Plastic and Laser Surgery. “It is not whether cosmetic surgery is acceptable. It’s a question of what procedures they are going to do and when.”

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“Obviously, from my standpoint, [things have] changed dramatically, especially with all of these reality shows,” said Dr. Blane T. Shatkin, a cosmetic surgeon in Weston, Fla., and chief of staff at Memorial Hospital in nearby Miramar. “I mean, the reality shows have just gone crazy with plastic surgery.”

There are other influences, to be sure. Advances in technology have made cosmetic surgery safer and have cut recovery time, while they also have brought down the cost enough so elective surgery is within reach of much of the middle class. And, as with pretty much every other social trend, you can blame the baby boomers.

“I think it’s an outgrowth of Freudian psychology,” said Dr. Brooke R. Seckel, an assistant professor of surgery at Harvard Medical School and founder of the Lahey Center for Cosmetic and Laser Surgery in Lexington, Mass. “The boomers, so to speak, are more centered, more self-focused and less concerned about others’ opinions.”

And now “they’re having children,” said Shatkin, who said he had worked on a lot of young women following in the footsteps of their mothers. “They’re much more educated [because] their mom has had implants and they know all that’s involved with them.”

No business like show business
But even as they welcome the new business, many medical professionals have a bone to pick with the reality shows. It may be safer today, but cosmetic surgery is still surgery, some of it very invasive, and that carries risks both physical and psychological.

“It’s a very unrealistic depiction,” said Dr. David Sarwer, a psychologist at the University of Pennsylvania’s Center for Human Appearance. “You only see what makes for a good hour of television. You don’t see all of the ups and downs of the healing process that would occur over the postoperative course.”

Seckel, in fact, generally won’t do more than one procedure at a time, because the risk of bacterial contamination is too high and because the likelihood of complications jumps sharply after a patient has been under three or four hours of anesthesia.

“I just tell patients that, in spite of the fact that they’ve seen it on TV, my practice is to do what’s safest for my patient,” he said.

It’s a message some patients don’t want to hear once they’ve gotten their hopes up for a weekend face lift.

“We try to do safe surgery with limited down time, but the bottom line is [when you have a face lift] you need two weeks off,” Shatkin said.

“You’re not going to go back to work in a week,” he added. “If I told you that, you might like me, but you’re not going to like me post-op when it takes two weeks to recover.”

‘Worthless piece of television’
The TV programs have their genesis in more sober documentary-style shows on The Learning Channel and Discovery Health, where programs like “Allison’s Augmentation” and “Plastic Surgery: Before & After” have drawn some of the highest ratings on cable.

When “The Swan” debuted on Fox last year, it was met with horror by television critics, but viewers’ fascination was only fueled by the addition of slick network production values and the signature “Survivor”-ish element of competition to the familiar mix. In barely a year, the genre has spread to ABC (“Extreme Makeover”) and even MTV, whose “I Want a Famous Face!” promises to reshape average Americans into their favorite celebrities.

Producers themselves are clear that they’re selling entertainment, not education. In remarks reported by The Calgary Sun, David Lyle, who helped produce “The Swan” for Fox and is heading up the new Fox Reality Channel, acknowledged this summer at a Canadian television festival: “‘The Swan’ was a worthless piece of television I’m sad to say I produced. Those women were left sort of looking like cheap hookers and sent back to their small towns.”

A. Smith & Co. of Los Angeles, the production firm behind “The Swan,” declined to make anyone available for comment. But in an interview last year with The Globe and Mail of Toronto, company founder Arthur Smith defended the show.

“Plastic surgery is part of the mainstream now. You either believe in it or you don’t,” he said. “And what you see in this show are incredible transformations. I really, really feel good about how these women come out of it. Nobody goes home a loser.”

Producers, in fact, are casting a wider net than ever for potential projects. “Extreme Makeover,” for example, has taken to “nerd-trolling” in Internet discussion groups devoted to comic book enthusiasts; it is also looking for a “small town girl ... who wants to change her physical appearance through plastic surgery and who desires to venture into high society” and for “Veterans/Firefighters/Police/EMS, etc. who may have been injured in the line of duty.”

Inappropriate patients?
Sarwer recoils from the seeming casualness with which people look to change their bodies like a suit of clothes. He writes extensively about body dysmorphic disorder, a psychiatric condition characterized by extreme self-consciousness — sometimes debilitating — about an imagined or vastly exaggerated physical defect, according to the American Psychological Association.

A little more than half of American women and a little less than half of men are unhappy with how they look, Sarwer said, but for 1 percent to 2 percent of them, the dissatisfaction progresses to body dysmorphic disorder. For plastic surgery patients, it is as high as 12 percent.

Sarwer said surgeons were “drawing inappropriate patients” because “as a society we are often seduced by the mass media images of beauty that we see, and we forget how artificial those images are in terms of how they’re computer-generated and enhanced.”

“We’re bombarded by these images unlike ever before in history,” he said, “and I think inevitably it ends up making many of us feel very unhappy about the way that we look.”

The psychological factors mean many patients with body dysmorphic disorder don’t respond well to cosmetic surgery anyway. Sarwer said more than 80 percent report no change or a worsening in their symptoms.

Internal qualities can make the difference
In a new book, “Save Your Face,” Seckel warns that a patient seeking plastic surgery can be especially vulnerable at the hands of a sloppy or inexperienced surgeon. Chapter 10 of the book is titled “Don’t Let Just Anyone Touch Your Face.”

“This is not a liver transplant. This is not cancer surgery. This is not heart surgery. This is elective, fee-for-service surgery to change your normal appearance,” he said. “It’s very lucrative, and there are a lot of people doing it that have a different approach to their patients than the average cancer surgeon, let’s say.”

Buying beauty

By going to a doctor’s office, patients are “choosing that doctor as a professional — they’re putting their lives in the hands of that individual, and they are paying for their operation," Seckel said. “Patients need to have a sense of caution, a sense of self-esteem and a sense of self-worth when they go to see a doctor.”

That sounds right to Guarena, who warns against unrealistic expectations at Yes, They’re Fake! and catalogs a vast array of informational resources for potential patients.

Guarena said she’s happy with the results she’s had — she’s “far more secure now, partially thanks to plastic surgery, of course.” She said others were following her example by starting much younger and going back for more each year. It’s logical — you have to protect your investment.

“It’s like your car,” she said. “If you continue to take care of it while it’s new, instead of waiting for it to break down 10 years later, it’s a lot easier to keep it nice-looking.”

But even she acknowledges you can go too far. Had her Web sites not taken off, she said, she “probably wouldn’t have had this much.”

For her, the long march of trips under the knife is as much about education as it is self-image. After all, “how can someone expect to look to me for any kind of guidance or support if I’ve never been through what I’m trying to preach?”

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