COLUMN ONE : A Frenzy of Lifts, Nips and Tucks : Celebrity endorsements and better techniques are bringing cosmetic surgery to the masses. In a largely unregulated field, the urge to sculpt the perfect body seems unstoppable.

“The Phantom of the Opera” is playing softly in the background as a third of the woman’s face is flopped over on itself, permitting the electric prod to stem some incidental bleeding. It’s a ghastly sight, but no need to worry as Dr. Steven M. Hoefflin, the celebrity surgeon famous for rearranging Joan Rivers’ face, concludes the four-hour ordeal by lifting the skin taut over cheek implants, snipping off patches of excess and cutting new “V” inserts for the ears.

A silicone chin, manufacture size No. 2, is shoved in through the mouth, fat collected from the thigh is shot into the lips for a fuller look and the fifty-something woman now has a forty-something face for only twenty-something thousand dollars.

“We treat these conditions in much the same way you would ‘take in’ a blouse or dress that is too large, by removing excess material, restitching the garment and ironing out the wrinkles,” says a patient brochure issued by Hoefflin, who can do two or three face lifts a day in his Santa Monica clinic, and who is booked for the next three years.

There are cheaper procedures, and not every surgeon deals with celebrities, but the public disclosures of facial and body sculpting by the likes of Michael Jackson, Phyllis Diller, Barbara Walters and Cher have set a new standard for the masses and created a multibillion-dollar medical industry.

This year, millions of Americans will tamper with the once-immutable laws of physical beauty and aging, availing themselves of cheek, breast and buttock implants, vacuuming fat from their thighs and having their noses redesigned and tummies tucked.

What plastic surgeons tend to call “aesthetic” surgery and rival specialists refer to as “cosmetic” surgery has broken through technological, medical and economic barriers to revolutionize expectations for the human body. After a century in which such surgery was a rare art practiced almost clandestinely for the benefit of a few rich clients--mostly high-priced entertainers and socialites--it is now a mass commodity. Like it or not, liberating or grotesque, a cosmetic surgery revolution is upon us and unstoppable.

Even the occasional health scare, as in the recent Food and Drug Administration inquiry into breast implants, seems to have little lasting effect on this lucrative and largely unregulated market.

The prospect of a “New You,” as the shingle of one successful Irvine surgeon promises, is now only a matter of a few thousand dollars away. And if cash is a problem, a new nose or breasts can always be charged on the MasterCard.

“There’s a waiting list of people who want the surgery that don’t have the money,” says Dr. Liz Ashley, one of the few women cosmetic surgeons. “They try everything that they can. ‘Can I bring you my gold jewelry?’ ‘Can I give you my pink slip to my car?’ ‘Can you hold the check three days?’ Well, you do the surgery and the check bounces.”

Ashley, whose advertising flyer proclaims “Body by Ashley” and promises that “larger fuller breasts can be achieved usually in about one hour,” practices in Newport Beach, where the competition for the perfect body can be fierce.

“We’re so health conscious--and part of it is being able to fill out clothing,” says Dr. Malcolm D. Paul, an Orange County surgeon, contending, in effect, that implant surgery is a logical extension of the fitness craze.

Paul, a member of the American Society of Plastic and Reconstructive Surgeons, says that some prospective candidates for breast enhancement “go to the gym and they see other girls and they get concerned about getting undressed because they are not as full. Of course, the standard is different because some of the girls have had it (breast augmentation) done.

The problem, as Paul indicates, is that the standards keep getting raised. Now women at the health club are attempting to compete with bodies that are often the result of surgery, not exercise.

One result, Paul says, is that, the “B” cup that was typically requested when he began doing breast enhancements a decade ago has gone to a “C” and increasingly a “D.” “In the 1,000 women I have done,” he notes, “I’ve never had one come back and say to me, ‘They’re too large.’ ”

Demand is somewhat seasonal. A rise in the demand for breast implants coincides with the swim-suit season; face lifts are popular when college reunions near.

“They are dying to go to their reunion to see how everybody looks so old but them,” Ashley reports.

The cosmetic surgery boom is being fueled by celebrity endorsements, improved techniques, eroding taboos and declining revenues in other medical specialties. Billions of dollars are involved, and in a frenzy of sutures, implants, nips and tucks, the verities of beauty and age are being shattered.

Buttock lifts and chemical facial peels have joined such traditional aids to vanity as cosmetics, fashion and exercise. Once rarely achieved but natural standards of beauty are now routinely replicated in a new tribal tradition in which noses and chins are pulverized to make way for the reconstruction of that which is smaller, straighter, upturned or indented. No one need be plain; patients often appear with clipped photos of stunning magazine models, expecting the same for themselves.

Anything is possible--almost.

“To the limits of surgical ability, you can really change a lot,” Paul observed, “But you have to have a good underlying bony structure, especially in the face. In the breasts it’s amazing how you can change around not only small breasts to larger, but asymmetrical breasts. . . . It’s a very rapidly changing field. The other day I did a body contour, breast, plus nose, all on the same gal. It took about four hours to do everything. She went home well motivated.”

The transformation of physical appearance--formerly relegated to National Geographic magazine layouts about stretching lips and the like in what were thought of as more primitive cultures--is now the subject of high medical science and physicians’ whims.

“Patients say this is what God gave me, now I want you to do better,” says Dr. George Brennan, a leading Newport Beach cosmetic surgeon, adding, “You are working the most precious medium of all art. You are doing living art on living human tissue.”

Perhaps, but sometimes in the process the aesthetically exotic has been rendered commercial and mechanical.

In his Irvine office, dermatologist and surgeon Dr. Jeffrey Alan Klein, a widely published expert, draws crude circles dissected by lines on the inner thighs and buttocks of women in preparation for liposuction. Looking like the graffiti symbols of underground cults, the lines are intended to guide the metal rod probing under the skin sucking up blood and fat to be passed through tubes to collection jars.

Klein, who has pioneered one of the more widely used techniques of liposuction, is proud that he works with patients who are under local anesthesia. He reasons that an alert patient will warn a doctor who probes too deeply, perhaps threatening to puncture the liver or some other vital organ, as has happened in other surgeons’ offices.

Offices like Klein’s are popping up everywhere in the Southland and are now threatening to be as common to mini-mall life as fast-food outlets. The enormous profitability of elective cosmetic surgery has resulted in a frenetic turf war between plastic surgeons, who are certified by the American Board of Plastic Surgery, and an increasing number of other specialists--gynecologists, dermatologists, ophthalmologists--who contend that they are equally qualified to perform such procedures.

A few blocks from dermatologist Klein one finds the “New You” office of Dr. Martin P. Elliott, a plastic surgeon who tends to stress the distance between his world and that of the other specialists who have entered the field. Whereas Klein uses before-and-after pictures to advertise in slick magazines, Elliott restricts himself to a conservative ad in the yellow pages. But Elliott and Klein are clearly in the same business, and fishing in the same pool for customers.

Whatever the differences in doctors’ training, it remains very much a commercial business, as one is reminded in Elliott’s consulting room, where a score of new breast implants, squiggly and quite sensuous in their own right, are spread out over a layer of past issues of Playboy and Cosmopolitan, along with the standard industry brochures describing nipple placement, fat vacuuming, buttock lifting, pectoral implants, face lifts, nose reconstruction and the other achievements of the modern art of live body sculpture.

Elliott, a respected plastic surgeon, seems a bit embarrassed by the “New You” sign over his office but has resigned himself to salesmanship.

The alternative--simply performing fine medical work--didn’t bring in the customers. As he recalls:

“When I started out, I covered 12 emergency rooms, I worked every night. I stitched people up and they came back to the office and I did a lot of hand surgery and I did this and I did that. I became known as the best reconstructive surgeon in the area. It didn’t bring one single cosmetic surgery patient into my office.

“All the guys down at the beach were busy cultivating the cosmetic surgery patients and talking to some ladies’ society. I wasn’t doing any of that. It was time to change, and I got wise too. The bottom line is that unless you do some form of self-aggrandizement, you don’t get the work. It’s like the phone book ad, the TV commercial. Businesses that want to be successful, advertise.”

The market incentive is pervasive, as respected surgeons vie in advertising before-and-after pictures of the bodies they have worked over, often implying that the major surgery involved is painless and risk free. Competition is so fierce, media exposure so crucial, that many doctors are represented by professional public relations agencies.

“There’s dollars and cents involved here,” says Dr. Thomas R. Stephenson, a West Los Angeles surgeon whose breast implant ads featuring bosomy women in negligees run frequently in The Times, “and you’re going to have fellows figuring out ways to get the public to come to them rather than go any place else.”

In fact, even by medical profession standards, the payoff can be enormous. Surgeons in Southern California can easily earn more than $1 million a year; it’s obvious that doing even a face lift a day for a $15,000 fee can send that figure much higher. What is more, this is money “up front”--offered from the private stash of patients who do not have to wait for the approval of insurance providers.

If the surgeons and their public relations agents can be believed, most patients will be pleased with the results, cheerfully hock themselves to the hilt, be generally oblivious to the real risks in what is, after all, major surgery, and emerge grateful that their features now conform to a surgeon’s notion of beauty. For many patients it is a big but compelling decision--an obsession to look better can suddenly be fulfilled.

“I’m still being asked if I’m glad I did it,” Vida Dean, 65, fashion and beauty writer for the Newport Beach/Costa Mesa Pilot, wrote of her face lift last year. “Who would not be glad to have the bags gone from over and under the eyes; have the saggy jowls gone? Any regrets? Oh, yes. Why didn’t I do it 10 years ago?”

Given the proliferation and power of American media throughout the world, the implications are enormous for imposing a worldwide standard of beauty. Thanks to cosmetic surgery, people everywhere, if they can afford it, can now order up the eyes, cheekbones or breasts of their favorite North American television star.

Turning a Japanese housewife, for example, into a typical product of the dominant white American genetic mix--for whatever that is worth--is now eminently doable.

“When I was in Japan, I wanted to be like an American,” said a patient of Brennan, the Newport Beach surgeon. “You know. Big eyes. Everybody, all my girlfriends did their eyes deeper, so I did. . . . “

What was she having done now? “Nose and chin this time around.” Eyelids are often redone too. Asian women don’t have a crease in the middle. Why does one need an extra fold like two tracks running horizontally across the eyelid? Why is the smooth expanse of eyelid skin not perfect enough? The answer is that the desirable eye, the one extolled in the massive cosmetic industry blitz campaigns, is the Western eye, and the two lines provide the border for eye shadow and other makeup applications.

What is to be made of all this? Apart from the issue of breast implant safety, there has been surprisingly little discussion about what might be regarded as the transmogrification of the human appearance. Since most of the customers--at least 85%--are women, is this not yet another assault on a woman’s independence?

Not according to Ms. magazine when it celebrated Cher, one of the main role models of the surgeon’s designer-body movement. Cher, who has appeared in ads for Jack LaLanne health spas, admits that her body comes from “LaLanne and La Knife” and her plastic surgery has been the subject of photo essays and feature stories in magazines and television throughout the world. Yet she is celebrated in the July, 1988, issue of Ms. precisely for having taken hold of her life in part by employing surgeons who took hold of her body.

“Her message is loved and needed: You can change a lot in your lifetime, and be . . . honest, and who you really are,” said Gloria Steinem.

“With a little help from plastic surgeons, Cher has done wonders with exercise. But we love her just the same,” Flo Kennedy, the feminist, is quoted in the same issue.

Oddly enough, this blase view of plastic surgery ignored a devastating article in Ms. just the month before by Sybil Goldrich, a doctor’s wife who documented her disastrous experiences with breast implants.

Although the majority of operations may cause no complications, serious problems and even horror stories about cosmetic surgery abound--from breasts that painfully encapsulate to face lifts that produce muscle paralysis.

But, whatever the actual risks, the lines for these procedures are ever longer and the word of mouth from most patients seems to be exultation at bursting onto the scene bustier, younger-looking and, in some cases, more Anglo-American.

The concern about various aspects of plastic surgery expressed by those who claim to be victims and by public interest groups has been overwhelmed by the gushing enthusiasm of show business celebrities.

“I’m a walking billboard for cosmetic surgery,” Phyllis Diller said last year. “At 73, I look a red-hot 50, so I think it’s great.”

With the stars setting the standard, it’s no wonder that their fans have followed uncritically. Patients interviewed often mention the augmented lips of actress Barbara Hershey in the movie “Beaches,” or television personality Barbara Walters’ candid discussion of her face lift.

“You start watching television and you start looking at these people. Like these news commentators,” said Barbara Pigeon. “You think, ‘What have these people done?’ ” Pigeon, who worked in a surgeon’s office, was inspired by the example of the TV newscasters to have her eyes done, and much more.

“I had a breast operation first, about five years ago. I was older, I had never had children, I was not very well endowed. . . . I just wanted to be a little bit bigger. I did not want to be the broad on the beach. I wanted to be more aesthetic looking. None of the clothes fit properly.”

She now is rather busty and says she has never had any medical problems as a result of her surgery.

Her husband followed suit. “He had his waist ‘lipo’ed.’ I had to take all his pants into the cleaners to be altered,” she said.

The motivation for cosmetic surgery most often cited by women is that they want clothes to fit right, and indeed the demand for cosmetic surgery is highest in those areas that also are given to a greater preoccupation with fashion, such as Southern California, New York and Florida.

Stephenson, the West Los Angeles surgeon, mentions that he has a doctor friend in Anchorage to whom he taught the technique of breast enhancement he uses. But, by Southern California standards, the Anchorage surgeon’s business is very slow. “He’s done five a month. I could do two a day,” said Stephenson, who charges $5,000 for the procedure, and says he has performed 3,000 implant operations.

Stephenson explains the interest in fashion and the body that is needed to go with it: “Face it, women are dolled up for us.”

This matter-of-fact condescension is typical of the male surgeons, many of whom tend to refer to women patients, including some aged 60, as “girls.”

Surgeons also engage in a form of “outing,” discreetly dropping names to a reporter of prominent people they claim have benefited from procedures they offer. They scoff at the notion that aging is to be accepted or that its visible proof, such as lines in the face, might be an indication of maturity, wisdom or attractiveness. Most of the surgeons interviewed were themselves less than perfect in appearance and showed some signs of aging, but none had availed themselves of the opportunities for a cut-rate face lift.

“The only way to age gracefully is with cosmetic surgery” says Brennan, who could be described as youthful-looking. He says he is willing to undergo such surgery himself at some point and observes that his face lift clientele now is 15% male.

In a recent operation in Brennan’s office a man who seemed to be over 60 was indeed having the fat sacs scrapped from under the skin around his eyes as part of a total face lift. But, even if such extensive surgery went well, it was clear from seeing him on the operating table that the aging process would not easily be reversed.

One problem at the outset is how much to alter. For example, another patient in Brennan’s office, a woman also in her 60s, had recently had her face lifted, fat removed from her eyelids, a chin implant and a “nose correction,” but clearly she had not visited the fountain of youth. She volunteered that for the time being she would resist having chemical peels to remove her wrinkles. “I don’t want to become a plastic surgery junkie,” she said.

In any case, cosmetic surgery is not a stable solution to the aging process. Most surgeons, while they are proud of their results, concede that they are not permanent, and that periodic and costly tuneups are called for, lest gravity and other natural effects have their way.

For example, collagen injections to the face to give it a more youthful look last less than four months.

Sometimes this has led to the use of questionable procedures. Before it was banned, some surgeons had been injecting silicone directly into the face as an alternative to the temporary effects of collagen. Silicone is indeed permanent, so much so that if it is misapplied or shifts it can result in disfigurement.

Because silicone is a product, the federal Food and Drug Administration has regulatory authority over its use, and last year it intervened to ban the sale of silicone for facial injections. But there is no comparable regulation by any government authority over the techniques, skills and training required of physicians performing cosmetic surgery procedures.

Instead, there are competing advertising campaigns conducted by the more aggressive surgeons, which many professionals in the field believe confuse and trivialize the serious choices confronting patients. Physicians have been allowed to advertise, since a 1979 decision of the Federal Trade Commission, which treated medical advertisements as no different than those for other consumer services.

Extensive advertising in the trendier magazines, together with the celebrity endorsements, has created an aura that renders cosmetic surgery both respectable and inevitable, and many in the field expect it to be as common as orthodontic work in the near future. In some circles, it is even now an expected aspect of the successful lifestyle. Often, surgery that is selective tends to be packaged as something that is both healthful and a requirement for success.

That was the theme, for example of a 1981 article in the magazine The Executive by Dr. Robert Kotler, who extolled face lifts as a way for male executives to meet the oncoming competition of “well-educated minorities and newly liberated, ambitious women” by eliminating “any signs of fatigue or slowdown.”

Kotler, who is a faculty member at UCLA and a consultant to the Medical Board of California, did not mention any medical risk in connection with the face-lift procedures and peels he advocated. Nor was there a hint that this might not be for everyone.

“While other societies and cultures may venerate the aged, ours prefers to emphasize agelessness,” Kotler wrote, in an article he now says has become “a classic.”

The article included a catalogue of possible surgeries, along with advice to corporations to include cosmetic surgery in their executive incentive programs as a way of improving productivity. Implying that those offered surgery really ought to go along, Kotler wrote, “Even if the executive does not see the value of improved appearance, his company might.” Why? Simply because “Regardless of how well they are functioning they also have to look like they are functioning well.”

Some surgeons insist on a less aggressive marketing approach. They stress that the procedures are not for everyone and warn their patients not to expect too much change in their lives, personal or professional, as a result of the surgery.

Dr. Lawrence N. Seifert, a Los Angeles surgeon and spokesman for the American Society for Aesthetic Plastic Surgery, for example, takes pride in the patients that he has turned away “because they weren’t ready.” He spends more time with patients discussing the pros and cons of the procedure than in the actual operation, and requires a signature on an extensive and detailed consent form. He is not alone in stressing that this is major surgery that ought to be carefully considered.

The need for such caution seems obvious when one realizes that the vast majority of such operations are performed in a doctor’s office outside the purview of state and federal regulatory agencies.

Under such circumstances, “No minimum standards exist either for doctors, for their staff that assists them or for the facilities in which they operate,” Frank A. Papineau, a congressional investigator, concluded after a three-year study. Papineau, of the Government Accounting Office, added that “No certification process exists to give consumers a true idea of whether the physician is actually qualified to perform a given procedure, no requirements exist even for the basic life-support equipment in these office-based surgeries. Doctors in their medical facilities are not required to have medical malpractice insurance, and we found far too many did not.”

Most surgeons agree on the need for increased regulation, but they remain jealous of their medical prerogatives and divided over which way to proceed.

While cosmetic or aesthetic surgery may be an enormous boon to some patients, it has been a disaster for others, and many health care professionals fear that there is little reason to expect the two types of patients and the two types of doctors--knowledgeable and not--to be carefully sorted out in today’s overheated market.

Times researcher Nina Green contributed to this story.

Costs, Effects and Risks

A quick survey of the most popular cosmetic surgical procedures.

Procedure: FOREHEAD LIFT (Coronoplasty). Lifts sagging eyebrows and diminishes frowning horizontal wrinkles and deep vertical frown lines between eyebrows.

Fee: $1,000 to $4,000; Average $1,980

Possible Risks and Effects: Injury to nerves that, when affecting only one side of forehead, can result in asymmetrical forehead movement. Temporary numbness of the scalp. Temporary hair thinning around incision site. Temporary itching.

Procedure: EYELID SURGERY (BLEPHAROPLASTY). Removes excess fat and skin around eyelids creating, a more youthful or rested appearance.

Fee: Uppers and Lowers, $1,000 to $5,000; Average $2,450

Possible Risks and Effects: Upper eyelid may not close completely for a period of time during healing, resulting in drying of the cornea and need for eyedrops. Loss of vision is exceedingly rare but has been reported.

Procedure: NOSE SURGERY (Rhinoplasty). Reshapes nose to contour of face, and can improve nasal breathing.

Fee: $300 to $6,000; Average $2,590

Possible Risks and Effects: Formation of scar tissue inside nose with poor healing; this can require a second procedure to remove scar tissue.

Procedure: CHEMICAL PEEL. Non-surgical procedures that peels away the skin’s top layers, eliminating wrinkles and age spots through application of a chemical solution.

Fee: Full face--$500 to $3,000; Average $1,640

Possible Risks and Effects: Scarring and infection. Skin pores commonly appear larger. Permanent pigment changes (usually lighter). Skin may appear shinier and remains swollen and sensitive for a time.

Procedure: CHIN AUGMENTATION (Mentoplasty). Improves the shape and projection of the chin and jaw by inserting a chin implant or sliding part of the jawbone forward.

Fee: Implant--$300 to $2,500; Average $1,060

Possible Risks and Effects: Slippage of implant, which gives chin slightly asymmetrical look. Also reversible if patient is not pleased with result by removing implant.

Procedure: CHEEKBONE SURGERY (Malarplasty). Improves contours of facial structure through an implant over the cheekbone, generally performed through an incision within the mouth.

Fee: $600 to $4,000; Average $1,760

Possible Risks and Effects: Slippage of implant. One of few cosmetic surgeries that is reversible if patient is not pleased with result by removing implant.

Procedure: FACELIFT SURGERY (Rhytidectomy). Loose skin of face, jawline and neck are tightened and “redraped,” reducing wrinkles.

Fee: $1,200 to $8,000; Average $3,880

Possible Risks and Effects: Infection or hematoma (blood under skin) and nerve injuries (though rare). Temporary tightness of numbness in face and neck. Must have protection from sun for several months.

Procedure: EAR PINNING (Otoplasty). Reduces ear protrusion or reconstructs deformed ears.

Fee: $750 to $4,500; Average $1,900

Possible Risks and Effects: Faint scar. Little risk.

Procedure: BREAST ENLARGEMENT (Augmentation). Increases size and shape of breasts by surgically inserting an implant behind each breast.

Fee: $1,000 to $5,500; Average $2,400

Possible Risks and Effects: Increased difficulty in reading mammography X-Rays. Hardening and pain from fibrous tissue growing around implant. Breakage of implant’s outer envelope, causing the gel filling to be released. Undetermined risk of minute leakage of silicone into the body.

Procedure: TUMMY TUCK (Abdominoplasty). Reduces excess skin and removes stretch marks; tightens stomach muscles.

Fee: $1,200 to $8,500; Average $3,430

Possible Risks and Effects: Movement Severely restricted for 10 days to two weeks after surgery. Scar hidden beneath undergarment.

Procedure: LIPOSUCTION. Suctions fat from specific areas; procedure removes fat cells making reduction permanent. Can be done on neck, stomach, thighs, hips and buttocks.

Fee: (single site) $500 to $5,000; Average $1,480

Possible Risks and Effects: Skin over treated are not perfectly smooth and skin dimpling still present. Sagging of skin if elasticity is insufficient. Temporary numbness up to three months.

Pain, swelling, bruising and discoloration are considered normal following cosmetic surgery and therefore are not indicated in the description of risks. There is always danger of infection following any surgery and this is not noted separately unless the risk is exceptional. Conditions noted under Possible Risks and Effects are not necessarily commonly experienced.

Compiled by NINA GREEN / Los Angeles Times

SOURCE: American Society of Plastic and Reconstructive Surgeons.