Plastic surgery, as seen on TV

Like many plastic surgeons, Dr. Randal Haworth has developed a complex relationship with reality TV shows that feature surgical makeovers.

Haworth, who set up shop in Beverly Hills in 1995, readily acknowledges that he has benefited from the increased interest in plastic surgery that productions such as ABC’s “Extreme Makeover” and MTV’s “I Want a Famous Face” have sparked.

In 2003, the number of cosmetic procedures performed nationally -- from liposuction and tummy tucks to Botox treatments -- jumped by 33% over the year before, reaching 8.7 million. Those numbers have increased steadily since the American Society of Plastic Surgeons (ASPS) began tracking them in 1992.

But physicians such as Haworth say that in the last year, they have fielded a spate of inquiries from new clients and a few of their established patients that make reference to what they’ve seen on TV.

“That’s a good thing,” Haworth says. But, he adds, “it’s a double-edged sword.”

That’s because the expectations of his clients -- about what plastic surgery can achieve and its risks and discomfort -- have swollen larger than a patient’s face after a nose job. Flush with excitement over the seemingly overnight transformations they have seen on TV, prospective clients have flocked to Haworth’s office with wild demands and little notion of the pain or risks that so many procedures entail.

Within three weeks after surgery, Haworth says his patients tell him “I don’t look like myself; I see some swelling here. It wasn’t like this on ‘Extreme Makeover.’ ”

The new reality shows and documentaries “in a way are just making plastic surgeons’ lives more difficult,” adds Haworth. “They instill unrealistic expectations in patients and those patients bring them into their surgeons, who have to spend more time” counseling them on the limits of plastic surgery.

Complicated? That’s not the half of it for Haworth. Last year, the popularity of the cosmetic-surgery makeover shows landed a new kind of client on his doorstep: TV producers intent on making a show of their own. And that’s how Haworth became one of two plastic surgeons helping to transform 17 self-professed “ugly ducklings” for Fox’s new entry into the makeover game, “The Swan,” which premiered Wednesday.

Now, with the skill of a surgeon, Haworth is threading a fine line between his dual roles. At the same time that he is touting “The Swan” and busy with new clients brought in by similar shows, he has joined his colleagues at the ASPS in warning that viewers of such shows are developing inflated hopes about what plastic surgery can do for them.

“The new wave of plastic surgery reality television is a serious cause for concern,” Dr. Rod Rohrich, president of ASPS, warned in a news release recently. “Some patients on these shows have unrealistic and, frankly, unhealthy expectations about what plastic surgery can do for them.”

That said, however, Rohrich acknowledges that plastic surgeons have been buzzing about the shows, even as their offices have hummed with the increased business.

“It’s a unique time in plastic surgery,” says Theresa Hill, a spokeswoman for ASPS. “The stigma is decreasing and the popularity is increasing, and that’s certainly due in part to these shows.”

She adds, however: “But this is not hair highlighting. People need to know there are risks” with these procedures.

Plastic surgeons say patients undergoing invasive cosmetic procedures must understand that they face all the risks of surgery generally, including infection, complications from anesthesia, pain, swelling and sometimes a loss of sensation around the site of the incision. And because beauty is in the eye of the beholder, plastic surgeons must add disappointment with the results as another risk that patients face. All of these, say surgeons, must be part of the “counseling” they are obligated to give patients.

Rohrich also expressed concern that patients will come to doctors expecting that they could have a large number of surgical procedures done with a single visit to the operating room. Multiple procedures performed in one operating session are common -- 32% of patients last year had more than one done in a single session.

That illusion may be great for the “before-and-after” drama of television, Rohrich says, but in real life “you can only do so much in one operative setting.” For patients’ protection, procedures are divided up into separate operative sessions that don’t last too long or do too much.

Plastic surgeons in recent years have learned that they need to protect themselves as well.

In 2000, one New York patient brought suit against her plastic surgeon, charging that he should have recognized that she had a psychological disorder and denied her further treatment. The patient maintained she suffered from body dysmorphic disorder, a condition that distorted her ability to perceive herself accurately. The suit failed, but for many plastic surgeons, it underscored their vulnerability to legal action.

“Extreme Makeover,” now in its second season, presents two transformees per episode and takes them through a litany of cosmetic, dental and ophthalmological procedures, as well as sessions with hair and makeup artists and personal trainers.

The show culminates in an emotional “unveiling” of the subjects to their family and friends, and there is much dramatic before-and-after comparison.

“I Want a Famous Face,” in its first season, bills itself as a documentary. It does not pay for the surgical makeovers of its subjects, but follows and documents “the journey” taken by people who want the look -- or the breasts or the lips -- of some celebrity. Some of its documentary coverage is graphic, and its portrayal of surgery’s aftermath is occasionally unsparing.

Both shows have proven extremely popular. But ASPS’ Rohrich warned that the public “is being lulled into a sense that there are no real risks or complications in cosmetic plastic surgery.”

He further cautioned against the desire to look like someone else. “Everybody is unique,” he says, adding that each person’s bone structure, musculature and skin tone will prevent them from looking exactly like another person -- a point that a reputable and board-certified plastic surgeon would know to underscore.

“Patients need to be careful of any physician claiming they can make you look like someone else,” says Rohrich, who is chairman of plastic surgery at the University of Texas’ Southwestern Medical Center. “We can all look better but it has to be a better you,” and patients who expect otherwise should raise a red flag for a doctor.

In an interview last week, Rohrich was also deeply critical of “The Swan.” The show sets out to make over 17 women “inside and out” -- psychologically as well as physically -- and then conducts a pageant to pick which one will be crowned “The Swan.”

“I don’t think that’s real plastic surgery,” he says. “We don’t have contests. That to me is over the line.”

Haworth, however, contends that unlike the makeover shows that have come before it, “The Swan” will show the lengthy recovery processes that follow patients’ plastic surgeries, and notes that the participants’ physical changes are only one part of a larger transformation -- a key to keeping their expectations realistic.

Participants in “The Swan” were rigorously screened to ensure that plastic surgery wasn’t used as “surgical psychiatry” -- a well-known term in the profession, he says.

As they winnowed prospective participants down from 600 applicants, the show’s producers sent a final group of applicants to be screened by independent psychologists to look for “red flags we might not have seen,” Haworth says.

“I wish we could do that on all paying patients that come into my office. But we don’t have the luxury of doing that,” he says.

Until that becomes standard procedure, plastic surgeons are cautioning that those watching TV’s new crop of makeover shows should nip and tuck their expectations first.