To Keep or Not to Keep Your Nose

All over the world, to paraphrase Dorothy Parker’s observation about singer Fanny Brice’s plastic surgery, people are cutting off their noses to spite their race.

They are doing it everywhere, but the front lines are probably in Beverly Hills. On any given weekday in the offices of Dr. Paul Nassif on Spalding Drive, men and women, teenagers to 50-year-olds, wait in a luxuriously carpeted and upholstered reception area. On a comfortable chair, a young African American woman in her 20s reads a book. An older Asian woman in a broad hat emerges from the consulting rooms. A Latina chats with the receptionist. The door to the outer hallway opens and in comes a perfect Hollywood blond in a lacy white blouse, white linen trousers, gold bracelets, diamonds on her fingers, a designer handbag hanging from her shoulder. An older white man leaving the office jokes with a nurse: “Now I’m ready for a weekend of golf.” On a closed-circuit television in a corner, testimonials by former patients and video footage of procedures play to current and prospective clients.

The patients are ethnically diverse. What many have in common, of course, is a desire to appear more youthful. But page through the before-and-after album that lies on a waiting room table and you see the other trend.

In this office it’s known as westernization.

Here is a 31-year-old Asian woman who “feels that her nose is too bulbous.

Procedure: westernization rhinoplasty. Comment: Notice the smoother, softer nose with a ‘natural’ appearance.” Next, a 26-year-old African American male “desiring a ‘westernization’ rhinoplasty . . . he has an ethnic nose and wants it thinner and desires more projection. Comment: Notice the improved but not over-corrected profile with more projection and a slimmer nasal tip. His nostrils also were narrowed with a natural appearance.” Over on this page, “a 25-year-old Middle Eastern male desiring removal of the hump on his nose.”

While all this westernization is going on, the cautionary example of Michael Jackson remains on people’s minds. Patients and doctors say he is often mentioned as they discuss plans for surgery. No one wants to make his mistakes; no one wants to turn into a monster of tragic racial confusion.

Both doctors and patients say the lessons of multiculturalism learned in the 1970s and 1980s have had a significant impact on the practice of cosmetic surgery. Today’s patients are seeking a look that could almost be called mestizo, and a kind of racial syncretism seems to be the goal of many. Dr. Charles Lee of Beverly Hills (not of Spalding Drive, but of Roxbury Drive), whose patients are often Asian Americans, dislikes the word “westernization.”

“If I performed an operation to westernize an Asian patient,” Lee says, “they’d be unhappy because it would look unnatural. When I give someone a double eyelid, which is a very popular surgery among Asians today, I try to retain the Asian look of their eyes. I want to create a natural appearance, an Asian appearance. Ideas of beauty have evolved over a long time, and there is now an evolving standard that is transracial.”

There has always been a cultural debate surrounding cosmetic surgery. The debate swirls around such emotionally charged issues as God-givenness and individual free will. Should one bear for life a physical or mental burden that one was dealt at birth? What constitutes a physical defect? There are questions of masquerade and racial or ethnic passing, as well. Should people undergo procedures that make them less perceivably members of the socially stigmatized race or ethnic group into which they were born? Does an unconscious self-hatred, stemming from discrimination by a dominant culture, push people into the waiting rooms of cosmetic surgeons?

“It’s all about the politics of appearance,” says Patricia J. Williams, a Columbia professor and columnist for the Nation magazine. “It is distressing to see those who are getting cosmetic surgery trying to appear more Western European. Plastic surgery, which began as a process to reconstruct in medical emergencies, has been taken up by those who have been so oppressed that their ethnicity is perceived as a medical emergency.”

That is one side of the debate. Cultural historian and Emory University professor Sander Gilman, who has written extensively on the cultural impact and significance of cosmetic surgery, represents another. He says critics like Williams can “end up sounding like Catholic cardinals from the 17th century. Their implicit argument is that you must suffer with it, because it is God’s will. Aesthetic standards, however, are not absolutes, but rather questions of negotiation and accommodation within a culture and among individuals. I think that one must be careful not to assume that self-hatred is always the motivation behind the patient’s desire for surgery. For example, by the 1970s here, the idea wasn’t not to look Jewish--but not to look too Jewish.”

In the late 1800s, a German Jewish surgeon named Jacques Joseph (he had changed his name from Jakob Joseph) developed many of the non-scarring techniques followed in present-day rhinoplasty. Scarring itself, as Gilman points out in his book “Making the Body Beautiful,” was controversial in Germany at the time. In order to advance in elite society, a man was better off if he could show certain facial scars inflicted during gentlemanly dueling. Joseph himself had such scars. Indeed, some even had treatments to enhance the facial scars of swordsmanship.

Yet a Jew was better off socially if he had a straight nose (preferably by birth, but if not, by surgery) and no scarring to show that he had altered himself in order to pass. (In the late 18th century, syphilitic noses, eaten away by the venereal disease, were repaired with skin grafts taken from the patient’s forehead; the scar there served as a sign of disease emblazoned on the patient’s brow. Other nonvenereal nose jobs were equally scarring, thus negating the value of the operation.)

Among German Jews, the cultural debate was this: Is it right to deny your Jewishness by changing your facial structure? Moreover, can cosmetic surgery really achieve what the patient is setting out to do? Will the non-Jew accept the Jew simply on the basis of a straight nose? In other words, there was the distinct possibility that cosmetic surgery was both morally wrong and wouldn’t achieve the desired goal. Once Joseph perfected his non-scarring techniques, however, the nose job was more willingly accepted by his Jewish patients. Yet nose job or no, the Nazis were later quite able to isolate and identify the Jewish population. What then was the value of the cosmetic operation?

Let’s be real. The history of plastic surgery, with its references to venereal disease and genocide, can seem a little . . . heavy . . . when you’re sitting in a Beverly Hills waiting room on a nice spring day in the year 2006 waiting for a Botox injection. Like, don’t harsh my buzz, dude; I got my hair done, too. I just wanna look good for the after-party tonight.

The truth is that cosmetic surgery today is almost as accepted as makeup application, hair treatment and orthodontia. Since 1997, there has been a 444% increase in the number of cosmetic procedures in the U.S., according to the American Society for Aesthetic Plastic Surgery. Surgical operations have increased 119% since then, while nonsurgical, minimally invasive interventions such as Botox injections, laser hair removal, acid wrinkle fillers, and skin abrasions and peels have shot up 726%.

This is not, as one might suspect, purely the result of a baby-boom generation that wants to cling unwrinkled to the word “baby.” The desire for what might be called “ethnic revision” has helped pump up cosmetic surgery numbers. In the U.S. in 2005, the number of ethnic patients opting for cosmetic surgery rose about 65%, with almost 2.3 million procedures performed. In the U.S. last year, some 20% of all cosmetic procedures were performed on ethnic or racial minorities, according to the society. Latinos underwent more than 921,000 procedures, the largest number for any ethnic group, followed by African Americans, with 769,000. Both of these ethnic groups saw a 67% rise in the number of procedures over 2004, while Asian cosmetic surgery rose 58%.

The phenomenon is global. According to the International Society of Aesthestic Plastic Surgery, the number of cosmetic surgical procedures performed worldwide has increased 15% to 20% each year over the last five years. National types of beauty apparently no longer hold sway, with all continents lurching madly toward an improved, modified, Aryanized look--a westernized face with a narrower, more protruding chin; a higher-bridged, more slender nose; smaller, narrower, downward-facing nostrils; and wider eyes with double lids. (In China, the enormous upsurge in cosmetic surgery has taken place both in hospitals and in small back-alley shops called “beauty-science centers.” Not surprisingly, this boom has caused an uptick in lawsuits against cosmetic surgery practitioners, with an estimated 200,000 such filings in the last 10 years.)

In many ways, the American entertainment industry has fueled the craze, first by beaming images of the dominant world culture to a global audience and then by offering television shows that make cosmetic surgery seem less dangerous and less stigmatizing than it used to be. “Dr. 90210” and “Extreme Makeover,” which depict patients undergoing reconstructive procedures, have expanded the population interested in cosmetic surgery from a small, elite minority to one of millions. “Extreme Makeover” airs in more than 100 countries.

There is a famous joke about nose jobs that no longer holds true but is instructive in explaining the trend in ethnic cosmetic surgery. It’s about a New York-area woman who had a nose job as a teenager. One day, she’s walking down the street with her husband in Paris, or Rome, or London, and she sees another woman walking toward her. “Look,” she shouts at her husband, clutching his arm and pointing, “a Dr. Diamond nose!”

Howard Diamond of Manhattan was a real person, a master plastic surgeon who probably performed more nose jobs than any other in his field in the 1960s and 1970s. It has been said that all the noses Diamond did ended up looking the same: cookie-cutter noses, or assembly-line noses. In the joke, “Dr. Diamond” is simply the name that stands for all plastic surgeons of his era, when the nose job was king. Many of the real Diamond’s colleagues and patients deplore this besmirching of his reputation.

Still, there is no question that rhinoplasty in the ‘60s and ‘70s produced hundreds of pinched, ski-slope noses intended to look like the adorable button nose of a Barbie doll or a Cheryl Tiegs, a top fashion model of the era.

No longer. Indeed, many of the postoperative noses fixed today by Nassif and other plastic surgeons have flaws very much like the ones “Dr. Diamond” was called in to correct. “I’m not making people similar,” Nassif says. “If you take 10 of my African American patients and put them in a room together, they will not look alike.”

On Spalding Drive in Beverly Hills, patients don’t want their names printed, but they aren’t shy. A Latina explains that when she had her nose “fixed” in the 1980s, the doctor did an awful job. “It looked terrible, and it didn’t even work properly! And when I finally went to have it redone, I did not want to look like anything but my own race. That first time, I didn’t know what to say, what to ask for, I was so young. But now I knew: I still wanted to look Hispanic. And the revision was good. The doctor returned my look to a natural look; he returned my ethnicity to me so that now I have something that looks like I was born with it. I never wanted to look cutesy or . . . Caucasian. I wanted to have my mother’s nose--my mother has a perfect nose.”

Another rhinoplasty patient, this one Afro Caribbean, thinks westernization isn’t the right word for what’s happening. “After all, there are plenty of Africans who have straight, narrow noses--look at the Ethiopians. I went from a wider to a narrower nose, but I did not want any arrow-straight nose. I wanted a nose that was in proportion to my small face. And my family and friends, when it was done, they couldn’t even tell--they thought I’d lost weight. Somehow I looked better, but why they could not say. I always wanted it to look like me, only enhanced.”

In his main office in Beverly Hills, and at satellite offices in various parts of town, Dr. Lance Wyatt has a diverse patient population that includes Persian Jews, Latinos and African Americans. “What I really enjoy is the mix,” Wyatt says, challenging westernization. “You simply cannot assume that because a patient wants rhinoplasty, he’s going to want a European nose. That may have been the assumption of physicians in yesteryear, but it’s certainly not the assumption today. With the heterogenous mix we have here in L.A., and the vast number of interracial couples, you have to appreciate the specific ethnic standards. The concept now is to retain and improve.”

Wyatt says there is a give-and-take going on, a lot of play within ethnic stereotypes, so that in the past a Jewish woman would have been unlikely to ask for thicker lips or buttock enhancement, but she might do so now. His Middle Eastern patients come in and say: “I want lips like . . . yours, doctor.”

Wyatt is African American, although he is quick to point out that he is of African, European and Native American descent. “And in this, I am not unusual,” he says. “It’s a beautiful thing about living in this fabulous city: You’re exposed to people’s ethnic characteristics every day. . . . My Jewish patients leave my office on their way out for a Mexican dinner; my Latino patients come in eating a bagel.

“The average person is getting ideas from what they see in the mass culture, coming out of Hollywood, television . . . but you can’t forget that the elite that creates the mass culture here in L.A. are getting their ideas from what they see in our streets. . . . The mass culture is producing patients who say I want a Jennifer Lopez behind, Angelina Jolie lips, Pamela Anderson breasts and Halle Berry’s nose.”

Still, an observer--noting that most people go from wide noses to narrow, from hooked noses to straight, from flat noses to raised-bridge noses, from wide Asian faces to thinner-cheeked faces, from wide hips to narrower hips--can’t quite banish the thought that someone is being fooled here.

Is it that the doctors and patients are suffering from a kind of mass Stockholm syndrome in which they don’t realize that they have accepted the beauty standards of the dominant culture, of which Michael Jackson is the most prominent cosmetic victim? It seems clear that a lessening of ethnic characteristics (rather than a “refining”--whatever that means) is what is going on. In the days of Dr. Joseph of Berlin, if a Jewish rhinoplasty patient had asserted that he wanted to “refine” his nose but retain his Jewish ethnicity, other Jews would have laughed.

Here in the U.S., our Hollywood- and New York-bred celebrity/fashion culture has infected us with what seems to be an adolescent desire for conformity (to which even celebrities must hew). Forgotten is the idea that variety is the spice of life. Anyone, no matter his or her background, can imagine being a potential postoperative star.

Maybe the trend is good, in that it has the potential to make us all equals, each looking more or less like the other. Many have argued that the widespread acceptance of cosmetic surgery represents a new kind of democracy. Carried to its extreme, the trend would level the physical field and make each generation a brave new postoperative world. In that world of beauties, we could all compete for Orlando Bloom or Kate Bosworth. But as Charles Darwin wrote, “If every one were cast in the same mould, there would be no such thing as beauty.”