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Body work

Body modification is not restricted to gender or limited to any group. Physicians talk about a generation they call the "robust elderly," 60– and 70–year–olds who are striding confidently into old age and want to look good doing it.

Eve Fries is a cosmetic surgery veteran, although she is only 34 years old. At 24, she had an operation to make her stomach flat as a board. At 28, she had her breasts lifted and recontoured and fat removed from her thighs. At 30, she had her nose reshaped to make it thinner. Then, three years ago, she had her eyes done to eliminate dark circles and sagging lids. Now she's saving up for a face lift.

Fries is a Fall River resident working as a special needs teacher at an alternative elementary school, a mother of two teenagers, happily married to a state policeman who loved her as much before the surgery as he does now. She didn't do any of this for him or anyone else. She wasn't deformed or even oddly shaped. She just didn't like the way she looked. She was 30 or 40 pounds overweight, and after childbirth more than 15 years ago, "I had all this loose skin, just hanging," she says. She wore big shirts and never tucked them in, never let herself be seen in a bathing suit, never wanted to participate much in social events. Shy and withdrawn, she even delayed her marriage, she says, "because I didn't want to get up in front of everyone in my wedding dress and feel bad about myself."

She tried Jenny Craig, Weight Watchers, and other weight-loss regimens. She tried every diet pill she heard about. She saw a psychiatrist for about two years. But none of this helped much. She worked as a hairdresser and then as a licensed embalmer at a funeral home, restoring bodies after suicides, homicides, and traumatic injuries. "I could make anyone look better - anyone but me," she says.

Then, on a tip from a colleague, she went to see Dr. Barry Davidson, a cosmetic surgeon in Newton. Her elation over her first surgery, which removed fat from her midriff, "gave me the fire to start my engines," she says. With each succeeding operation, she became happier and more confident. She started working out, finally married the man she loved, went to college to train for the teaching job she really wanted.

Now, $30,000 in surgeries later, "I really love the way I look," she says. "I feel like a million bucks. It's like the surgery let out this person who had been there all the time but afraid to come out. I consider that I've found myself."

She's so pleased with the way she looks and so comfortable with her new self that she's bared all publicly, though anonymously: Her "before" and "after" photos are posted on Davidson's Web site, www.cosmeticsurgery-Boston.com.

Americans as never before are treating their bodies like works of art, redesigning and sculpting them to do what nature and nurture have not. Flesh can be like canvas. Flesh can be like clay. It can be carved, cast, sanded, branded, braided, dyed, etched, stretched, scarred, smoothed over, tucked under, tightened, rolled back, plumped up, peeled, pierced, and embedded with jewelry. So many things can be done to alter its texture, color, shape, and look that a term has been coined for the process. It's called body modification.

Cosmetic surgery is by far its most common form, and the numbers are staggering. Since 1997, more than 10 million people have gone under the knife to enlarge their breasts, drop a few pounds, tighten drooping eyelids, lift wrinkled brows, recast noses, or recontour their bodies in some other way that they find pleasing. This means that about one in every 28 people has had some sort of body makeover in the United States in just the last three years.

Signs of the popularity of cosmetic surgery are everywhere: on Web sites where devotees post snapshots of their altered bodies; in magazine and book-length memoirs of personal adventures in various branches of this skin trade; in televised operations that have turned what once was a strictly medical procedure into a pop culture event. Network and cable channels draw high ratings through weekly programs such as The Operation, with live broadcasts of surgeries to enlarge breasts or suction off fat.

As the surgery becomes more familiar, the stigma is fading. In a February 2000 poll by the American Society for Aesthetic Plastic Surgery, 82 percent of the women surveyed and 72 percent of the men said that, if they had cosmetic surgery in the future, they would not be embarrassed if people other than close friends and family knew about it. A 1998 study by the American Society of Plastic and Reconstructive Surgeons found that 19.2 percent of women and 7.3 percent of men said they already have had cosmetic surgery or expected to have it sometime. The same survey found that 47 percent of women and 34 percent of men had more favorable attitudes toward cosmetic surgery than they did 10 years ago.

For those who find surgery too invasive, an arsenal of mechanical and chemical weapons has been developed to resurface the skin, remove wrinkles, and create a more appealing body - including laser and chemical peels, collagen and botulinum toxin injections, and assorted skin sanding techniques. Spas offering these services and often linked to cosmetic surgeons are spawning as fast as Starbucks, and with roughly the same clientele. One 12-block section of Boston's Back Bay boasts a total of 85 spas and cosmetic surgery centers.

What's going on? How did Americans, who two generations ago rarely even pierced their ears, come to embrace all this cutting, sucking, and sanding of their flesh?

In part, major age and demographic shifts are at work. The country's 76 million baby boomers - people born between 1946 and 1965 - are entering midlife. One turns 50 years old every 15 seconds, according to the US Census Bureau. The boomers have the power of numbers and the economic wherewithal to get their way, and they have spent much of their collective lives challenging norms of behavior and appearance. Many are determined not to age in the old, tired ways. Last year, boomers accounted for 43 percent of all cosmetic surgery, far more than for any other generation.

And they're more open about it. People are sharing tips on physicians and procedures, even forming cosmetic surgery clubs. Marie, an alcohol and drug counselor who lives in Newton, is one of several veterans who have banded together in an overnight women's cosmetic surgery group. They stay at one another's homes during the first unsightly days of recovery, "so our husbands don't have to see what we look like" until the wounds have healed, she says.

Men also are opting for the procedures in record numbers. Since 1992, there's been a 50 percent increase in men's cosmetic surgery, mainly for liposuction - in which fatty tissues are suctioned off - eyelid tucks, nose jobs, and hair transplants.

And the boomers' enthusiasm has spilled over to other generations. Many cosmetic surgeons say their teenage clientele has increased significantly in recent years. Why bother with padded bras when silicone implants promise permanence? Why spend adolescence brooding over cauliflower ears or a large, bumpy nose when plastic surgery offers immediate relief? Former patients transmit tips about surgery and surgeons to their children in a modern rite of passage. Davidson says he routinely sees two generations of breast implants, and three generations is not uncommon. "A daughter with the same build as her mother and grandmother sees what they had done and decides she can do something about it, too," he explains.

Even the elderly, who might once have feared complications from this often delicate and painful surgery, increasingly are joining the nipped and tucked. The United States enjoys the lowest death rate for the over-80 set of any industrialized country, and cosmetic surgery is largely an American phenomenon. Physicians talk about a generation they call the ''robust elderly," 60- and 70-year-olds striding confidently into old age. Living to be 100 no longer seems out of the question. Why not do so looking good?

These are people like Janet, a vivacious platinum blonde who at age 70 lifts weights, walks a mile in 17 minutes, acts in amateur theatricals, and loves oddball adventures like spelunking in faraway caves and walking over glaciers. She parties late and gets up early. She isn't embarrassed about the face lift she had last year but won't give her last name for another reason: Since the surgery, she has been dating a man 20 years younger, and she doesn't want him to know her true age.

You won't find her languishing in some retirement community or lulling herself to sleep in a rocking chair, says this South Shore resident and former schoolteacher, waving long orange fingernails as she talks. "I'm creating my own aging process. I'm not going to live on someone else's schedule. I think you can be whatever you want to be, do what you want to do."

Advances in medical procedures and changes in the economics of health care also have contributed to the cosmetic surgery boom. At his stylish office in Wellesley, Dr. Richard Ehrlichman, 45, a spokesman for the American Society of Plastic Surgeons, says the last 10 years have brought stunning advances in equipment and resources.

Anesthesiology is safer and better. A new 4mm endoscope, a tube with an attached fiber-optic camera, allows cosmetic surgeons to do forehead and face lifts with tiny incisions and to watch their work on overhead screens. Developments in laser equipment have given them cutting and resurfacing tools as precise as a pinpoint of light, causing less bleeding. Lasers can zap away bikini-line hair, spider veins, liver spots, crows' feet, and fine lines around the mouth. New Erbium lasers are cooler than their predecessors and can be safely used not only on the face but on thinner, more delicate skin on areas such as the neck and chest. Liposuctions now are done with smaller fat-sucking devices or ultrasonic probes that liquefy fat before removing it, also decreasing blood loss.

Less invasive procedures mean shorter and easier recovery periods for patients. They typically experience soreness, swelling, bruising, and numbness for about five days after surgery, Ehrlichman says, but most are back at work within a week or so.

As procedures improve and competition grows, prices drop. Makeovers for celebrities like Phyllis Diller, Dolly Parton, Joan Rivers, Carol Burnett, Mary Tyler Moore, even exercise guru Jane Fonda, are highly publicized. But the surgery also is becoming an affordable fashion statement for middle-class folks. About 65 percent of cosmetic surgery patients today have household incomes of less than $60,000, according to the American Society of Plastic and Reconstructive Surgeons. Last year, the average charge for liposuction, the most popular procedure, was $2,300; a breast augmentation, second in popularity, was $3,100; a face lift was $5,135; $2,400 bought a laser resurfacing.

At the fringes of this phenomenon, some people are turning attention to body parts not previously considered in the aesthetic domain. Some doctors report a minor vogue in cosmetic removal of one or two bottom ribs to make a waist look smaller. thers have been alarmed by a small but growing demand for genital surgery among women, typically by 15- to 30-year-olds who think the inner labia are too large or elongated. Several Web sites report interest in amputation of fingertips or toes for aesthetic reasons, ear sculpting to create a Mr. Spock-like effect, and tongue splitting for that snaky look.

Changes in the provision of health services also have spurred the cosmetic surgery craze. In an era of managed care, doctors need paying customers, so perhaps it isn't surprising that the ranks of cosmetic surgeons have increased by more than 200 every year for the last 10 years. Cosmetic surgery is the country's fastest growing medical specialty, estimated at $15 billion last year - $5 billion more than all other forms of cosmetics combined.

"It's more lucrative than many forms of medicine now, and you don't have some nurse practitioner calling to say your patient has to go home because Medicare won't pay for another hospital day," Davidson says. "Third parties don't dictate whether and how the procedure can be performed."

But this freedom can also create problems, Davidson notes, since physicians must police themselves. "The surgeon needs to be a significant filter to discourage patients when it really isn't advisable for them," he says. "If [the patients] have low self-esteem, they may never be happy no matter what you do. They may need counseling more than surgery."

The results of all this money and effort are not uniformly rosy, and there are serious risks. The American Society of Plastic Surgeons acknowledges a death rate of 1 patient per 57,000 surgeries. Its data show that about one-half of 1 percent of all patients develop serious complications, such as heavy bleeding, infection, permanent numbness, or scarring. Since these patients are not ill or diseased, some observers feel that even this relatively low rate of death or injury is unacceptable for surgery that is, after all, optional.

Part of the problem is that several organizations issue cosmetic surgery licenses, with required training ranging from several years to a few weekend courses. As Leida Snow, senior communications officer for the American Society for Aesthetic Plastic Surgery, observes, "Any physician, legally, can call himself or herself a surgeon." Dermatologists, ophthalmologists, or any other doctor can provide cosmetic surgery services. About 6,125 doctors are certified by the main professional group, the American Board of Plastic Surgeons, but they account for less than half of the country's total number of doctors performing these surgeries.

And there have been well-publicized horror stories. In Florida, where 1 out of every 17 physicians now provides some form of cosmetic surgery, the Ft. Lauderdale Sun-Sentinel - in a series of widely reprinted articles that won the newspaper a Pulitzer Prize - found a bevy of rogue doctors, including one who cut open a woman's breasts using kitchen utensils he bought at a discount hardware store. The newspaper's reporters claim to have documented more than 1,200 injuries, ranging from serious burns to disfiguring scars.

But, in general, most patients and the public at large apparently view such incidents as isolated and atypical. A January 2001 survey by the American Association of Retired Persons found that fully half of all Americans know someone who has had cosmetic surgery, and 61 percent think they look better for it. Only 6 percent say they look worse.

In more than a dozen interviews, former patients in the Boston area said they are generally satisfied with the results of their surgery. Some are relieved to be rid of what they considered a deformity, such as a bulbous nose or protruding ears. Some hadn't felt deformed, just unhappy with some unattractive body part. They wanted smaller breasts or bigger breasts, plumper lips, leaner thighs, flatter stomachs, less puffy eyes. Some had been troubled by a hereditary body type - a pear shape, for instance - which they believed no amount of diet or exercise could fix. And a few - like an exotic dancer who came to Ehrlichman for breasts he describes as "huge" - already looked good; they wanted to look great.

But more than anything else, those who opted for cosmetic surgery were fighting the sags and bags of aging, the lines that made them look tired or sad or angry, forever frowning. They wanted to look as young and vital as they felt.

Marilyn Bluestein of Stoughton, a 59-year-old secretary for a giftware manufacturer, says she always felt good about herself. She dressed well and exercised religiously. With her family in the cosmetics business, she knew how to use the tricks of makeup. But about six years ago, she began feeling "that my face just hung. There was no line between my chin and my neck, and I had this turkey-gobbler effect."

She wore turtlenecks and scarves to hide her neck. "Then one day I remember walking into T. J. Maxx, and I saw a reflection in the mirror. As I got closer, I realized this person was me. It made me sick," she says. She turned to Davidson.

The three days following her face and neck lift last December were "the worst days of my life," she says. She was so bruised and swollen that she could barely breathe. She felt as if she were constantly choking. But now, she says, "I'd do it again. Finally, my body shows the way I feel inside."

For some patients, though, the physical improvement has come at a high cost. Margaret, an artist living on Cape Ann, says she felt depressed for months after surgery to reduce her size 48 DD breasts. They had felt "like a burden I was always lugging around," she says. But after the operation, "I missed them." She thought she had done something brutal and alienating to herself. She mourned. Now she's glad she had the surgery, but she has never felt quite the same about her breasts. "They're someone else's," she says. "They're designer breasts."

Odette, a Boston real estate agent, wishes she hadn't had a face lift and nose job 10 years ago. She says she lost something irreplaceable: her own identity. "Sometimes I glance at my reflection in a shop window, and I don't see me," she says. "I have to look carefully, closely, to recognize myself."

Not only cosmetic surgery but more decorative forms of body modification - piercing, tattooing, and scarification - are thriving, too. Body art that would have stamped the wearer as low-class or renegade 20 years ago has become mainstream. Teens at tony private schools, even white-collar professionals, have multiple earrings, nose studs, and ankle tattoos, reflecting new attitudes and mores.

North Quincy resident Mik Miller, 54, has seen the changes more personally than most. Born in California's Napa Valley, he attended the University of California at Berkeley law school, intending to practice corporate law. But his experience with the Marine Corps 37 years ago in Vietnam changed his ambitions.

The Marines had a ritual to mark the first time a platoon member shot someone, he says: They'd pierce that Marine's ear. Miller became the company's piercer, and he loved it. After Vietnam, he worked in Boston as a customs official and a private security consultant. But he continued piercing ears for fun.

One night in 1976, he was at a fetish party when "a dominatrix drug some guy into a room, handcuffed him to a wall, and dared anybody to pierce him," he recalls. "To them, it was a rite of passage. So I did it. I pierced his nipple."

Miller was fascinated by this experience. He went to London to study piercing and to learn more about anatomy and physiology. He also began piercing himself and getting tattooed. He was invited to more S&am;M parties, where his piercing skills were sought.

"There were only two or three of us doing this in the US in the late '70s and early '80s, so I went all over the country," he says. "I'd set up a scene with candles, incense, robes, music. I did weddings where I'd pierce the nipples or the genitals of the bride and groom as a bonding ritual."

Gradually, he realized that piercing was becoming popular outside the S&M world, so in 1986 he opened a part-time piercing parlor in North Quincy. Ten years later, the business had increased enough to occupy him full time. Now, on almost any day, a steady stream of humanity flows through his shop, Body Xtremes, where he pierces about 200 tongues, navels, noses, nipples, even genitals, each week. Tongues and belly buttons are the favored piercings du jour.

His store is thriving, but Miller laments the loss of rituals and ceremonies. "It's so mainstream now," he says. "I miss the pageantry, the adventure. Now it's just a business. People walk into my shop, sit in the chair, and get pierced. Then the next one walks in and sits down. There's no mystique anymore."

Maybe not, but the teens, young executives, and office workers who make up most of Miller's clientele are unlikely to forget him soon. He has 108 body piercings, including 36 on his ears and face. About 80 percent of his body is covered with tattoos, most in black ink. A tattooed spider web sits on one cheek; scorpions adorn the other. An arrow points down his nose to the tarantula crawling up his chin. Flies and spiders dance on his forehead, below a day-glow yellow strip of Mohawk-style hair. And on the back of his shaved head is a cartoonish tattoo of his face - "so I can see myself coming and going," he quips.

As a child, he was afraid of spiders, Miller says. "So the tattoos were my way of proving that I've beaten my fears. They also mark events in my life. If I met someone nice or wanted to make myself feel better, I'd get a tattoo." The piercings, he adds, "show that I don't allow pain to conquer me."

Most of Miller's customers say they went for piercing because it looks "cool" or "cute" or because someone they admire is pierced - such as former Bat Girl Alicia Silverstone, Madonna, Janet Jackson, Dennis Rodman, or members of the band Metallica. A few say they also enjoy the mild shock value.

"I did it on a whim, on my lunch break," says Shannon Carroll, 27, manager of Hill & Partners, a Somerville firm that makes customized trade-show exhibits. "You feel a little bit daring," she adds, as Miller pierces her right nostril to insert a nose stud matching the stud already in the left one.

Miller's next project is a tattoo parlor. As of February 1, tattooing - previously allowed in Massachusetts only if performed by a physician - became legal for nonphysicians as well, provided they meet certain health, safety, and training standards. Nancy Ridley, an assistant public health commissioner, says she expects 600 to 900 tattoo and body-art parlors to open in Massachusetts this year. And some chic local spas will begin offering another form of tattooing: lipliner, eyeliner, and other permanent makeup.

With state and local regulations comes new interest in other types of body art formerly permitted but unregulated - including branding, in which skin is burned in a symbolic or arty way, and scarification, which involves cutting flesh and picking the scab until a scar forms or implanting objects under the skin to create decorative patterns. Miller says he hopes to offer these art forms at his tattoo parlor. And he's planning another new look for himself: five 6-inch cones that will sit under the skin on his skull to give him a shocking, fleshy Mohawk.

Of course, body modification is nothing new. As Rufus Camphausen shows in his book Return of the Tribal, Australian aborigines scarified themselves more than 50,000 years ago; masked figures engraved about 10,000 years ago on rocks in caves in Dordogne, France, show signs of tattooing. Egyptian pharoahs elongated their necks and skulls, ancient Mayans chipped their front teeth to resemble animal fangs, Greek slaves were branded. A portrait of Russia's Catherine the Great shows her with pierced nipples. Some 18th-century European craftsmen, lacking written diplomas, used tattoos to establish professional credentials. Chinese women bound their feet until the practice was banned in 1949. In various parts of the world, people have used body modification to indicate allegiance with a clan or social group, signal mourning, deflect evil or illness, show status, attain magical powers, appear fierce to enemies, celebrate coming-of-age ceremonies, or enhance sexual experiences. Many still do.

The body as canvas for individual or social expression seems universal. Every culture deals somehow with the mind/body split, and what each does reveals its attitudes toward the dichotomy. That exotic piercings and tattoos are penetrating more deeply into US society shows the increasing globalization of culture, the growth of the global village, says Rachel Ruben, an assistant professor of American studies at the University of Massachusetts at Boston who specializes in popular culture.

As tattooing shakes free of its working-class associations in the United States and as more men opt for cosmetic surgery, barriers are coming down between genders and classes as well as cultures, Ruben observes. People are using their bodies as sites for more specific messages about who they are. This can be empowering and can enhance group identification. But especially in the case of cosmetic surgery, she notes, it also can reflect conformity to a narrow standard of beauty that exalts youth above all else.

Social analyst Andrew Kimbrell is one of many who think the focus on body has become a national obession, unnatural and unhealthy, abetted by advertising and spurred by greed. What's new about the current body wars is not just that technology has raised the rate and extent of aggression against our bodies, he says, but that we are alienated from them as never before. "Our overworked, high-speed lifestyles have severed any relationship between our bodies and the cycles of nature, including our body's own natural rhythms," he writes in the Utne Reader. "Our narcissistic culture has turned us into a nation of body-image 'junkies.' ... We are ruthlessly polluting, exploiting, and remaking our most intimate environment - the human body."

Therapist Anne Teachworth, who has explored the mind-body link professionally for nearly 25 years, also believes the body modifiers have gone too far. Ours is a society full of people who don't feel good about themselves and project this onto their bodies, she says. "They'll have surgery after surgery, but the complaint will keep traveling across their bodies. ... They're unhappy inside and don't think they can deal with it themselves. They're dependent on someone else to do it for them."

If these trends continue, Teachworth foresees a day when genetic engineers will mix sperm and genes to create designer bodies, "like dial-a-body." If geneticists can inject a cell into someone's body that governs the shape of a nose, then they "will command the body from inside," she says. "And cosmetic surgeons will have serious competition."

But most of the folks turning to body modification don't see it this way or aren't worried if they do. Right or wrong, says John, a 37-year-old Boston firefighter who got liposuction last fall for his hereditary hip fat, "we live in an image-conscious world." His reshaped body gave him the confidence he needed to start dating again after a divorce.

Appearance is the coin of the realm, the measure of one's worth, a key to success in job and dating markets. "Don't tell me you're not discriminated against, especially in these high-tech companies, if you look old and tired," says Bluestein, the 59-year-old secretary from Stoughton. She isn't looking for another job, but with her face and neck lift, a chin implant and eyelid surgery, she says, "I bet I could compete."

The body increasingly is treated like a commodity, a casing that can be manipulated to become as attractive as its occupant can afford. So perhaps it's only logical that more people are turning to technology for the quick fix that sucks away fat and erases wrinkles. Society has reached the point where people are entitled to look good, Ehrlichman says. "If you eat well, exercise, don't smoke, and you look in the mirror and still don't like what you see, I say the technology is available now. Something can be done to help you. And I don't think it should be considered vanity. It's self-improvement."

It's the puritan call to good works fueled by prosperity and aided by technology in an increasingly narcissistic, youth-oriented culture. Muscle tone is its own morality. Looking good is a sign of virtue. The body, for better or worse, has become not only a window into the soul but an expression of it.

Says Janet, the 70-year-old with the face lift: "If you look good, you feel good. ... I don't see why everyone doesn't fix up their faces. When people look at you, that's mainly what they see. It's almost spiritual. So get rid of a couple of those chins!"ufdot