Illustrated by Hervé Kwimo
When Kate* arrived at the office — a light-filled, CB2-meets-clinical-chic space in midtown Manhattan — she had one thing on her mind: a crop top.
“I’m a pretty small person, but I’d always had these little pockets of fat on my stomach,” she says. So when a friend raved about a minimally invasive treatment designed to target so-called stubborn areas, she decided to give it a whirl as a birthday present to herself — a flatter belly and the confidence to bare her midriff with abandon. But the procedure left her covering up more than ever before. “Immediately after taking the bandage off, I noticed there was a problem,” says Kate. “There was this dent in a diagonal line across my stomach.”
Millions of people in the U.S. undergo a cosmetic procedure each year. In 2020, roughly 2.3 million plastic surgeries and 13.3 million minimally invasive, nonsurgical treatments, like Kate’s, were performed, according to data from the American Society of Plastic Surgeons.
Less common is Kate’s poor outcome. A 2018 retrospective published in Plastic and Reconstructive Surgery looked at over 26,000 outpatient plastic surgeries between 1995 and 2017, and found that complications occurred in less than 1 percent of cases. The most common issue? Hematomas, which are essentially very bad bruises. There still isn’t great data on minimally invasive treatments as a whole, which include injectables and lasers, but a 2013 review published in the Aesthetic Surgery Journal estimated that the incidence of severe complications after soft-tissue filler injections is .0001 percent, for example.
A Rise in Misleading Before and Afters
The 2022 procedure playbook, however, looks very different than it did 10 or even 5 years ago. And that’s making already complex cosmetic treatments more complicated for everyone involved, increasing the likelihood of disappointing results. “People used to come in with pictures of themselves when they were younger or a movie star’s [face],” says Melissa Doft, M.D., a plastic surgeon in New York City. Now, says Dr. Doft, they’re bringing in photos that have clearly been Facetuned, filtered, or otherwise edited. “But you can never really match that. Surgery is not Photoshop.”
Blurring the lines between beauty and reality has made it increasingly difficult for patients and providers to set expectations, an integral part of any consult, says Steven Williams, M.D., a plastic surgeon in Dublin, California. While that may not increase the likelihood of, say, an infected scar, it can result in a dissatisfied patient nonetheless. “Even the perfect surgery may not meet expectations,” says Dr. Williams, “and that can be a source of a lot of patient frustration and sadness.”
In some cases, though, it’s the providers who are living in an alternate aesthetic reality, skewing patient expectations. “I’ve had a lot of people come forward saying, ‘That’s me [on the provider’s social media], but that’s not what I look like,’” says Melinda Farina, a patient-safety advocate best known by her Instagram handle @beautybrokerofficial. This is why she recommends a return to the old-school, leather-bound, before-and-after books at doctors’ offices for a lower-tech but more accurate depiction of their track record.
Illustrated by Hervé Kwimo
When Sharon* suffered nerve and muscle damage after her facelift, her doctor still uploaded her before and after to his Instagram page. He simply altered the after to look better. “He turned my head around on my headshot so that you don’t see the bad part,” she says.
Sharon’s surgeon is one of many who have found success showcasing their work — doctored or no — on social media, which has become a directory for cosmetic providers of all kinds. Who needs a referral when you have DermTok?
That’s how
Kerri found her doctor. After searching Instagram for #liposuction and #lipo360, she stumbled upon a digital portfolio of her doctor’s handiwork. When, on the morning of her surgery,
he encouraged her to tack on a
Brazilian Butt Lift — a trendy cosmetic procedure now infamous for having one of the highest mortality rates in plastic surgery — she agreed, on the condition that it be very minimal.
“I said, ‘If you suggest I’m going to look better, I’ll do it, but I don’t want to look like a video vixen.’ I’m a professional and I wanted to keep it very discreet,” adds Kerri, who was initially seeking to tighten up her belly post-baby. “When I looked in the mirror afterwards, I screamed. It was double the size of my butt before surgery, double and a half.”
Kerri shared her story on social media. So did übermodel Linda Evangelista, detailing her experience with the fat-freezing technique CoolSculpting, which she alleges gave her paradoxical adipose hyperplasia (PAH), a rare side effect that results in excess fatty tissue. (A representative for CoolSculpting did not respond to a request for comment.) In Evangelista’s words, as posted on Instagram, she is “brutally disfigured” and “permanently deformed,” even after two corrective surgeries.
But it’s not just the bad work that’s getting talked about these days — it’s the work, period. See: Designer Marc Jacobs documenting his facelift, bruises and all, for the world to see on their iPhones. This openness has minimized the stigma associated with cosmetic treatments, says Dr. Williams, but it’s also minimized the seriousness. “As it’s become more acceptable, in some ways it’s become trivialized,” he says.
The Medispa Risk
Dr. Williams also points to increased accessibility as a contributing factor. The number of medical spas in the U.S. more than tripled between 2010 and 2018. And in a 2020 survey of dermatologic surgeons, the majority reported that more than half of the complications they saw were attributable to medical spa treatments. Going the medispa route may come with the same disclosures, says Dr. Williams, but they aren’t exactly held to the same standards — by institutions like hospitals or medical boards — as doctors’ offices are for delivering successful outcomes and explaining the very real potential for complications.
“A physician’s assistant or nurse took me through all the warnings, but I didn’t pay much attention to them; they all sounded standard,” says Kate. “Nobody said, ‘Hey, I might accidentally leave the cannula in one spot for too long and you’re going to be left with a dent in the middle of your stomach.’” (According to Kate, this is what her current plastic surgeon suspects caused the complication.)
In the event that something does go wrong — whether a medical complication or an unsatisfactory result — it’s the doctor’s job to find a way forward, says Dr. Williams. “The general policy for most plastic surgeons [is that] within a period of time (six months to a year), if there’s something the patient wants a little different, [they’ll perform a revision], waiving all or part of their fees.” (Kate says after a second attempt at the procedure, her clinic gave her plenty of complimentary in-office treatments in an effort to minimize the dent. That didn’t help, either, she says.)
But the patient may not be eager to return. “I wanted nothing to do with him,” says Kerri. “The fact that he didn’t listen to me the first time, I was so pissed. I was like, ‘Forget it.’”
Emotional Side Effects
Sometimes the damage beneath the surface is just as painful. Sharon reports having felt sad and isolated, and says, “I cry a lot.” These feelings can arise in anyone who has a surgery complication (Sharon says she’d never had anxiety before her facelift), but they can be especially acute for those with a history of mental health disorders, which Dr. Williams says should be ascertained in the initial consultation.
“For someone who is depressed or has another mental health condition, it may be more difficult to tolerate a stressful experience such as this,” adds Katharine Phillips, M.D., a psychiatrist and professor at Weill Cornell Medical College and adjunct professor at Brown University.
This can also exacerbate the appearance concerns the patient was trying to resolve in the first place: “You already have a patient who’s hyperfocused on this one part of their body,” explains Dr. Doft. “Now, all of a sudden, instead of it being improved, it’s [somehow worsened]. So now they’re even more focused on that area.” If the patient has body dysmorphic disorder, which Dr. Phillips says affects upward of 15 percent of cosmetic procedure patients, even a flawless surgery is unlikely to alleviate their concerns.
The lumps that appeared on Tina*’s body after a series of minimally invasive contouring treatments contributed to her developing severe depression. “[The complication] has damaged my life in many ways,” she says. “I’ve been in the fashion business all my life, but I can’t wear anything anymore. I don’t even go for meetings.” Evangelista has said that not only was her livelihood “destroyed” by PAH but the experience also triggered “a cycle of deep depression, profound sadness, and the lowest depths of self-loathing.”
Because aesthetic treatments are elective, many patients place some of the blame for complications on themselves, says Amy Wechsler, M.D., a dermatologist and psychiatrist in New York City. And that can open a Pandora’s box of negative thoughts: “They think, Why did I do this? or, What’s wrong with me that I felt so bad about myself?” says Dr. Wechsler.
“If I had gone to five or even two people to check this out and taken the time to sit with it and talked to a friend, even if it still happened, then at least [I could say] I did everything I could do to make sure I was making a smart choice,” says Kate. “Also, changing the shape of your body, there’s always that idea that, Oh, if I got up every morning and went to the gym for two hours, or stopped eating candy or whatever, I could just do it myself. So, if I took a shortcut and it didn’t go the way I wanted, then is it my fault for not just doing the work?”
The possibility of a physical complication, says Dr. Wechsler, is something that every patient should prepare for. “I always think it’s good to reflect: What are the potential side effects? And if they happen, how am I going to handle them emotionally?” But, she adds, it’s also important to set yourself up for success in the first place, starting with realistic expectations and getting clear on your motivations. “If someone comes in and they want a nose job because their significant other is complaining about how ugly their nose is, that is never a good reason to do something.”
When choosing a provider, board certifications specific to the procedure — i.e., a tummy tuck from someone board-certified in plastic surgery, not emergency medicine — matter. So does bedside manner, says Dr. Doft. All of the patients interviewed for this piece say they had a bad feeling at some point before the surgery, but went ahead anyway because they didn’t trust their instincts, wanted to get it over with, were afraid to speak up, or all of the above.
In the end, Kerri had three additional liposuction procedures to remove a total of 1,800 cubic centimeters of fat and deflate the Brazilian Butt Lift she never asked for. “Nobody really wants to hear that something could go wrong. I tell patients there’s [always] the possibility of a complication,” says Dr. Doft. “Who’s going to be there with you, standing by your side, if that happens?”
*Names have been changed.