"When people look at my old photographs, they say the old pictures don't look like me. But when I look at the pictures, I remember how unhappy I was when they were taken. That feeling stays with you."
For Nancy Ford and millions of cosmetic surgery patients, the procedures that nip and tuck, lift and suction have been successful and satisfying.
"My life changed, it was very exciting. It was like buying a new car," Ford recalled. "It's an excitement you want to share with everyone. I was happier in everything I did. When I went away to college, I had great positive outlook. I was very self-confident, very aggressive. This was a fresh start."
But there is a down side to cosmetic procedures - call them vanity, beauty or plastic surgeries.
"One consequence of marketing of cosmetic surgery has been to under- emphasize the seriousness of the procedure," said Dr. Michael Pertschuk, a psychiatrist with the Center for Human Appearance at the University of Pennsylvania Medical Center.
"It's not open-heart surgery, but it's not getting your nails done, either. There are real risks. It's surgery."
Most cosmetic procedures are done under general anesthesia, with its attendant risks. Infection and scarring are other possible complications.
And then there are the people whose expectations don't match the results.
A patient who comes in to meet a plastic surgeon carrying a page torn from a magazine, the way a woman shows her hairdresser a new style, disturbs Dr. James W. Fox IV, Thomas Jefferson University Hospital's chief of plastic surgery.
"If someone looks like Albert the Anteater and he brings in a picture of Paul Newman, or a woman with a dark olive complexion and a Greek nose brings in a picture of Doris Day," said Fox, "these are people with unrealistic expectations.
"Or someone who says she wants this taken up 1/8 of an inch and this moved over 1/32 of an inch. Then I worry. Cosmetic surgery is not that exact a science. People may say, 'I want to look 20 years younger.' What you're really doing is making a patient look fresher or brighter."
Responsible surgeons try to weed out patients with unrealistic expectations, or at least deflate their dreams.
"Is this someone who wants to change a feature or change their life?" said Dr. Emil P. Liebman, head of facial and plastic reconstructive surgery at Temple University. "If they bring in a photo from a magazine, that's a red flag. They're saying, 'I want this person's face. I want to be this
Estimates on the number of cosmetic procedures performed on Americans in 1989 range from 600,000 to 2 million.
Figures from the American Society of Plastic and Reconstructive Surgeons (ASPRS), which represents almost all plastic surgeons certified by the American Board of Plastic Surgery (ABPS), present a partial look at the field.
In 1988, according to the ASPRS:
* 100,000 people had liposuction.
* 78,490 people had the baggy skin above or below their eyelids removed.
* 73,250 noses were reshaped.
One reason why it is so hard to pin down the number of procedures done annually is because so many physicians are doing them and the field is unregulated.
Technically, any medical doctor can perform cosmetic surgery. This includes the 3,200 physicians certified by the American Board of Plastic Surgery (ABPS), which is the only board recognized by the American Board of Medical Specialties to certify plastic surgeons.
Plastic surgeons certified by the APBS have graduated from an accredited medical school in the U.S. or Canada, had residency training in general surgery or another field followed by two or three years of residency in plastic surgery and passed written and oral exams.
In addition, physicians who specialize in otolaryngology (ear, nose and throat work), ophthalmology and dermatology and carry the approved board certification also have been trained in esthetic plastic surgery relating to their field.
Some of these physicians practice only beauty surgery, including Dr. Julius Newman, who operated on Nancy Ford. Although he is board-certified in otolaryngology, he may be the most recognized cosmetic surgeon in the city, with such celebrated clients as Patti LaBelle and Trudy Haynes.
Then there are the physicians who've had no intensive training in plastic surgery, but take a quicky course in a specific cosmetic surgery procedure, such as liposuction, and plaster an ad on a billboard. Sometimes they call themselves board-certified; however, the board they refer to may not be one of the 22 specialty boards recognized by the American Board of Medical Specialties.
The upswing in cosmetic surgery in the 1980s - and reports of patient deaths and disfigurements - prompted hearings by a U.S. House subcommittee last year. Congressional investigators recorded at least 30 deaths caused by less-than-qualified physicians doing cosmetic surgery in their private office operating suites.
"The barn door has swung open and quacks have waddled out," read a 1989 report prepared for the U.S. House Subcommittee on Regulation, Business Opportunities and Energy in preparation for hearings on the subject.
Cosmetic surgery is a lucrative field for physicians. Beauty isn't cheap. And most procedures are not covered by health insurance.
According to an ASPRS member survey, the average surgical fees range from a low of $800 to a high of $4,000 for liposuction; $2,000 to $2,800 for eyes; $1,700 to $2,900 for a new nose; $800 to $2,000 for a chin; and $2,500 to $5,800 for a face lift.
Women aren't the only beauty seekers. Today, an estimated 25 to 30 percent of cosmetic surgery patients are men. Generally, they have a nose reshaping, liposuction or the bags removed from under their eyes.
Marketing executive Kel Ritter, 49, chose liposuction two years ago after his exercise program couldn't eliminate the spare tire around his middle.
"I thought, 'What the heck? The most it can do is cost me a few dollars," said Ritter. Between the liposuction and his subsequent exercising, he has lost 2 1/2 inches from his waistline. "But that's it. I'm finished with liposuction or anything else. Not because it hurt. There's nothing I'd like cosmetically altered. I'm vain but I'm getting no vainer."
A man often justifies having loose skin removed from around his eyes - something that develops primariy because of genetics - as a career necessity, something that will keep him competitive in the marketplace. ''Someone in middle management who's 45-to-55 years old, he's starting to get threatened by younger guys. He looks OK but haggard. And he wants the pouches removed from under his eyes," said Liebman.
Another cosmetic surgery that is considered elective is breast reduction. But the women who have this procedure done - and a sizeable number of African- American women are choosing it - consider it a necessity.
"One woman who had eight pounds of breast tissue removed told me later that that she is able to feel comfortable standing upright for the first time in years," said Dr. Charles Pappas, head of plastic surgery at Roxborough Memorial Hospital.
"These women are elated with the results of reduction mammoplasty. They're quite sure they made the right decision."
By no means is every patient pleased with the results of their cosmetic surgery.
"A small minority are scared by their changed look," said Newman. "But in a couple of weeks, when people are telling them they look great, that feeling of being afraid is over with."
Almost everyone has heard a horror tale - breast implants that shifted, a nose that ended up more crooked, a face lifted unnaturally high. But documenting the dissatisfaction is another story.
In Philadelphia, few cosmetic surgery patients are suing, according to interviews with a half-dozen legal experts in medical malpractice.
"These suits are a negligible part of my practice," said Herbert Kolsby, an attorney who specializes in medical malpractice.
He cited three reasons why there are few malpractice claims. Philadelphia- area cosmetic surgeons generally are well-trained and their expertise has improved throughout the 1980s, reducing the number of errors, he said.
"There used to be more cases brought than now," said Kolsby. "There were a lot of cases involving implants, but these cases have dwindled because technology has become more sophisticated and solved the problems."
Second, cosmetic surgeons generally are making more realistic promises to patients and have a patient sign forms prior to surgery that describe the
procedure. Even if she is dissatisfied with the result, knowing she signed the statement may chill her desire to seek legal action.
Finally, many potential lawsuits never make it to court because "juries are not terribly sympathetic to cosmetic surgery gone awry unless, to the jurors, there was not a valid reason for this to happen," said Kolsby. ''There is the exceptional case, but those are rare."
Instead, what he encounters are "hundreds of potential claimants" who complain their surgery was disfiguring and yet, "almost invariably, you don't know if she is the plaintiff or her sister. She doesn't look horrible at all."