Jesse A. Taylor, a plastic surgeon with Penn Medicine, said he turns down an even higher estimated number, up to 40 percent.
"The surgeon's most important job is to figure out what the patient's concept is of what they want changed," Taylor said. "It's challenging. It's sitting down and getting to know somebody. Listen to the quality of the questions they ask."
Taylor said he will not operate on anyone until he has seen them at least twice for an office visit, with the visits spaced several weeks apart.
"You're taking a healthy person with no medical problems and doing something invasive that has known risks," he says. Even when the surgeon tells a patient, for example, that a face-lift could result in postoperative bleeding, "they may not be listening really well. You have to repeat it."
While new technologies like lip fillers and Botox have made it easier and in some cases more affordable to change one's appearance, that doesn't necessarily mean transformation is a good idea.
Surgeons say patients often have exaggerated ideas about what the procedure can accomplish, or may want surgery for the wrong reasons.
"Surgery should be for the patient, not the patient's boyfriend," said Chris Tzarnas, a plastic surgeon with the Temple University School of Medicine.
In some cases, surgeons say, unrealistic expectations are fueled by movies, makeover reality shows, or the Internet.
Eva Ritvo, a Miami Beach psychiatrist who treats many patients considering cosmetic surgery, speaks of women wanting "Angelina Jolie lips" even though the change might not go with their other facial features, or wanting tummy-tuck surgery that is premature because it could make it harder to lift their baby.
"The Internet is one of our banes," said Solomon. "People will go and find somebody in South Korea who does something we don't even do here" because it hasn't met the "safe and effective" requirements of the U.S. Food and Drug Administration.
"What do they want, and what can I do?" he said. "If those two messages don't intersect, it's not going to work."
And sometimes unrealistic expectations cross the line into mental health issues.
An estimated 1 percent to 2 percent of the world population shows symptoms of body dysmorphic disorder (BDD), in which someone becomes so fixated on a slight imperfection in appearance that it disrupts daily functioning.
David Sarwer, an associate professor of psychology at Penn's Perelman School of Medicine and an authority on mental health issues in cosmetic surgery, said that in some cases the disorder can turn someone into a virtual recluse.
Sarwer estimated that between 5 percent and 15 percent of people seeking cosmetic surgery have the disorder, although he cautioned that research into the problem is much less advanced than that involving, say, major depression and eating disorders.
Recognizing the symptoms of BDD is particularly important for cosmetic surgeons, he said, because 90 percent of patients with it who have cosmetic surgery end up dissatisfied with the results and may even act out that dissatisfaction with lawsuits or worse. There have been four documented cases of patients killing their plastic surgeons since 1990.
Taylor said that if he thinks a patient may have BDD, he does not hesitate to refer her tactfully to a mental health professional. And if she is already seeing one, he asks that the patient get a letter from the therapist endorsing the procedure.
"If you put it in the right perspective," Tzarnas added, "many patients understand."
But Sarwer said that even mentally healthy patients sometimes need to be reminded of cosmetic surgery's limitations.
"There's no evidence I'm aware of," he said, "indicating that if you have surgery, it profoundly impacts judgments of your appearance . . . or that it impacts how other people are going to interact with you."
Repeat procedures are common. Sarwer cited statistics from the American Society of Plastic Surgeons showing that in 2010, half of all cosmetic surgery patients were repeat patients and just under half - 47 percent - were having more than one procedure.
Sarwer also offered a tongue-in-cheek reminder about comparing oneself to what's really out in the world instead of on TV: "The Jersey Shore isn't a Coors Lite commercial."
Questions to ask before the surgery
David Sarwer, of Penn's Perelman School of Medicine, an authority on mental health issues in cosmetic surgery, offers a course at the annual convention of the American Society of Plastic Surgeons and has drawn up lists of three questions physicians should ask of patients requesting cosmetic surgery and three questions the patients should ask themselves.
For the physician
Can the plastic surgeon really see the defect?
Does the patient report impaired daily function based on his or her appearance? "If they say, 'I'm not dating because of my appearance or I'm not working because of my appearance,' " says Sarwer, "that could be a sign of BDD" (body dysmorphic disorder).
Does the patient have a history of psychiatric treatment? "About 20 percent of patients presenting to plastic surgeons are engaged in mental health treatment."
For the patient
Do other people see the feature they're concerned about? Do close friends and family members see and agree with their concern?
Is the interest in surgery internally motivated, coming from a desire to improve their self-esteem, rather than, say, trying to save a sinking romantic relationship? Or get the promotion the person hasn't received?
Is there recognition that the changes are often quite subtle? "People expecting a Cinderella-like transformation may be setting themselves up for disappointment."
- Paul Jablow
Contact Paul Jablow at firstname.lastname@example.org.