Life, liberty, and the pursuit of lipo

Cosmetic surgery is drifting from a cash-up-front business into a credit market that accommodates -- and sometimes specifically recruits -- people who thought they couldn't afford it. The pitch is simple: Doesn't every American deserve to be beautiful?

by Ellen Barry

The lady in the commercial is thin, and professional, and she has good news.

"Wouldn't it be great to be the best you could possibly be?" she says, with the savage enthusiasm unique to daytime infomercials. "You bet it would. But cosmetic surgery is only for the rich and famous, isn't it?

"Not anymore. Thanks to our IMAGES-1 program, you can now have a complete cosmetic procedure for no money down and payments as low as $38 a week. That's right -- your choice of breast, liposuction, or facial procedures for no money down and payments as low as $38 a week. You can be the person you always wanted to be, for no money down and payments as low as $38 a week."

Surprise, surprise. We associate cosmetic surgery with the Joan Riverses of this world: wealthy women throwing cash in the face of advancing physical decay. But if that stereotype was ever accurate, it isn't now. Average patients are both younger and poorer than you think. According to figures published in the 1992 American Society for Plastic and Reconstructive Surgeons Guide to Cosmetic Surgery, the most recent statistics available, 30 percent of cosmetic-surgery patients had a household income of less than $25,000 a year (by way of comparison, the nationwide median family income that year was $35,700). Another 35 percent earned household incomes between $25,000 and $50,000 a year.

The specialty has undergone serious changes since the 1970s, when it was a genteel, word-of-mouth, cash-up-front affair. Health-care reform has driven scores of doctors (not only plastic surgeons, but dermatologists, gynecologists -- even the odd psychiatrist) away from HMOs and into lucrative cosmetic-surgery practices. Because of the increased competition, advertising -- which was actually illegal 20 years ago -- suddenly became a professional imperative. More people, and younger people, are going under the knife: over the past four years, the number of cosmetic procedures has increased 77 percent, according to statistics from the American Academy of Cosmetic Surgery. And the two fastest-growing procedures over the last five years -- breast augmentation and liposuction -- are the two most popular among 19-to-34-year-olds. Particularly breast augmentation: nearly two-thirds of patients are between 19 and 34, and the number of operations is increasing 40 percent a year.

A race is on to capture this burgeoning market -- and to generate a brand-new client base. The people who are working hardest at this task are not doctors at all, but the entrepreneurs behind a new breed of financing plan that extends loans to patients who can't afford to pay any other way. According to the folks at Jayhawk Medical Acceptance, a Houston-based plastic-surgery financing company, the stakes are huge: Jayhawk president Doug Theodore says the credit market for plastic surgery could be four or five times the size of the cash market.

The credit market is also distinct from the cash market in a very human way. Theodore identifies the credit customer -- the patient he is bringing into the operating room -- as a woman in her "very late 20s," earning "in the high 20s," possibly with a "C" credit rating. She is getting the procedure as an "investment." What is remarkable about this woman is how normal she is: not rich, not famous, not ugly, not old. Welcome to the democratization of plastic surgery.

The people who stand to benefit from this trend, it would seem, are the plastic surgeons who do the work. But most surgeons interviewed for this story are not inclined to take pride in what Theodore calls "market-building"; they almost seem worried that Americans will start getting too much plastic surgery. They look at the plans, at the daytime TV ads, at the bulging patient dockets, and see nothing but disaster.

THE IDEA of elective plastic surgery as a normal consumer choice has always been a peculiarly American one. In her book Venus Envy: A History of Cosmetic Surgery (Johns Hopkins University Press, 1997), the University of Kentucky historian Elizabeth Haiken explains that plastic surgery developed around the same time as trench warfare: in the early days of World War I, a coalition of American, British, German, and French doctors learned, quickly, out of necessity, how to reconstruct the faces of injured soldiers. These pioneering surgeons returned home as a species of war hero, but the British and French doctors stopped practicing their newfound skill, in part because they got the message that their nations didn't need more than a handful of plastic surgeons.

America was different. By the beginning of World War II, America had twice as many plastic surgeons as the rest of the world combined. When Haiken began research for her book, she wondered why this was: were Americans that much more invested in physical appearance? Were they richer? Were they vainer? Ultimately, after scrutinizing decades' worth of medical records and marketing material on cosmetic surgery, Haiken found an answer: unlike Europeans, Americans weren't resigned to what God had given them. Not only did they believe deeply in the possibility of personal transformation, but they were willing to pay for it -- even investing money they couldn't really spare. Reading through medical records, she ran into letter after letter from young women who had saved up for their nose jobs, or who had agreed to pay off the bill in small increments.

"They're nurses, teachers, and factory workers -- a range of low-paid, mostly female occupations. Some of them, of course, want to be movie stars," Haiken says. "But most of them just want a better job. So it's always been connected to the idea of social mobility."

From the moment the Federal Trade Commission made it legal for doctors to advertise, in 1978, marketing campaigns have sounded the same theme: social mobility -- especially through competitiveness in the workplace -- or at least self-improvement. And, to be fair, generations of surveys have suggested that the procedures tend to deliver, at least in the eyes of the patients: in the 1960s, a Johns Hopkins study found that 85 percent of face-lift patients had an enhanced sense of well-being after their surgery, and 25 percent said they felt their careers had benefited. (And if there is any question about the translation of good looks into salary, that relationship can also be quantified: a 1993 study performed at Michigan State University showed that men and women who rated "below average" in attractiveness earned 15 percent less than those rated above average.)

So the sales pitch is pretty simple.

"It's a self-improvement decision, so you have people from all socioeconomic groups deciding to have elective procedures," says Anne Tynion, president of a brand-new financing company called Unicorn Financial Services. "There's research that says the number one reason [people undergo cosmetic surgery] is for self-improvement. That, to me, is not a luxury. That is a life-quality decision. It's a real issue for the job, for their personal self-esteem, for all aspects of their life."

Seen this way, surgery is anything but decadent. Here's Jerry Powell, president of Cooperative Images, a cosmetic-surgery financing plan operating out of East Stroudsberg, Pennsylvania: "It affects so many different things in their life. They're more confident, they have better jobs. . . . We think that it is a necessity for some people."

TEN YEARS ago, our Jane Doe was expected to pay cash up front for this "necessity"; most cosmetic surgeons wouldn't even accept credit cards. Now, if she doesn't have the cash for a $4000 liposuction procedure, or a $5000 breast augmentation, or a $10,000 face-lift, she has a vast array of credit options available to her. And she uses them. Ted Schlegel, who operates the MediCredit financing plan out of Los Angeles, says he'd estimate that half of all cosmetic procedures are now paid for with some form of financing. Although doctors interviewed for this story say the number is lower, the proliferation of cosmetic-surgery finance plans out there -- I found at least a half-dozen companies dedicated to cosmetic and other elective surgery -- tells its own story.

Some plans, like the Colorado-based MediCredit and Tynion's Unicorn Financial Services (which grew out of a Harley-Davidson motorcycle financing plan), are offered to the patient by the doctor after the surgery is set up. In these arrangements, the finance companies buy the contracts from the doctors and space the payments out over time at an annual interest rate that can range, depending on the plan and the applicant, from about 9 percent (not far above the prime lending rate) to about 20 percent (higher than most credit cards). But if Jane Doe has already maxed out her Visa, she might get refused -- the ASPRS's in-house plan, for instance, approves only 40 percent of applicants.

Other plans are more liberal -- and more aggressive. It's possible that Jane wasn't even looking for a plastic surgeon until one day, while she was watching Jerry Springer, she saw an advertisement for Cooperative Images or Jayhawk, which assured her that no matter how far out of reach she thought cosmetic surgery was, she could get her liposuction without paying any money up front. These plans operate a little differently from the ones offered in doctors' offices. Not unlike HMOs, they sign up a slate of physicians who are willing to work for a significantly discounted payment. In return, the companies take over the onus of soliciting business, promising to flood the office with fully prepared patients. (As a test, I applied to Jayhawk over the Internet; within three days I was approved for a breast augmentation at 14.8 percent APR, which would leave me with two years' worth of payments of about $48 a week, not including finance charges.)

To Doug Theodore, Jayhawk is a pioneering company that stands to do for cosmetic surgery "what GMAC financing did for automobiles" -- in other words, make the product available to every American, turning what was seen as a luxury into an understood necessity, and thereby boosting sales sky-high. So far, the financing plans appear to be doing their job, at least according to their executives: Jayhawk, which grew out of a bankrupt used-car financing company, has arranged 10,000 surgeries in a little less than two years, according to Theodore. Jerry Powell, the president of Cooperative Images, which was formerly a home financing company, estimates that his three-year-old referral service has set up 12,000 consultations and is scheduling surgeries for 400 or 500 new patients a month -- of whom 70 percent were not even interested in cosmetic surgery before seeing the company's television commercial, according to his research. "Our biggest problem is controlling volume," Powell says.

But despite the promise of an untold wealth of customers, not everyone is delighted by this development. Surgeons contacted about plastic-surgery financing plans expressed serious anxiety about ceding control of their practice to -- and, more broadly, about the profession falling into the hands of -- people one doctor referred to, not pleasantly, as "MBA types."

USED-CAR SALESMEN don't take the Hippocratic oath, after all. Board-certified plastic surgeons go through 15 years of training -- more than any specialists except brain surgeons, says William LoVerme, a Newton surgeon who is president of the Massachusetts Society of Plastic Surgeons. It may seem strange to speak of ethics in a field where invasive procedures are performed on healthy people, but cosmetic surgeons have always reserved one important right: to decide who should have plastic surgery and who should not.

It's common, for instance, for a doctor to refuse to perform liposuction on a patient who is too thin, or who is simply overweight, rather than having the disproportionate, localized fat bulges liposuction was designed to remove. Bruce Shack, an assistant secretary for the American Society for Plastic and Reconstructive Surgeons who practices at the Vanderbilt Medical Center, in Nashville, Tennessee, estimates that he turns away 30 percent of the patients who come to him requesting liposuction. James Baker, a former president of the American Society of Aesthetic Plastic Surgeons (ASAPS) who has been practicing in Winter Hill, Florida, for 27 years, puts it this way: "We don't want to see someone overweight with a bad ticker who comes in here and wants to look like Gina Lollobrigida."

So far, so good. But there are a lot of reasons doctors might reject a patient, and some of them aren't medical. Some of them are what you might call social. The ASAPS code of ethics requires physicians to avoid soliciting business from a patient if "the physical, emotional, or mental state or degree of education is such that the person could not exercise reasonable judgment in employing an aesthetic plastic surgeon." In other words, uneducated patients might not know what's good for them.

The same might be said of poor patients. If a would-be patient isn't paying for the procedure with discretionary income, then a doctor may decide she is what is known as a "bad candidate." For Baker, any doctor who fails to consider a patient's ability to pay is on shaky ethical ground. The reason, he says, is that "this isn't somebody who has been burned. This is someone who looks good and wants to look better." In other words, cosmetic surgery is a luxury item, and Baker thinks doctors should keep that in mind.

"I think we have a moral obligation to our patients. I ask if they have children," Baker says. "We want a patient to benefit from the operation not only from the aesthetic viewpoint, but also not to the detriment of other members of the family -- for example, the children. Mom will look better in a bathing suit at the beach, but the kids might not be able to take that special class or something."

Baker's stance is relatively hard line; plenty of doctors say they don't have any way of knowing how much a patient earns, or how she or he is paying. But most have given some thought to the matter.

"If someone is stretched and going to sell the family jewels, it's really inappropriate. I like to sleep at night," says Robert Cooper, a New York surgeon who, remarkably, gives an interview over a headset while cutting into the breast of an anesthetized patient. He offers this parallel: "About a year or two years ago, there was that nine-year-old girl who went flying across the country to set a record." He's talking about Jessica Dubroff, who crashed and died. "She went out with her flight instructor, and he [should have known] better. It's not about being patronizing. People go to you for caring."

These doctors say financial plans like Jayhawk and Cooperative Images -- which act as referral services -- carry the hidden dangers of malpractice and hard-sell hucksterism. First, they sign up doctors who are willing to accept less money for higher volume. Second, they spend lavishly on mass-market advertising, which still strikes many doctors as ethically suspect. And third, since there's no asset to repossess, the loans are unsecured, so anyone who defaults stands to go through a painful collection process.

"Wouldn't you like to have a 500SL Mercedes convertible?" says Baker. "So would I, but neither of us has one. Why? Because we can't afford it. We could get it on credit, but then we suddenly realize we have a tax payment, and then your husband gets sick, and guess where your Mercedes goes? Bye-bye. Guess where your face-lift goes? It can't go anywhere. Because you're strapped in. You don't have an asset that you can sell to make enough money to eat. That's the moral problem I have with this."

"I'm not going to prostitute what I've spent 27 years doing for a little cash," he adds. "If my practice was dependent on something like that, I might as well go sell used cars."

These qualms are not purely altruistic; as many doctors see it, patients who have trouble paying for their surgery are also more likely to be dissatisfied. Dissatisfied patients are more likely to sue (according to LoVerme, the average cosmetic surgeon is sued every two years). Sometimes, dissatisfied patients do worse than sue; this year, in reaction to a series of attacks on plastic surgeons over the past decade, the ASPRS added, as a perk of membership, a half-million-dollar life insurance policy covering fatal attacks in surgeons' offices.

So doctors are always on the lookout for "bad candidates," and bad candidates are sometimes the ones who put an irrational amount of money at stake when they sign up for their surgery. As LoVerme puts it, "The higher percentage of yearly income that you're paying, the higher your expectations."

And, as cosmetic surgeons know perhaps better than anyone else, unreasonable expectations can get everyone into trouble.

WHEN YOU bring these ethical scruples under the high beams, they begin to sound pretty paternalistic. That's certainly what the finance-plan entrepreneurs will argue, and so will the doctors who signed up with the finance plans. If poor or debt-ridden people are able to buy cars they can't pay cash for, why shouldn't they be able to get a nose job they can't pay cash for? And if cosmetic surgery is proven to enhance your career so much, why should doctors deny their services to the people who need career boosts the most?

Good question, says John Barnett, a Dallas surgeon who sometimes refers to himself as the "Sam Walton of breast augs." Doctors who steer clear of credit patients, he says, are straight-out elitists -- holdovers from a time when cosmetic surgery was for the pampered wives of the upper class. Needless to say, this is not Barnett's constituency.

"I'm not ashamed to say that I've never had a carriage-trade practice," says Barnett, who is looking at a thank-you picture from a centerfold as he talks on the phone. "I do a lot of people in the entertainment industry, anyway. Most of these folks are just working folks. You don't get Lady Astor's pet horse."

He sounds like someone who's accustomed to defending his practice. Over the years, Barnett has strained against the ethics of the plastic-surgery establishment, even as those ethics have shifted. Nearly 20 years ago, Barnett was quoted in a newspaper article and faced a barrage of criticism from colleagues who felt that giving the interview amounted to advertising; a few years later, he says, "the same guys who were screaming as loud as a pig caught in a gate were advertising in Texas Monthly."

Now, by filling up his schedule with Jayhawk's credit patients, Barnett has once again found himself on the wrong side of the profession's establishment. Part of the problem, he says, is that cosmetic surgeons are just snobs about whom they want to serve. He uses the word prissy.

"Some of the doctors tend to look at [credit] patients as less than human," he says. "If you try to treat everyone, some people are very sensitive at the lower pole of the economic status, and you have to make them feel comfortable."

Barnett's democratic indignation is shared by Kate Altork, a Palm Beach psychotherapist who consults, sometimes through surgeons' offices, with pre- and post-op cosmetic-surgery patients. "If a woman who makes 500 grand a year can have a surgery, why shouldn't a woman who makes 20 grand?" she says. "A lot of discretionary items are considered mandatory. We can't be moral cops for people. That's not our job."

Doug Theodore says cosmetic surgeons will have to adapt Barnett's philosophy if they want to survive. To doctors' objections that they might sacrifice quality of care for the sake of volume, Theodore points out that "Sam Walton built an empire on volume." He also says it's the young doctors who will make it, in part because they acknowledge something that has been true all along: that they are really entrepreneurs.

"We're finding more and more physicians, younger physicians in their mid-30s, who are becoming astute businessmen, which has not always been the case," says Theodore. "The days of a doctor being a healer and researcher are -- not gone, thank goodness -- but today's environment allows a doctor to become a businessman. And a doctor who has made the decision to go into cosmetic surgery has decided to be a businessman."

COSMETIC SURGERY has always teetered between the world of commerce and the world of medicine, but surgeons held onto the serene conviction that they fell to one side of the line. If there was one act that asserted their membership in the Hippocratic club, it was turning down business for ethical reasons. If a doctor sent someone away because the surgery appeared to present too much of a financial strain, that meant that the doctor still knew best. A line in the sand separated business from medical practice.

That line has been drifting for some time, but now that doctors are putting their business in the hands of professional marketers, it is vanishing entirely. This much is clear: if surgeons entrust the business side of their practice to salespeople, the salespeople will sell it, and cosmetic surgery sells extremely well. Anne Tynion, of Unicorn Financial Services, says medicine is "moving away from a cottage industry into a customer-service industry" and that doctors have no choice but to acknowledge that.

"Elective procedures have become a consumer product, and consumerism necessitates an ability to finance," says Tynion, who was formerly vice-president for global marketing at Harley-Davidson. "Think back -- today, most doctors [accept] a high-interest-rate credit card. Five years ago, nobody did. What you're seeing is the more progressive doctors -- the visionary doctors -- who really see [surgery] as a consumer product."

With this statement, the power of the doctor drains away, and the patient -- or, more accurately, the consumer -- is in charge, with whatever ideas she may have about how her body should look. It's hard to imagine the tide will turn back of its own accord, now that this philosophical shift has begun. People in America still hate their bodies. More people still want cosmetic surgery than have it, and the business will continue to grow, and doctors will have a harder time saying no. This doesn't answer the question of what will happen as the lending infrastructure develops -- whether default levels will bankrupt lending companies, and whether dissatisfied customers will react by suing their doctors, or attacking them, and whether, in 20 years, a large number of Americans will be liquidating their assets to pay off breast implants. But if you ever wondered what it would be like to live in a society where cosmetic surgery was seen as an inalienable right, put your mind at rest. You already do.

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