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Why San Diegans have so much plastic surgery

The incision decision

Between 250 and 500 suction-assisted lipectomies have been done here within the last eighteen months.
  • Between 250 and 500 suction-assisted lipectomies have been done here within the last eighteen months.
  • Image by Craig Carlson

Last May a former El Cajon elementary school teacher placed an ad In the Personals section of the San Diego Union that read: “Lipolysis. If you have had this done, please call me,” and she included her phone number. Five responses came. Two who were obviously cruising the personals ads were quickly discounted; three female responses were serious. All the women, including a medical doctor, had undergone lipolysis, a surgical procedure in which fat deposits are suctioned from various spots on their bodies.

Body contouring, before and after

Body contouring, before and after

The schoolteacher, whom we shall call Ruth, had expected to hear horror stories that might have dissuaded her from seeking this new “body-contouring” treatment, but the enthusiasm from virtual strangers over the phone was so infectious — about their bodies and the physician who had defatted them — that she immediately called Dr. Michael Ahmed Pousti (pronounced Poos-tee) for a consultation.

Michael Pousti: “When a patient comes in demanding to look like Elizabeth Taylor, I tell her what’s possible and what isn’t."

Michael Pousti: “When a patient comes in demanding to look like Elizabeth Taylor, I tell her what’s possible and what isn’t."

Then, last July, in the operating room of Pousti’s La Jolla office, under general anesthesia, the excess adipose tissue (sometimes known as "saddlebags”) that she’d carried around since puberty was extracted from the petite forty-eight-year-old’s inner and outer thighs and buttocks. The doctor had first inserted into a small incision a hollow, tubular instrument called a cannula, to which a suction unit was attached.

Silicone breast implant

Silicone breast implant

Pousti skillfully manipulated the instrument in the tissue under the skin and separated the amount of fat to be removed, and by then creating high vacuum pressure, Ruth’s “saddlebags" were literally sucked up. Post-operative procedure required Ruth to wear a knee-length girdle day and night for six weeks to help prevent lumps and ripples in the skin.

Breast augmentation opening incision

Breast augmentation opening incision

Although the best results are expected on women under the age of forty (due to the elasticity of younger skin), Ruth is very pleased. “I'd rather have loose skin than globs of fat,” she says. “I wish this had been available ten years ago.”

Inserting silicone implant

Inserting silicone implant

Lipolysis is the latest development in “body contouring.” It has been used in Europe since 1977, but it wasn't until January 15, 1983 that its use was sanctioned by the American Society of Plastic and Reconstructive Surgeons. Although it’s not effective for general obesity, lipolysis has been used successfully to remove the fatty deposits commonly known as cellulite or “cottage cheese,” clumps that are determined by heredity and hormonal factors and are diet-resistant and exercise-resistant.

Checking silicone implant

Checking silicone implant

According to Dr. Richard Escajeda, immediate past president of the Plastic Surgery Society of San Diego, our city is in the forefront of advancements in cosmetic surgery. He estimates that even though only a handful of San Diego’s plastic surgeons are doing lipolysis, between 250 and 500 suction-assisted lipectomies have been done here within the last eighteen months. “For cosmetic surgeons, San Diego is definitely where the action is,” Escajeda says.

Dennis Nigro: “There’s more breast surgery in spring and summer.”

Dennis Nigro: “There’s more breast surgery in spring and summer.”

Michael Pousti has done more than forty such procedures in that time, mostly on women under thirty, including a flight attendant, a dancer, a TV reporter, and a nurse, who reports that she now sings in the shower as she soaps her newly contoured flanks and is frankly delighted with how she now looks nude.

Rhinoplasty, blepharoplasty

Rhinoplasty, blepharoplasty

“Results depend on many factors besides chronological age. No two patients respond the same way to lipolysis or to any kind of surgery,” explains Pousti, who speaks about two remarkable successes — one, a forty-three-year-old nurse who lost three sizes within two weeks after surgery, and a fifty-five-year-old grandmother who went from a size fourteen to a size seven. Because the fat cells are surgically removed, the results are considered permanent.

Nose before and after

Nose before and after

Some inquiries about cosmetic surgery in San Diego come from viewers of TV reruns of Ash Wednesday, the soapy 1973 Hollywood film that shows Elizabeth Taylor having her face lifted and her body contoured (in a private Swiss clinic). Richard Escajeda says the film is not only technically accurate, the plot is realistic. Although Taylor emerged from surgery in the film looking twenty years younger, her attempts to recapture the affections of her straying husband were futile and the marriage failed. “We cannot change lives,” Escajeda warns. “We can only correct what disturbs patients when they look in the mirror.” That’s why Pousti and Escajeda and other responsible plastic surgeons insist on having a lengthy initial consultation in order to determine the patient’s emotional as well as physical suitability for cosmetic surgery. “Patient selection is paramount to determine a stable emotional base,” says Escajeda. “We have to learn what motivates the patient to elect surgery and find out if their expectations are realistic. If in my opinion they’re not ready for surgery, I often recommend an exercise program, different cosmetics, or even a new hairstyle. If patients look to surgery to solve their social, sexual, and business difficulties, I sometimes recommend counseling,” he says. Pousti agrees. “When a patient comes in demanding to look like Elizabeth Taylor, I tell her what’s possible and what isn’t. Psyche is an important factor,” he says.

San Diego plastic surgeon Matthew Gleason, president last year of the California Society of Plastic Surgeons (with 293 members, it is the largest state society of plastic surgeons in the United States), advises that prospective patients be realistic about their motives. “Surgery cannot guarantee a promotion, a new future, or save a marriage,” Gleason says, “but it can make you feel better about yourself and your body. It can make you look considerably better and increase your self-confidence. As you project an improved self-image, family, friends, and employers will also benefit as they begin to see you in a new light.”

According to the National Center for Health Statistics, more than a million cosmetic surgeries are performed in hospitals every year. Because even more than a million of the same kind of surgeries are performed in doctors ’ offices or in private facilities (which are often as sophisticated as those in a hospital), accurate statistics are impossible to obtain, so the following figures may be distorted: the 1981 national survey conducted by the American Society of Plastic and Reconstructive Surgeons showed that sixty-five percent of patients undergoing plastic surgery were female, and that of those patients surveyed, forty-three percent were thirty-five years of age or younger.

A 1984 survey taken of members of the California Society of Plastic Surgeons reveals certain trends in this area of medicine. Blepharoplasty (eye tucks) is the most popular kind of cosmetic surgery done on men. Performed on upper and/or lower lids to remove excess wrinkled folds of skin and to eliminate bags under the eyes that project a sagging, tired look, eye tucks are being done today on San Diego males in their thirties and even as young as the midtwenties. The same 1984 survey reveals that the most popular elective surgery for females in California is augmentation mammaplasty (breast enlargement), which blossomed in the post-Twiggy early Seventies. Ironically, feminist consciousness-raising campaigns — remember “bra-burnings”? — were occurring at the same time in places across the nation where women seemed to be beyond breast-envy. But apparently not in California. The heavy traffic through the operating rooms of plastic surgeons in San Diego seems to indicate that two packets of silicone gel or saline solution can restore a great deal of self-esteem to local women.

A little drama takes place beginning at 6:45 a.m. on a hot August morning in Dr. Michael Pousti’s operating room in his second office, next to Sharp Cabrillo Hospital in Point Loma. An El Centro bar manager named Karen is giving herself a thirtieth birthday present of two breasts. (As with the other patients in this story, her real name has not been used.) Breast augmentations normally take two hours on women who have small breasts or who have breast-fed, but this case is more difficult because the patient is virtually flat-chested; there is no tissue with which to work, and virtually no areola (the colored area that surrounds the nipple) — just two nipples.

As Karen stands in the operating room, Pousti takes a surgical marking pen and diagrams the proposed contours on her chest. She is then given a local anesthetic and, as she lies on the operating table, her view of her own body blocked by an operating room drape, Pousti makes a four-centimeter-long incision in the crease beneath the breast. As his two nurses assist him, the doctor tries half a dozen different packets filled with silicone gel — each of the packets has a fixed shape — in order to find a size proportionate with Karen's five-foot seven-inch, 113-pound body. Meanwhile, all that’s visible is Karen's upper torso. Her skin, suntanned and taut, resembles a rubber mold as it is stretched and poked with instruments, and two plastic-lined pails begin to fill up with bloody gauze as a result of the incisions. Though her vital signs are being monitored by machine, every once in a while during the three-and-one-half hour procedure Pousti announces, “You’re doing great, Karen.” He is aware that although his patient feels no pain and sees nothing, she hears everything being said in the operating room. “Are you enjoying yourself, Karen?” Pousti asks. Karen says she is, except that she’s hungry. Then she casually inquires about a girlfriend who’d like to discuss possible breast augmentation with Pousti, who is quite intense in his blue surgical gown as he probes and cuts and massages with his fingers, with instruments, with both his hands, blending the tactile art of what he calls “body sculpting” with the science of “sterility, hemostasis, and wound healing.” He bends over these two bloody openings until everything looks and feels right, squeezing together to achieve symmetry, observing how the silicone prostheses fit into the pockets he has created, and then a size is finally selected: 240 cubic centimeters each of mammary implant.

All the while Pousti is carrying on a conversation with Karen about her concerns. She chirps on that her flat chest had never bothered her lovers or her husband: nobody ever said anything about it, she says, so she’s doing this strictly for herself. When the silicone envelopes are tucked nicely inside, Pousti sews up the openings with dissolvable stitches and catgut, and he says, “Now it’s your turn to take care of them, Karen.” (Though the silicone won’t change shape, he means the breasts have to be massaged for fifteen minutes a day for six to nine months in order to prevent the silicone gel from hardening.) He invites Karen to take a look at her new size-B breasts, and after three and a half hours stretched out on the operating table, Karen raises her head and looks down and says, “Oh, my, my!” Tears are coming out of her eyes, headed straight for her chin. She repeats herself — “Oh, my, my!” — and her eyes are glistening, and when she is wheeled on the gurney into the recovery room, she quips, “From now on I can wear a nightgown without looking like a boy in drag.” In Pousti’s waiting room the seats are filled, mostly with women, many of whom are waiting for breasts. A slim, blonde truck driver in her mid-twenties stops in to discuss prices and take home a brochure that explains breast augmentation. There may be lawyers, doctors, dentists, social workers, college professors, topless dancers, hairdressers — idle rich and working poor — those who deal with the public and those who don’t. There’s a forty-eight-year-old former nun who’s just had her nose and eyes done, and there’s a chaplain in the military who’s just had his ears done — and they all want the same thing. “I want to feel better about myself. I want more self-esteem.” It’s clear that self-esteem is not only the issue, it’s the commodity.

The thirty-year-old housewife and mother of two is in an examination room waiting for Pousti to check her ten-day-old breasts. She had come in recently for a rhinoplasty (nose surgery) to correct a deviated septum, and while she was in the outer office waiting to discuss the shape of her proposed nose, she became so inspired by another of Pousti’s patients who spoke enthusiastically about the silicone gel packets that had just been implanted in her breasts that the housewife impulsively made an appointment to have her breasts enlarged, too. Today she wears a bra two sizes larger than the one she wore several weeks ago — and she’s thrilled, she says. “I'm seriously considering having a lipectomy at the end of the summer. The only reason I don't want to do it now,” she adds, “is because it’s too hot to wear a long girdle.” Today she’s wearing shorts, her torso looks fine, there are no deformities. Why then is she contemplating more surgery? “I’ll be able to give more to my husband,” she says earnestly, “because I’ll feel better about myself.''

A blonde certified public accountant, also thirty years old. also a wife and mother, accompanied her sister to Pousti’s office last month for a breast augmentation and, right on the spot, the CPA herself decided to have one done, too. And she did, without discussing it with her husband beforehand. “It’ll be a surprise for him,” she grinned. She stayed at her sister’s place for several days while she and her sister healed. Yet ten days later the husband was still not aware that his wife’s breasts had been implanted with silicone gel. When will her mate find out? “When he notices,” she shrugs.

Word-of-mouth reputation is powerful for plastic surgeons, but there are patients who find surgeons via the Yellow Pages or the referral service of the Plastic Surgery Society of San Diego (by geographical area alone). George is a sixty-eight-year-old retired draftsman who lives with his wife in Point Loma and is spending his retirement years puttering around the yard. What bothered George was his neck. “My skin was so loose that whenever I wore a necktie, it tickled,” George says, “so it was either wearing open-necked shirts forever or getting a face lift.” George opted for surgery. Since he didn’t want anyone to know what he'd done, George stayed in his house for weeks while he was healing. Neighbors noticed he wasn’t puttering around anymore so they asked his wife what was wrong and she told them he was feeling a little under the weather, but after four weeks the concerned neighbors rang George’s bell and demanded to see him. “All they said was, ‘For someone who’s been sick, you’re lookin’ pretty good, George,' but they never noticed that I had a face lift and I didn’t tell anyone,’’ he says.

Not all Pousti’s patients are local. His reputation seems to extend to Los Angeles, Palm Springs, Europe, even to Teheran, where he grew up and where his interest in plastic surgery began in high school, when he himself had rhinoplasty to correct what he terms a deformed nose. In July, for instance, a twenty-seven-year-old female bank teller flew into San Diego from Washington, D.C. for a Pousti nose. Known for its proportion not only to the face but to the entire body, a Pousti nose can be considered an art form. “Two of my sisters had their noses done in Maryland and they're unhappy with them,’’ said the bank teller. “I'm happy I came here to have mine done. How will my new nose change my life? I’ll have more self-confidence, more friends, more fun. I expect to get more out of life with this nose,’’ she smiles happily.

Rhinoplasty is a year-round business but breast implantation is seasonal, according to Dennis Nigro, a popular North County plastic surgeon whose art-deco waiting room is jammed with young, suntanned tennis players, sleek young matrons, and an occasional Hollywood character actor (the thirty-seven-year-old surgeon is booked solid several months in advance). “There’s more breast surgery in spring and summer,” Nigro explains, “because it’s beach weather and women want to look better in bikinis,” he says. (But Gail Allen, Pousti’s office manager, has a different opinion. She's noticed an increase in breast augmentation in the early part of December. “With all the holiday parties coming up, women want to be able to wear low-cut dresses and have some cleavage,” Allen observes.)

There’s a supportive camaraderie among cosmetic surgery patients in Nigro’s office. A young woman has flown in from Los Angeles in her husband's private plane tor a routine breast checkup, and as she leaves, the waiting room chorus of ten men and women in various stages of bandages and bruises calls cheerily after her, “Enjoy your new boobs!”

After five consultations with surgeons here, a local fifty-year-old divorcee chose Nigro to do her second face lift and eye job and her first eyebrow lift. Even though Ellen had undergone the process eight years ago, followed by a rhinoplasty and a mentoplasty (chin job — some of the cartilage from her nose was transferred to her chin) and an otoplasty (ears pinned back), she is still concerned with her image. She recites a litany of therapeutic cliches as justification for this newest extravagance: “this gives me more choices, more options. It’s a psychological lift, a morale booster. I want to put my best face forward.” Pleased in general with this latest face and neck work (although she reports a little numbness behind one ear), she says her only disappointment is that she had expected more personal attention than she received. “I’m not sure where I 'll go for my next surgery," she muses.

Doreen Adamson (her real name) is a fifty-four-year-old operating room supervisor at Scripps Hospital in Encinitas. Eighteen months ago Dennis Nigro lifted her face and eyebrows and did her upper and lower eyelids because “I didn’t want others to think I looked too old to do my job. It’s not a question of vanity," she says. “It’s a matter of staying on the job." Six months later, after her children encouraged him to "go for it," Adamson’s husband had his upper and lower eyelids done.

Marian is a quality assurance auditor for a large San Diego company. She's sixty-one years old and divorced. Prompted by a recent $1500 birthday check from her daughter that came inscribed, “Down payment on a face lift,” Marian quickly came up with another $3000, consulted with several local plastic surgeons, and chose John Alexander. During the operation, incisions were made at the temples and extended down in front of the ear, around the lobe, and up behind the ear ending in the hair at the back of her head. “What's holding my ears in place?” Marian asked. “Crazy Glue," joked the nurses.

Then the skin of the face and neck was undercut forward into the cheeks, downward and backward into the neck, thereby freeing it so it could be drawn up, tightened, smoothed, and the excess cut away with the skin edges carefully tailored to fit smoothly into the scalp and around the ear — in a process that took five hours. (Since face lifting involves a major dissection of the skin, it can take as long as six hours.) "I'm thrilled every day when I look in the mirror and I put on makeup," Marian says, but she knows that it won’t last forever. Though most cosmetic surgery on other parts of the body is permanent, face lifts are not; within five to ten years, Marian will be back to undergo another operation. How soon she must return depends on a number of variables, including heredity, her skin’s characteristics, even her nutrition and whether she smokes.

Not all surgical results are felicitous, of course. Jury Verdicts Weekly lists court cases in which patients have been awarded up to six-figure settlements for permanent disfigurement, botched tummy tucks, and silicone implant disasters. Doreen Adamson, the Scripps operating room supervisor, tells the tale of a forty-five-year-old woman who found a Hillcrest surgeon through an advertisement in a local publication. She was unhappy with the results of her eye tuck because one eye was noticeably different from the other, so she had the surgeon redo the procedure. While she was in this surgery she heard the doctor tell his assistant, "I think I took too much off this time." Because she was even more miserable with the results of this second attempt, she ended up in a North County surgeon’s office for yet another session under the knife.

The possibilities for mistakes are numerous: a surgeon can hit a muscle, causing an eyelid to droop; rhinoplasty “revisions” (second attempts at surgery) are not uncommon; elongated ears can result from a face lift; cheek implants have been known to slip into the wrong places. But the most common complaints are of unnecessarily large incisions, large scars, and slow healing.

Some surgical mistakes are irrevocable. Cases are known in California of improper breast augmentation which became chronically infected, resulting in rejection of the prosthesis and scar tissue that would not heal. A patient's nose became so badly infected after a rhinoplasty that the bone dissolved, leaving the patient with a mass of formless tissue between his eyes. There s the infamous case of the surgical lipectomy, in which too much of the patient’s inner thighs were sloughed off; in an attempt to cover his mistake, the surgeon kept the patient in his office for seven days (feeding her with a steady diet from a nearby fast food restaurant) until he finally released her with instructions to “take lots of baths.”

The patient lessens his chances appreciably of such disasters occurring by going to a board-certified physician. “To operate in his own office, a doctor must be licensed by the State of California in medicine and surgery,” explains Dr. Matthew Gleason, who has given seminars on the complications of plastic surgery. “But plastic surgeons who perform aesthetic and reconstruction procedures should be highly trained in their specialty and should be board certified." To become board certified in plastic surgery by the American Board of Plastic Surgery, doctors must complete from five to seven years of postgraduate medical training and then have a thorough grounding in general surgery and two to three years' further study at a plastic surgery training center approved by the residency review committee in plastic surgery.

Biochemist Ed Pastore of UCSD is an exception to the general rule that plastic surgery patients conceal their surgery from their friends and fellow workers. He wants to tell people, and like Doreen Adamson, he allows his real name to be used. “When I was a kid in junior high school on the East Coast, the other kids called me ‘Eagle Beak,' and even as an adult I felt intimidated by Waspy-looking ski instructors with pug noses. My nose has disturbed me all my life,” Pastore says, ‘‘but I come from a culture where vanity was considered terrible — if you got caught combing your hair in public, you were taunted —so I couldn’t even discuss my problem with anyone.” Last Christmas Pastore noticed that his hairdresser looked different, and when she told him she'd had her nose done (by Pousti), the fifty-five-year-old Pastore made an appointment with Pousti for rhinoplasty on January 3. Although the before-and-after photos show a remarkable difference, and Pastore feels "rejuvenated” and is no longer self-conscious about something that was formerly beyond his control, his eighty-seven-year-old mother has made no comment about it.

It's clear that aesthetic surgery is no longer the exclusive domain of the privileged. People of nearly all economic levels endure long waits in surgeons' offices, eager to suffer discomfort. swelling, bruising, bandaging, suturing, scarring, body trauma, anxieties both before and after the operation. They willingly run the risk of infection and other complications to have their necks surgically smoothed, their bulging thighs diminished, their noses shortened, and their silhouette excesses sucked up — all without a guaranteed outcome. Betsy is one person who thinks she can explain why people endure such discomforts.

She is forty-four years old, bright, slim, attractive, an articulate brunette. Divorced and the mother of two teenagers, she has completed extensive training as a computer programmer. Although her courses terminated nine months ago and she’s had numerous interviews, Betsy has been unable to land a job. and she is beginning to feel depressed about her future. She went so far as to consult with a plastic surgeon, but she balked at the cost of the operation. “The dumbest one in my class got a job right away,” Betsy says, “probably because she's got a lot of other things going for her. She’s twenty-four years old and she's bouncy and adorable. Maybe I should get a dermabrasion or a face lift,” Betsy muses. “To compete for jobs, for men, for mates, you've got to look younger than you are. You can't look your age.”

Betsy's views are not exclusively those of women. Stan is also divorced. He’s an insurance salesman with four adult children. He plays tennis four or five times a week, sails, and jogs — and he attributes his success with clients to the youthful appearance he acquired, not on the tennis court but in the office of a La Jolla plastic surgeon who lifted his face and smoothed his “turkey neck.” Grecian Formula turns his white hair beige, and his naturally crooked, stained teeth are now beautifully capped.

For social and economic survival in San Diego, Stan and Betsy both agree that new beginnings require improved appearances. Encouraged by the “Go for it!” mentality, San Diegans like Stan and Betsy are having cosmetic surgery in increasing numbers in order to ease their midlife crises, career crises, and marital and relationship changes. In his book The Culture of Narcissism, social critic Christopher Lasch confirms what Stan and Betsy fear most. “The fears that derive from long-term social changes that have redefined work have created a scarcity of jobs,” Lasch writes, and although he clearly states that the cult of youth weakens the social position of those whose adolescent charms have faded, he further suggests that the denial of age, or dread of aging, originates not so much in a cult of youth but in a cult of self. Lasch discusses the premature panic at the appearance of the first wrinkle in conjunction with the emergence of the narcissistic personality structure in our society that bows to an irrational terror of aging. “The most obvious sign of this panic is that it appears in our lives so prematurely,” Lasch writes. “We begin to fear growing old even before we arrive at middle age. and what should be considered the prime is overshadowed by the fear of what lies ahead.”

As the noisy campaigns against external aging increase, it is perhaps this peculiarly American — and more specifically Southern Californian and San Diegan — denial of age that accounts for our numerous fairy godmothers who arrive not in golden halos waving magic wands but rather in surgical gloves waving scalpels and cannulas and inspiring before-and-after photos to deliver us from our sagging skin and our cellulite. “Aging holds a special terror,” writes Lasch. “for those whose self-esteem requires the admiration of youth and beauty.” It’s a view that fits the San Diego axiom that when a woman turns forty, she gets a divorce, a real estate license, and a face lift all within the same fiscal quarter.

For those people to whom life seems to offer no chance of new beginnings, plastic surgery may give them hope. In 1970, when Michael Pousti was an intern at the University of Texas, he was sent as part of a plastic surgery unit to the maximum security prison near Galveston, where he performed cosmetic surgery to improve the appearance of hardened criminals, of murderers. “In order for these prisoners to be seen by a plastic surgeon, they had to behave well for a year or two in advance — just to get themselves on the waiting list,” Pousti explains. “They behaved because it was important to them to have their scars removed and their deformed features corrected so that they'd look good. Many of the prisoners who had grossly deformed features naturally had low self-esteem.” By improving their appearances, the tendency toward antisocial behavior was diminished: in those cases, plastic surgery was used as a behavior modification tool. Pousti notes the numerous studies conducted by Harvard which indicate that ugliness and deformity can instill in certain individuals such hostility that there is a desire to strike out against society by maiming and committing other antisocial acts. Although these studies aren't conclusive, they do indicate the effect of physical appearance on self-esteem and behavior and give credence to the common word-association of “mean” and “ugly.”

How much does self-esteem cost? The majority of California plastic surgeons recently polled by the California Society of Plastic Surgeons report charging fees within the following ranges, although it should be noted that plastic surgeons in San Diego County charge fees that can exceed that range. The surgeries are listed in order of the frequency they are performed.

Breast augmentation $1500-$2500

Blepharoplasty (eyes) $2500-$3500

Rhytidectomy (face lift) $2000-$35(X)

Rhinoplasty (nose) $ 1500-$2500

Breast reduction $2500-$3500

Dermabrasion (skin) $500-$1500

Otoplasty (ears) $l000-$2000

Body contouring (thighs, buttocks, abdomen) $2000-$4000

Mentoplasty (chin) under $1000

Since cosmetic surgery is considered elective and therefore insurance companies don't pay for it, fees are usually paid in advance. One middle-age San Diego woman who was in the process of a divorce wanted a face lift immediately. Rather than wait for the cash to come from the sale of community property, she was so eager to have a face lift without delay that she left a diamond wedding ring and a diamond bracelet in the surgeon’s office as collateral.

One person who is quite willing to pay the cost of cosmetic surgery is named Theresa. She came to Dr. Pousti’s office recently to inquire about collagen treatments. (Collagen injections are used to smooth or to help eliminate certain smile and frown lines as well as the fine creases that develop in the corners of the eyes and above and below the lips.) “Dr. Pousti said he could give me a nicer chin. 1 never thought there was anything wrong with my chin, but I figured for $800, what the hell. I’ve had lots of other things done, so why not my chin? I had an eyelift in Japan when I was fifty-five years old and I had a face lift in Seattle when I was sixty, and I had my nose done when I was sixty-seven, but I don't remember where,” says Theresa, a retired civil servant who spent many years working in the foreign service. “So I had my chin done. Nobody noticed. People thought I looked good but they couldn't identify what it was about me that looked good. But I’m glad I did it. Why leave money to ungrateful wretches? You might as well spend it on yourself,” says the feisty, wiry-looking Point Loma resident. ‘‘People treat you nicer if you look nicer,” she continues. “Strangers do more things for you. Waiters in restaurants are more polite. Gas station attendants are more helpful,” she says. “It pays off. It makes your life better.

“Instead of spending money on jewelry, fix up your face. Fix up your body. That's what I tell people,” she adds. “If I were younger. I'd have my fat vacuumed off. I told my daughter to do it.” With Theresa’s long curly brown hair and smooth face, it’s shocking to learn that she's seventy-three years old. She looks at least twenty years younger. But when she removes her jacket, the sleeveless dress she wears reveals the skin on her arms. It is loose, wrinkled, and sagging, and gives away the secret of her age. At her age, Theresa is no longer competing for a job or for a man, yet she continues to spend time and money altering her appearance. “When I die,” she says, “I want to leave a gorgeous corpse.”

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