Under the Knife Cosmetic Surgery, Boundary Work, and the

Pursuit of the Natural Fake

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 For Thali, our clock, our tornado, our joy
—SK

For Brenda, my mother, for her unwavering love and support

through every battle I’ve fought
—JG
 Contents

Acknowledgments ix

1 The Cosmetic Surgery Paradox 1

2 Motivations and Concerns 22
3 Pursuing the Natural Fake 47
4 Setting Boundaries 66
5 Negotiating “Unnatural” Results 94
6 Resolving Paradoxes 128

Appendix: Participants’ Pseudonyms, Demographics,

and Surgeries 153
Notes 159
References 175
Index 191
 Acknowledgments

U
nder the Knife would not have been possible without our inter-
view participants. We thank them for their time and for shar-
ing their stories with candor. We also thank Ryan Mulligan for
his support of our project and his thoughtful editorship, Mary Ann
Short for her careful copyediting, and several anonymous reviewers
for their insightful comments. We are indebted to Camille Nelson
for reference and index preparation, Fanni Farago and Sara Rehman
for research assistance, and Wenli Gao for librarian support services.
Finally, we extend our appreciation to Scott V. Savage for his patience
and support.
Under the Knife
 1

The Cosmetic Surgery Paradox

F
or her fortieth birthday, Marianne,1 a successful banker in
Houston, treated herself to a $15,000 gift. Although she con-
sidered herself skinny at 5′3″ and 110 pounds, she had, to use
her word, “saddlebags.” Regardless of how much tennis she played or
how often she worked out, she could not get rid of them. Liposuction,
she hoped, would do the trick. And since she was going under the
knife, she decided she might as well get her breasts done. Marianne
had a clear vision of what she wanted out of cosmetic surgery. With
liposuction, she desired a more “curvy,” “symmetrical,” and “propor-
tioned figure.” With the breast augmentation, she told us, “I never
wanted to look like tits on a stick. . . . I wanted very natural-looking
[breasts].” She joked about scoring 100 percent every time she took
the “Fake or Real?” quiz—an internet quiz that presents images of
women’s body parts and then asks viewers to determine if that part
has undergone cosmetic surgery. She continued, “It was very impor-
tant that mine did not look fake.”
Marianne is not unique in prioritizing a “natural” outcome. In our
interviews with forty-six women who had cosmetic surgery, includ-
ing Marianne, a concern for natural results emerged as a ­pervasive
2 \ Chapter 1

theme. Under the Knife examines this theme in light of a cultural para-
dox. On the one hand, a beauty, makeover, and self-improvement cul-
ture encourages women to turn to resources within their means—in-
cluding cosmetic surgery—to improve their appearance. On the other
hand, despite increases in the number of some cosmetic surgical pro-
cedures among women, cosmetic surgery can still come with stigma.
Women who have cosmetic surgery thus face an inherent contradic-
tion—a double bind. Given cultural beauty and self-improvement
logics, they attempt to improve their bodies. Yet they potentially face
social condemnation for, among other things, being fake or unnat­
ural. So while women are encouraged to take advantage of surgical
innovations, there are also social forces that discourage them from
doing so. Faced with this contradiction, how do women who have
cosmetic surgery resolve this paradox? How do they make sense of
and negotiate their “unnatural” surgically altered body?

Body Projects in a Makeover Culture

The pop music icon Madonna purportedly once said, “No matter who
you are, no matter what you did, no matter where you’ve come from,
you can always change, become a better version of yourself.”2 These
words capture a telling Zeitgeist for women today. There is a cultural
imperative for women in America to better themselves. Whether
self-help books or reality television programs, a common message
emanates from them: Women can improve in all facets of their lives.
Whether coordinating the clothes they wear more fashionably or
finding their authentic, unique, stable, or true self,3 they can, as Ma-
donna put it, become a better version of themselves. This is, at least
in part, because we live in a makeover culture that rewards people
for the work they put into the process of transformation.4 It is also a
culture that exhibits contradictions. For example, despite supposedly
being empowered through the process of transformation, one must
surrender to experts and authority figures (such as medical doctors
and beauty professionals). Additionally, while one wants to be unique,
transformation results in looking remarkably like everyone else. This
means adopting the appearance of conventional ­femininity—middle-
class, white, ethnically anonymous, and heterosexual.5
 The Cosmetic Surgery Paradox / 3

Because physical attractiveness is inseparable from cultural no-

tions of femininity,6 for women this self-improvement mandate often
centers on appearance. In America, despite subcultural and coun-
tercultural ideals, women experience pressure to conform to hege-
monic beauty ideals—that is, aesthetic forms exalted as the go-to
cultural standards at a given time and place. So at the same time that
researchers have documented, for example, black beauty norms and
appearance norms among lesbians,7 there is nevertheless an aesthetic
ideal pervasive in fashion magazines and blockbuster Hollywood
films.8 Embodied by A-list actresses such as Anna Kendrick, Jennifer
Lawrence, and Emma Watson, it spares no body part from rigid ex-
pectations. It demands youthfulness; slenderness; symmetry; coiffed
hair; taut, depilated, fair, and unblemished skin; and more.9 Natural
embodiment of this ideal is indisputably a statistical anomaly. One
study estimates that the probability of having a body shape similar to
real-life Barbie is less than one in one hundred thousand.10 Everyone
knows that most women do not have supermodel Gisele Bündchen’s
or singer Beyoncé’s body! Although embodying these standards is
equivalent to winning a genetic lottery of sorts, women still attempt
to embody these ideals, in part because there are social expectations
that they do so.
Research shows a “beauty bias,” in that women who meet these
aesthetic demands are often rewarded psychologically, socially, and
economically in the form of improved self-esteem, increased dating
and marriage opportunities, and higher earnings.11 Meanwhile, as
research on women of size confirms, those who do not meet these
aesthetic demands are frequently subject to criticism and even dis-
crimination.12 People who body shame others often feel justified in
their admonishments because makeover projects are not only about
the transformation of physical appearance. They are, to borrow the
term from social theorist Chris Shilling, body projects—“a project
which should be worked at and accomplished as part of an individ-
ual’s self-identity.”13 These projects involve a process of becoming
that is tied to an individual’s sense of self. They are self-improvement
projects that reflect personal expression—who one is and wants to
be.14 The body that fails to meet beauty standards is purportedly rep-
resentative of some moral deficiency—a lack of desire, effort, will, or
4 \ Chapter 1

discipline.15 Subsequently, these “failures” are supposedly deserving

of social derision.
In this demanding cultural context, it is not surprising that
women feel inordinate pressure to improve their physical appearance.
Cosmetic surgery is one of many tools at their disposal.

Cosmetic Surgery in the United States

Cosmetic surgery in the United States is a multibillion-dollar indus-
try, and the latest data indicate that in 2017, Americans spent more
than $16.7 billion on cosmetic procedures.16 The American Society
of Plastic Surgeons (ASPS) reports annual statistics by procedures
and not people.17 By ASPS calculations, women in the United States
underwent about 92 percent of all cosmetic procedures in 2017, with
about 1.4 million procedures involving surgery. (As a reference point,
there are about 124 million adult women in the United States.18) The
most common procedures for women are breast augmentation (aug-
mentation mammoplasty), liposuction, eyelid surgery (blepharo-
plasty), nose reshaping (rhinoplasty), and tummy tuck (abdomino-
plasty). Over the last two decades, rates of two of these procedures
dramatically increased. Specifically, in 2017, surgeons reported per-
forming 300,378 breast augmentations and 124,869 tummy tucks on
women, increases of 41 percent and 107 percent, respectively, since
2000. Table 1.1 presents these data, along with the average surgeon
fee associated with each of these procedures.
Cosmetic surgery patients are mostly between the ages of forty
and fifty-four.19 The limited data on socioeconomic status show that
about 60 percent of patients have annual household incomes less than
$63,000, suggesting that cosmetic surgery is not just a luxury item for
the wealthy.20 ASPS data on demographics reveal that the majority
of patients are white. This is the case for women undergoing all ma-
jor procedures. Table 1.2 contains a breakdown of cosmetic surgical
procedures by major racial and ethnic groups in the United States.
By and large, white women are the primary consumers of cosmetic
surgery. This may be because class is de facto correlated with race
and ethnicity in the United States21 or because researchers have docu-
mented more flexible conceptions of beauty among some racial and
ethnic minority groups.22
 The Cosmetic Surgery Paradox / 5

Table 1.1. Most common cosmetic surgical procedures for

women in the United States (2017)
Percent change Surgeon fee
Number of (from 2000 (national
Procedure procedures to 2017) average)*
Breast augmentation 300,378 41 $3,718
Liposuction 218,174 –28 $3,374
Eyelid surgery 177,290 –34 $3,026
Nose reshaping 166,531 –30 $5,125
Tummy tuck 124,869 107 $5,992
Source: ASPS 2018.
* Excludes anesthesia, facility fees, and other related expenses. These averages do not capture how
fees can vary considerably by geographic region.

Table 1.2. RACIAL AND Ethnic breakdown of cosmetic

­surgical p­ rocedures in the United States (2017)
Asian/
African Pacific
Caucasian Hispanic American Islander Other
Procedure (%) (%) (%) (%) (%)
Breast augmentation 76 11 6 5 2
Rhinoplasty 75 10 6 4 5
Blepharoplasty 83 7 3 6 2
Liposuction 77 10 8 4 1
Abdominoplasty 70 12 11 5 2
Source: ASPS 2018.
Note: Racial and ethnic labels are those of the American Society of Plastic Surgeons (ASPS 2018).
Blepharoplasty numbers do not add up to 100 percent likely because of rounding error.

Medicalization, Normalization, and a New Aesthetic?

A driving force behind the growth of these procedures, particu-
larly breast augmentation, is the medicalization of women’s bodies.
Scholars have written at length about the gendered nature of medi-
calization, arguing that women’s bodies and everyday experiences
are increasingly subject to medical surveillance.23 According to the
distinguished Brandeis University medical sociologist Peter Conrad,
“Medicalization describes a process by which nonmedical problems
become defined and treated as medical problems, usually in terms
of illnesses or disorders.”24 With the medicalization of appearance,
people who are unhappy with their looks and who suffer poor body
6 \ Chapter 1

image can use medicine to “correct” and “treat” aesthetic “problems”

and “abnormalities.”25 They can turn to medical experts and technol-
ogies to “fix” their bodies.26 Certainly, a long list of medical advances
is now available to combat an array of beauty-related problems. We
can have our hair transplanted, skin injected with fillers, and discol-
ored skin tempered by laser treatments. We can freeze our fat cells,
excise fat and skin, and manipulate the shape and size of our breasts
and buttocks. A number of the aesthetic challenges people use medi-
cine to combat are associated with aging.27 Thinning hair, liver spots,
and wrinkles are all a mainstay of growing old. Yet in a makeover and
beauty culture, we view these things as unattractive and therefore
problematic. Rather than embracing aging, cultural conventions say
we should fight its signs, especially given that we have the medical
know-how to do so. A profitable medical market driven by private
demand provides an endless array of medical services for those who
are willing and able to pay.
Medicalization legitimizes cosmetic surgery as an appropriate re-
sponse to beauty concerns. Surgeons function like psychoanalysts by
relieving psychological suffering and improving self-esteem—only,
the former work via alterations of the physical body instead of al-
terations of the mind.28 With the medicalization of appearance and
body image, cosmetic surgery becomes a reasonable solution to body
dissatisfaction. Thus, when women define what they perceive to be
an aesthetic flaw as a medical problem, they seek a cure, and they
are able to feel legitimated in their decision to turn to a surgeon. Of
course, whether women’s body image can be “fixed” with cosmetic
surgery is a different matter, and it is unclear if cosmetic surgery in
fact results in improved social-psychological outcomes.29 In their re-
view of extant research, the psychology professors Charlotte Markey
and Patrick Markey conclude, “Cosmetic surgery has the potential
to improve women’s satisfaction with particular body parts, but it is
less likely to improve their overall appearance evaluation and body
image.”30
Within a medicalization paradigm, as the Dutch medical anthro-
pologist Alexander Edmonds observes, one can think of cosmetic
surgery as a self-care health practice despite its elective nature. Beauty
effectively becomes an “integral dimension of health,” and the risks
of elective procedures are minimized as they “become absorbed into