Our new series, Closer Look, takes a deeper dive into the controversial, critical, and of-the-moment issues facing doctors and patients in aesthetic medicine.
“Oh my god, I need a nose job so badly!” I heard a high-pitched voice yell from a nearby table during a recent breakfast in New York City. I turned around to see three young women huddled around an iPhone, scrolling through photos. Another asked, “Have you guys seen that new filter on Insta that makes your lips huge and your face, like, perfect?” She pulled up the app to demonstrate. “This is exactly how I want my lips done!” the third girl said after trying it out for herself.
These sorts of self-deprecations are nothing new, of course. We’ve all looked in the mirror and thought, I really need to lose five pounds or If only my cheekbones were more defined. The difference is that now, in the age of selfie filters that smooth our skin and slim our faces, we’re able to better imagine what we might look like with a few tweaks. As a result, plastic surgeons around the world have noticed not only an increase in the number of patients seeking cosmetic procedures, especially those that will photograph well on Instagram, but they’re also noticing that patients’ expectations are alarmingly unrealistic.
“I think the rise of social media has definitely led a lot of patients who wouldn’t have considered surgery even 10 years ago to now want it,” says Dr. Leslie Irvine, a facial plastic surgeon in Manhattan Beach, California. “It’s a double-edged sword—social media has made cosmetic surgery a lot more acceptable and less taboo in the mainstream and it’s probably brought me a lot more patients, but then the flip side is that making people look good on camera is not the same as making them look good in real life.”
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Many young patients have turned to plastic surgery as a way of coping with what they see on social media, but they often do not consider how distorted a reality it is. There are filters and morphing software aplenty that can change a person’s appearance, but the very act of taking a selfie can also alter the size of facial features. “I think there are a couple of things to consider,” says Dr. Anthony Youn, a Troy, Michigan, board-certified plastic surgeon and the author of Playing God: The Evolution of a Modern Surgeon. “There was a study in the Facial Plastic Surgery Journal that showed that if you take a selfie, your nose appears up to 30% larger than it would in real life—and patients don’t know this. They haven’t read this study, and it’s not common knowledge.”
Dr. Youn notes that patients are also no longer taking selfies just from the front; instead, they’re positioning their cameras from the side, behind, above, and below—angles they never focused on previously and that aren’t necessarily how others are seeing them. “They’ll say, ‘Look, if I take a selfie from behind my ear, I can see this thing on my cheek that’s sort of an indentation, and that needs to be fixed,’” he explains.
Dr. Irvine says she’s seen a dramatic uptick in rhinoplasties in particular, and she believes that this trend is a direct result of Instagram culture and selfie distortion. “I see a lot more patients asking for a rotated nasal tip, and I think that’s partly because of the angle people take selfies from,” she says. “It’s okay if you have a more rotated tip when you’re taking pictures from above, whereas historically, people were always afraid of having an upturned, Miss Piggy-type nose.” In these sorts of cases, the burden then falls on the surgeon to explain to patients that a nose job is not temporary, nor should it be done to cater to anything but real life. “The reality is that every era has a fashion for the nose or the face or the breasts,” adds Dr. Stafford Broumand, a New York City board-certified plastic surgeon. “I have to tell patients that these looks come and go, and it’s my job to give them results that they’ll be happy with for a lifetime.”
Not too long ago, outrageous plastic surgery demands were a rarity and often came from patients who suffered from some psychological issue or dysmorphia. Now unrealistic requests have become commonplace in many doctors’ offices. “I’ve seen a lot of normal, high-functioning adults who want a very skinny nose that won’t actually look good on their face,” says Dr. Irvine. “What they’ll do is take a filter and make their cheekbones look more pronounced, they’ll make their face look skinnier, they’ll make their nose look skinnier. In their filtered reality, it looks great, but in real life, they wouldn’t be able to breathe if I made their nose that skinny. They often don’t take into account the reality of their face and keeping the proportions of it intact.”
Patients have begun bringing in these sorts of doctored or filtered photos in lieu of photos of celebrities whose looks they want to emulate. “I think it’s actually a lot more dangerous and a lot more unrealistic than a celebrity [photo], because at least a celebrity is a real person,” says Dr. Irvine. She remembers one patient in particular, who desperately wanted Scarlett Johansson’s nose. “She’d actually pasted it onto a photo of her own face. At first, that may seem like an alarm bell that patients are setting their expectations too high, but in my experience, those patients are actually fine—and compared to those who come in with filtered photos of themselves, it’s much less of a red flag.” But other surgeons think that edited photos can actually be a valuable asset. “Anytime you can have a representation of what a patient wants and you can then discuss it and see how it translates onto their face or figure, I think it’s helpful,” says Dr. Broumand. “I don’t want to say it’s a detriment. I think any added tool is a benefit.”
The consensus among the medical community is that with a continued dialogue and the help of cutting-edge technology, patients can typically be coached away from their unreasonable surgical expectations. “Their desire to look like what they see on social media or what they look like morphed has to be discussed, and an understanding must be developed between the patient and the plastic surgeon,” Dr. Broumand explains. “We have 3-D imaging in our office, so before I do a procedure, patients can see what they might look like.” He also makes certain his patients understand that what they see on Instagram or on reality TV isn’t really real. “There’s a lot of makeup and lighting and so much smoke and mirrors,” he notes. “And once they get that, most patients will be quite reasonable.”
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However, such behavior and unrealistic asks of surgery can often actually be symptomatic of a much larger issue. “I do believe that social media is definitely fueling this, but I think a lot of these people may have underlying body dysmorphia,” says Dr. Youn. “My hypothesis is that social media doesn’t necessarily cause body dysmorphia, but in those people who have body dysmorphic traits and inclinations, I do believe it brings it out and causes it to be more of an issue than it otherwise would.” This means that sometimes, patients’ expectations can’t be shaped. “It’s always a really big worry—if they are already so profoundly disappointed with such a miniscule, perceived defect, something that I can barely see, how am I going to treat that and make them happy?” Dr. Youn continues. “And that’s the big issue with body dysmorphia. It can be difficult to ensure that they’ll be happy, even after an operation or after filler.”
Despite how troubling many of these trends are though, they show little sign of slowing. “It’s a much more photograph-based population these days. It’s not that they have to take a picture and send it off to be developed—they see it instantaneously, and they see it all day every day,” says Dr. Broumand. “They’re now bombarded with images of themselves, and it might not be how they perceive themselves day-to-day, but when they see themselves as an image, they’re not happy, so they come in.” Patients are getting increasingly younger, and as Generation Z nears adulthood, rates of cosmetic surgery are sure to continue rising. It’s up to the surgical community to ensure that its members are privy to this phenomenon and prepared to face its potential dangers.
“As plastic surgeons, the vast majority of us are moral and ethical and are doing this for the right reasons, but that’s not everybody,” Dr. Youn says. “I think this trend will continue, and it may worsen, but there are good things about social media and plastic surgery. I have been able to educate so many of my patients on Instagram and on YouTube, and a lot of it is encouraging patients to be their own advocates, to learn about procedures before they consider them, and to use caution in picking a doctor. I do think there are a lot of positives to come out of it, but there are always going to be negatives too.”
