Beyond 'Before And After:' The Subtle Scoop On Cosmetic Surgery

I confess: Sometimes I think about getting a little work done. Nothing major. It's just that on occasion, I look in the mirror and think the bags under my eyes loom so large they wouldn't be allowed as carry-ons on a plane.

Mightn't something be done? Mightn't the cost and risks be minimal, and the benefits beautiful?

Thankfully, a study published this month in the journal JAMA Facial Plastic Surgery has helped pull me back from that ledge. (Yes, it's a ledge — for a health reporter who believes in self-acceptance and has written far too many medical stories that begin “Everything was fine until that minor operation...”)

The study has garnered headlines like this one from CNBC: "How much younger does plastic surgery make you look? 3 years." And this on Fox News: "Cosmetic surgery subtracts years, doesn't add beauty."

Phew. Suddenly, there was a counter-force to all those seductive before-and-after photos. Go under the knife for a three-year gain? (Or in my case, to look like I'd slept an extra hour?) Not likely.

But hold on. I spoke to the study's author, Dr. Joshua Zimm, a facial, plastic and reconstructive surgeon at Lenox Hill Hospital, and he warned me that many people were spinning his study's results into something they weren't.

"There are some out there saying if you get a facelift, you're only going to look three years younger," he said. "That is absolutely not what this study says. I want to be very clear."

So what does it show?

"I would say the results show consistently that there is an age improvement after aesthetic facial surgery, and I would say in terms of attractiveness, the jury is still out — there's more work that needs to be done for a variety of reasons."

The study was a first of its kind, he said — a first attempt to objectively measure the effects of cosmetic surgery on attractiveness and age reduction — so it's just the beginning of an avenue of research, and by no means definitive.

A note on nuts and bolts: The researchers asked 50 independent "raters" to look at photos of 49 cosmetic surgery patients — some had face-lifts, others had eyelid or brow lifts — and to guess their ages and rate how attractive they were on the classic scale of 1 to 10. The raters did not compare "before" to "after" photos of the same person; they just assessed mug-shot-type photos of patients without make-up or other adornments.

The average patient age was 57. The raters tended to put the patients' ages at two years less than their actual ages before the surgery, and five years less afterward. The gain in attractiveness was, on average "small and insignificant."

Dr. Zimm noted several aspects of the study's design that could lead to distorted findings. For example:

• In order to avoid cherry-picking people with the best results, the study pulled in consecutive patients over a four-year period. But it could only use patients who came back in for a six-month follow-up and thus had an "after" photo taken, and Dr. Zimm says it's likely that the happiest patients with the best results didn't bother to come to check back in, and so were left out of the study.

• The "raters" were asked to assess both the age and the attractiveness of the patients in the photos, and that focus on age could have skewed opinions on attractiveness, Dr. Zimm says. In future work, he wants to ask for ratings of attractiveness only.

Granted, methodology matters. But still, how to reconcile a study that finds only statistically insignificant gains in attractiveness with all those ads that show middle-aged ugly ducklings turned into youthful swans?

Dr. Zimm: "If you go on various physician's Websites, you're going to see all these dramatic results. And I will say, when surgeons are putting results on their Websites or even in their offices, they're showing you their best results, they're not showing you everything. So you're getting a bias in that regard."

"Certainly, there is a range of expectation in terms of improvement. Some patients are going to look ten years younger. Some are going to look more attractive. But you can't say that about every patient for a number of factors. Different surgeons get different results. You're also dealing with different material, if you will, to start with. Certain patients have better bone structure, better skin tone. Various factors influence your results, so all of that has to be taken into consideration."

Makes sense. For still more sense, I spoke with Harvard Medical School psychologist Nancy Etcoff, author of "Survival of the Prettiest" and a provocative thinker on issues of beauty and happiness.

She added still more factors that may have made the study's findings differ from results in real life. Among them: No one looks very good in mug shots. In real life, plastic surgery patients often go on to get new clothes and hairstyle and make-up. Also, mug shots tend to be devoid of expression, and in real life, studies have found that "confidence itself makes a person more attractive."

All of these — clothes, expression, confidence — may be more important than plastic surgery in affecting how we look, she said.

And one more point: "Aging is a bodily process, and if you're just tightening skin, you might have discrepant cues" — in other words, a tighter face might be offset by other telltale signs of aging, such as wrinkles or skin discoloration, which could have influenced the raters.

So, I asked her, what are we, ultimately, to make of this study?

"I think it suggested that on average, our wishes and our fears about plastic surgery are greatly exaggerated," she said. "We tend to demonize it, or valorize it — 'It's transformative, the reality TV shows, you can utterly change.' And we also see, at the other end, the disasters — the freaks, the uncanny appearance. And most people fall somewhere in the middle — much more subtle effects, and often done as much for the person's own sense of self as for what others see."

The study put cosmetic surgery to a useful hard test, she said: "Does it actually make you look younger and more attractive in the eyes of others?" And the answer is "Yes, it can, but not always, And when it is done well, its subtle."

Of course, she noted, subtle may be good; patients don't want to look like they've "had work done." But I can't help but think that subtle is also expensive; a facelift can run easily $10,000. And these days, The New York Times reports, some cosmetic practices are offering less invasive — and thus perhaps even subtler? — options "that some are calling a 'facial face-lift': a package of treatments that may include not just extractions but injections of neurotoxins like Botox and hyaluronic acid filler, as well as red light therapy." The price: $2,500 or $5,000 or more, depending on the package.

As for me, I've just found out that I need glasses, and I've ordered a pair of frames that will exactly cover the bags beneath my eyes. The price: $169.