Vanessa, by all accounts, is a beautiful, vibrant young woman, yet when she looks in the mirror, she feels she's lacking something. So, after doing some research and finding out she could finance more cleavage, the 28-year-old is preparing for a consultation with a local plastic surgeon. For her, it's about improving self-image.

"If I had those, I wouldn't have a problem," she says, pointing to a buxom co-worker's D-cup bust. Some cheer her on while others try to discourage her, but Vanessa is determined to go through with the surgery. "I am really a 32B/34A," says the advertising associate, who wishes to remain anonymous.

Vanessa, who lives in Port Washington, is about to join the more than 360,000 women nationwide who had breast augmentation surgery last year, according to the American Society for Aesthetic Plastic Surgery (ASAPS). She isn't at all worried about volunteering to go under the knife, and like many of the patients who came before her, conducted her own investigation into the increasingly controversial industry of medically enhanced beauty.

Inside the operating room of a local plastic surgeon, another woman, a 38-year-old mother of two, has a breast lift to rejuvenate her chest. The effects of childbearing brought the mother, who also wishes to remain anonymous, to the decision to have implants. But the finished product of new soft curves requires the sterile, bloody precision of the doctor cutting open her flesh while she's under anesthesia. It may not be open-heart surgery, and the procedure may be practically routine, but the gore—like that seen on Dr. 90210 or Nip/Tuck—is not for the faint of heart.

Patients can find it difficult to sift through all of the information, while dermatologists, ophthalmologists (eye doctors) and otolaryngologists (ear, nose and throat doctors) compete with the traditional plastic surgeon for clients bombarded with endless innovations in cosmetic procedures. For techniques such as injections, chemical peels and laser treatments, many doctors now have spas in their offices, and numerous spas now have physicians onsite. But new technology is constantly being introduced. And reality television shows aren't making anyone's job easier.

"The people that I see who watch these programs like The Swan and Extreme Makeover are led to believe that more can be done than can actually be done," says Dr. Arthur Wise, a veteran Roslyn Heights-based plastic surgeon. What people don't realize, he says, is that
makeup artists and cosmetic dentists "add greatly to the results." But like most of Long Island's cosmetic
surgeons, he believes patients in the region who are exploring the option of elective surgery are well-informed.

Like Wise, Dr. Alan Kisner started his career about three decades ago. Both have private practices and also perform reconstructive and plastic surgery at
various hospitals. But unlike Wise, Kisner has moved his practice away from doing solely surgical procedures, and has also brought a spa into his office in order to embrace the demand for less-invasive cosmetic procedures.

"Some people focus on the immediate return to socialization, but my patients are relatively well-informed as far as expectations," says South Africa native Kisner, who is also the chief of plastic surgery at Huntington Hospital.

For better or worse, the ravenous demand for beauty doctors is sucking up the supply of healers as medical school students seek to ensure themselves promising futures. Dr. Balvant Arora, an assistant professor of plastic and reconstructive surgery at Stony Brook University Medical Center, says the number of students in the field has increased "almost 20 to 30 percent."

Picking A Specialty

The varying focus of each surgeon is just the epidermis of the issue.

"When I first came to Long Island, in Nassau County there were four or five plastic surgeons, and in Suffolk County there were another four," says Wise. Those patients who were bold enough to challenge the old-fashioned stigma of plastic surgery and were rich enough to afford it back then often traveled to New York City instead, he says.

Now consumers can choose from more than 80 surgeons on the Island who are board certified by the American Board of Plastic Surgery, Inc. (ABPS). This certification means that the doctor has graduated from an accredited medical school, has completed at least five years resident plastic surgeon training, and has completed comprehensive written and oral exams. That doesn't include doctors who claim to be plastic surgeons who are board certified, but not by the same organization. The only board that matters is ABPS, experts say. "Doctors say they're board certified but they don't say by what board, and the public in general doesn't know the difference," says Dr. Elliot Duboys, a Woodbury-based plastic surgeon.

Then there's a bevy of skincare specialists, a growing number of MediSpas, or health clubs that come equipped with nurses, doctors or aestheticians. And then there are the head and neck doctors (otolaryngologists) who perform cosmetic operations on the face, and the skin doctors whose work is mostly noninvasive (procedures that don't require surgery).

Choosing may not be easy, but it's not impossible either. "The bottom line is: If the surgeon is good at what they do and they have a good aesthetic, then they
can do a good job," says
Dr. Stephen Bosniak, a Great Neck-based eye surgeon with offices in Manhattan—a specialty that is the minority in the turf wars of cosmetic doctoring.

"[The] doctor has to know how to do surgery, has to know how to use lasers, [and] has to know how to give injections, so that when they offer the patient a plan of treatment, the patient knows that there's not a bias," Bosniak says. "That it's not a doctor who only does surgery because the answer to everything is going to be surgery; that's not the state of the art anymore."

In the other corner are dermatologists, also physicians, who do simpler aesthetic work such as laser hair removal and Botox injections, and who tend to use cutting-edge external procedures to improve the patient's skin. These doctors have been in the business of making skin look better, but in recent times they have become more proactive about their approach rather than simply treating skin ailments.

Bias isn't all a prospective patient should worry about. "The turf battles are the most confusing," says Dr. Leland Deane, of Garden City-based Long Island Plastic Surgical Group. "The most important thing is for the doctor to share their background with the patient first," he says, noting that some advertisements intentionally blur the lines by saying doctors are "board certified" but don't say by what organization. There are gynecologists (physicians specializing in the care of women's reproductive systems) and gastroenterologists (doctors who specialize in the care of the stomach and intestines) performing liposuction, the surgical removal of fat deposits from under the skin, he says.

Vanity is big business, and for a culture as obsessed with good looks as the LI culture, business is booming.

"I even pray to God at night, 'God, can you make my boobs grow?'" says Vanessa, before her consultation with a local cosmetic surgeon.

So Much To Choose From

Nationally, there were more than 11 million surgical and non-surgical cosmetic procedures performed last year, according to ASAPS. One of the reasons may be affordability. Formerly only available to the affluent, cosmetic surgery has come down in price as baby boomers start to hit the wrinkle years, and has rapidly worked its way into the mainstream. Procedures are simpler and cheaper, and with just about everyone in Hollywood doing it, the stigma is gone.

"Cosmetic surgery patients used to hide out until they healed; now they run to the diner to show off the work they had done," says Dr. Stephen Greenberg, a Woodbury and Manhattan-based ABPS-certified plastic surgeon who regularly hosts plastic surgery seminars and writes a column for the Press.

According to ASAPS, if you count new treatments, like laser skin resurfacing along with the old standbys such as face-lifts and tummy tucks, Americans spent about $12.5 billion on surgical and noninvasive cosmetic procedures last year. That's a 444 percent increase overall since the group started tracking cosmetic procedure statistics in 1997—and the equivalent of one in 20 Americans having "a little work done." With increased affordability and accessibility drawing in younger patients, the industry grows each year.

Among the noninvasive procedures, the most well-known uses Botox, a type of toxin derived from bacteria, Botulin toxin. Botox is injected through the skin into a muscle to keep it from tightening and temporarily suspend the appearance of wrinkles in the face. The process sounds nasty, but some people will do anything to prevent crow's feet and frown lines from nesting between their brows.

Then there's Restylane, a close second to Botox. Injection of this non-animal acid, made from fermented bacteria, also involves little in the way of recovery and discomfort, but instead of erasing the wrinkles like Botox does, it fills in the wrinkle lines. While the filler lasts about the same period of time as Botox—about six months—this quick fix ranks among the most common noninvasive cosmetic procedures because of its ease and accessibility.

Local doctors, who do everything from rhinoplasty (a nose job) to innovative treatments such as the VelaSmooth laser (which nonsurgically treats cellulite), often offer financing packages for the pricier procedures.

"Plastic surgery on Long Island is at least half the price of Park Avenue plastic surgery," says Wise. Although there are surgeons in other areas of New York City who do similar work, "There's no reason to go into the city," he says, adding that many doctors have offices in the city in addition to a local practice. "You have the same modalities here as you can get anywhere else."

Major surgery still can cost several thousand dollars, but minimally invasive
procedures like micro-dermabrasion, a sort of sandblasting for the face, can cost a mere $150. Botox and Restylane each usually run upwards of $500, depending on the doctor and the extent of the procedure. But when it comes to shopping around, price should be second to professionalism when choosing a doctor, experts say.

Surgery, lipo and Botox are not the only measures Long Islanders are choosing. There are a variety of nonsurgical and even holistic procedures that fall under the loose title "preventative cosmetic care." Also gaining in popularity is the ancient practice of Chinese acupuncture. Like the East's green tea and yoga, this, too, has been harnessed for beauty purposes.

"Acupuncture is used for facial rejuvenation. It helps get rid of fine lines by stimulating the muscles," says Ronald Sandoval, an acupuncturist at the Huntington Holistic Health Center. "It is suitable for any age. The younger you begin the better. Prevention is the best medicine," he says.

There are a number of obscure surgeries that don't get talked about everyday. Such procedures include cheekbone chiseling or implants, tattoo removal, butt augmentation and chin augmentation. Many are one-day, outpatient procedures. Most of these procedures are requested by both sexes, but there are gender-specific procedures as well.

For men, there's calf, pectoral, and penile implants, which can be used to treat erectile dysfunction. Penile implants should not be confused with penile enlargement surgery or phalloplasty. For women, labiaplasty (labia reduction surgery) and hymen repair are available for various reasons—cosmetic, hygienic, or to relieve discomfort during sex.

The Changing Face Of Fountain Seekers

The increased acceptability of cosmetic medicine has brought with it younger patients, both male and female, in addition to the baby boomers who are
coming up on 60. A rising interest in pre-emptive procedures, such as "mini lifts," which offset the desire for full-fledged plastic surgery when patients grow older, has fueled doctors catering to younger generations.

Metrosexual or not, men are taking better care of their physical appearance than in the past. Some aesthetic (cosmetic) surgeons estimate that men now make up as much as 25 percent of their clientele—although the ASAPS puts the nationwide number at 9 percent.

Liposuction, eyelid rejuvenation surgery, Botox injections and laser hair removal are among the most popular treatments men go for, according to ASAPS, although they now can also get implants in the chest to give the appearance of large pectoral muscles.

While acquiring fake muscles may be extreme, most patients just want to look better. Some men and women ask to be re-formed as someone famous, with the most common current choices being Brad Pitt and Angelina Jolie, according to a study conducted by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

Cosmetic surgery is also becoming more acceptable among minority patients. Racial and ethnic minorities accounted for 20 percent of all cosmetic procedures in 2005, according to ASAPS. Hispanics again led minority racial and ethnic groups in the number of procedures at 9 percent, while African-Americans made up 6 percent of patients and Asians consisted of 4 percent.

Natalie Balboa, a 52-year-old Long Beach housewife and cosmetic surgery patient, says, "A lot of the young girls don't need to start when they do. I have nothing against wanting to feel better about yourself, but some of these girls want to be Barbie dolls."

Only 2 percent of all procedures were performed on patients younger than 18 years old in the U.S. last year, according to ASAPS. The most common procedures for those 18 and under were laser hair removal, microdermabrasion, rhinoplasty or otoplasty (surgical alteration of the outer ear) so the child isn't ridiculed. Local doctors say that while demand is up in all age brackets, they won't perform major surgery on minors without parental permission and without a valid reason.

"Ideally, the parents should be in complete agreement and support of the
procedure," Greenberg says. "At the same time, the teen should be undergoing the procedure solely because the teenager wants it and will benefit from it, not because of anyone else's expectations." It must be kept in mind that the child is still growing and changing, he says.

"I never thought I would get surgery when I was young, but then you get older and things change," Balboa laughs, motioning toward her torso. "Really change!

"I think some of the young girls abuse the idea of surgery. It becomes unreasonable," says Balboa.

The Dark Side

But if plastic surgery has become so common that people talk about so-called "lunch hour" procedures, it is still surgery, and the risks are not to be underestimated.

"During the liposuction procedure, his heart stopped from the anesthesia. Since it wasn't done at a hospital, but at one of those centers, they didn't have the kind of equipment hospitals have to revive someone in that condition," she says. In 2005, an estimated 48 percent of procedures were performed at private offices, 28 percent at freestanding surgical centers and 24 percent at hospitals, according to ASAPS. Over the past decade there have been improvements in the anesthesiology performed
in non-hospital settings, however.

"He would have been a brilliant lawyer," laments Mandel.

Stony Brook's Dr. Arora advises patients to find out about the surgeon they are considering before going under the knife, and to be sure she or he is certified with ABPS. Besides having the burden of keeping the patient healthy, plastic surgeons must also "visualize the desired outcome," says Arora.

"The most important component of this surgery is to listen to the individuals and to know what their expectations are," he says. Health risks also need to be considered, Arora adds. "I think the most important thing we look at is to minimize the risk that is inherent in each procedure."

Filling The Void

The pervasiveness of the instant transformation seems inescapable. Newspaper advertisements show amazing before-and-after pictures with the offer of "a better you," television portrays the Zen-like happiness of post-op models, and even radio touts financing options for every type of implant.

Body alteration addiction is nothing new. About 7 to 12 percent of cosmetic
surgery patients have body dysmorphic disorder (BDD), according to the American Psychological Association. BDD is a part of the obsessive-compulsive spectrum of disorders. An estimated 2 percent of LI residents suffer from BDD, say experts like Dr. Fugen Neziroglu, a Hofstra University psychology professor.

"If your appearance is causing incredible distress and obsessionality," says Neziroglu, "then I think that maybe it would be preferable to deal with it more therapeutically than cosmetically.

"These patients will really never be satisfied with whatever the plastic surgeon has done," adds Neziroglu, who is also clinical director of the Great Neck-based Bio-Behavioral Institute, a private medical, psychological and nutritional research and treatment facility.

"They go for repeated surgeries, they tend to be perfectionists and they're looking to change.

"Patients who fall into this category feel worse after the surgery, [they] may
be dissatisfied with their appearance after surgery," Neziroglu says.

Not everyone who has repeated cosmetic procedures has this form of obsessive-compulsive disorder. According to AAFPRS, about half of the people who had a cosmetic procedure performed returned for another within the same year. Researchers at ASPAS' Educational Research Foundation released a study recently that found that plastic surgery patients experienced a decrease in the frequency of negative body image emotions even a year after the procedure.

For some, however, cosmetic improvements are simply a way of life. While marketing herself at a cosmetic surgery convention recently, Gianna Miceli of Great Neck, the owner of www.KillforThisHair.com, a site that sells hair extensions, says, "You become addicted. You become a junkie." She adds, innocently enough, "It's all very girlie and it makes me happy."

Most of us have spent more time than we care to admit wishing we were
better in some way. The wish for a new body and eternal youth is a dream that is often ingrained in the human spirit, but until a time machine is developed that can freeze the aging process, plastic surgery will be the Rosetta stone for those seeking eternal beauty. And while Long Island has more than one fountain of youth, just remember: Nothing lasts forever. There is no surgery for that just yet.