Quotes of the Day

It's what's on the inside that counts. That's a sentiment Thierry Moreau is preparing, body and soul, to endorse, if not quite in the spirit the hoary old platitude is usually intended. In half an hour, a surgeon will make an incision below Moreau's left breast and push a transparent sac of gel into the cavity. To the strains of Procol Harum's A Whiter Shade of Pale, the surgeon will prod and manipulate the material until satisfied, before repeating the procedure on Moreau's right side. When the patient, sutured and bandaged, stirs from his anesthetized slumber, he'll find one of his dreams made reality. Augmented from within, Moreau will rise from his bed, the owner of a proud new set of pectorals.

Will his enhanced physique enhance his life? The 43-year-old two-time divorcé thinks it will. A financial manager in the French Ministry of Defense, he's devoted his out-of-office hours in the last year to researching what cosmetic surgery can do for him. "I've always had a complex with regard to my chest," he muses, as he waits to be escorted to the operating room. "There were times when it didn't bother me that much, when I was married and living the normal life of a couple. But I'm single again and I suppose you could say there is always that desire to seduce." Cherchez la femme. When a man behaves, well, oddly, there's bound to be a woman — or women — involved. Why else would Moreau travel 600 km from his home in Bordeaux to a clinic in a Paris suburb to risk an unnecessary medical procedure and the potential jibes of friends and colleagues — and shell out €3,900 for the privilege?

Moreau has been unhappy with his pecs for years. His first wife, he says, sometimes mentioned his chest lacked muscle. Like the rest of his body, his upper torso, while not buff, appears well-proportioned enough in the waiting room at the Institut Européen de Chirurgie Esthétique et Plastique. But, says Moreau of his ex-wife's commentary, "I took it well, but maybe deep down it kind of got to me." Dr. Paul Seknadje, the surgeon who is shortly to perform Moreau's operation, confirms that among the growing numbers of men seeking his services, a significant proportion are spurred to do so by female voices. "In many cases wives are the ones to suggest that their husbands get rid of fat to look sportier," says Seknadje.

Yet the rising demand for Seknadje's varied skills — he performs all manner of procedures including some 200 penis enlargements every year — cannot simply be explained by the emergence of a vocal generation of women. There are other voices, siren voices of the media and of a deeper collective unconscious, that are sending supplicants to his clinic and to similar private centers, hospitals and beauty parlors across Europe. The voices, as insistent as nagging spouses and as urgent as adolescent sex, promise that cosmetic interventions will deliver more than just better chances in the dating game or improved conjugal relations. They whisper that surgery can grant a gift greater than immortality — the chance to stay young until you die.

There are no comprehensive statistics to chart the astounding surge of Europeans demanding elective cosmetic surgery along with a gamut of "noninvasive" procedures that inject threads, compounds and potions to lift and remodel, smooth and tighten. Competing practitioners' associations collect information only from their own members, and many practitioners in Europe operate outside the ambit of any of these associations. Nor is there any reliable way to measure the numbers of budget-conscious Europeans nipped, tucked and stitched up in distant resorts or the haphazard metropolises of the developing world. But even fragmented data on Europe's booming transformation industry tell an extraordinary story.

Once an indulgence of the moneyed élite and a professional necessity for actress-model-whatevers, cosmetic alterations are becoming a mass-market activity. Think you don't know anyone vain enough or desperate enough to try it? Think again. Odds are that a friend, a colleague, the teller in your bank or that commuter you sit opposite most days has already gone in for a little work. It won't be someone you consider vain or desperate or from a different planet. According to the International Society of Aesthetic Plastic Surgery (isaps), a body representing 1,315 practitioners, Europe accounted for more than 33% of cosmetic procedures conducted in 2004, second only to all of the Americas.

In Britain, the market for elective cosmetic surgery grew by an astonishing 35% last year, says the British Association of Aesthetic Plastic Surgeons (baaps). Still, the British have yet to develop the ravening hunger for beautification displayed by some fellow Europeans. isaps places Spain, France, Germany and Turkey far ahead of Britain for consumption of cosmetic procedures. And opinion polls conducted all over Europe point to a widening acceptance of cosmetic surgery as a part of normal life — particularly among the young. The research company Forsa found that 13% of Germans say they would consider surgical enhancement; that number rises to 20% — 1 in 5 — among the under-30s. Fifteen percent of 14-year-old British girls and boys wouldn't rule out going under the knife, according to a survey by the Priory mental-health-care group.

Why is cosmetic surgery growing so fast in Europe? The Continent's aging profile may go some way to explain why older Europeans regard plastic surgeons as high priests. But the newly powerful appeal of the religion for younger generations — and for men of all ages and every sexual orientation — is tougher to interpret. Time reporters spoke to practitioners, social scientists and psychologists to try to fathom why Europeans place such a high value on beauty. And we talked to patients of different nationalities, from teenagers to retirees, about the choices they have made, their expectations and their lives — before and after. They mentioned the temptingly wide range of options on price, procedure and location. But their answers hinted at deeper cultural shifts, too. Cosmetic surgery today isn't just the preserve of the anciens riches who parade their taut faces along the promenade at Puerto Banus, or the starlets whose undernourished frames barely support their embonpoints. Rather, the cosmetic-surgery boom reflects changing patterns of behavior in Europe. Plenty of patients go under the knife for the oldest reason of all — because they want to look more beautiful. But a surprising number attribute their passion for cosmetic surgery to television — to the rash of programs designed to convince viewers that a makeover is something they need feel no guilt in desiring. Something else is new, too; increasingly, cosmetic surgery is for men as much as for women. In the intersection between the search for beauty, the power of TV and the needs of the new male, Europe's face is changing. Literally.

Breaking A Taboo
A woman perches on the only wooden chair in an overupholstered hotel lobby. She could be any one of the genteel 50-something ladies wandering past outside, up from the country for a day's shopping in London. She jumps to her feet as her friend enters from the street, already trumpeting a series of questions: "How was it? Did you find her scary? What are you having done?"

The pair have emerged from consecutive appointments with "the Knife Coach," as she calls herself — Wendy Lewis, a turbo-talking, wisecracking New Yorker. It has been a day of firsts for the ladies, and it's only lunchtime. They have signed up for their first elective surgeries — both will have face-lifts — a decision made easier by their first opportunity, courtesy of Lewis, to examine the results of this operation up close.

Later, in a busy café, Lewis grants me the same privilege, guiding my fingertips to scars under her hairline. Her forehead is preternaturally smooth for someone so expressive, and she has no laughter lines — though she laughs often and heartily. She doesn't look younger than her 46 years but she appears well rested — inexhaustible, in fact. Lewis is a walking advertisement for her self-created profession: she is a consultant on cosmetic surgery, independent from any practitioners, who makes her living by charging clients for advice on how they can improve their appearance and whom they should entrust with the task. She started in the U.S., but has seen clients in Europe since 2000. After this trip to London comes Paris, then Greece this summer. "The growth over here is exponential," she says.

In one important respect, the European market is different from that in the U.S. "Americans are notoriously litigious," says Lewis, "so American doctors practice defensively." Fillers — the injectable substances used to plump out creases and wrinkles — go through the arduous approvals process of the Food and Drug Administration before being licensed for use in the U.S. In Europe, most are classed as "medical devices" so require only a "Conformité Européene" certificate, a cheaper and quicker process. As a result, explains Lewis, "there are more than 70 fillers available in the European Union," but only eight approved for cosmetic use in the U.S. Professional qualifications vary from one European country to the next. "The fact that there are fewer restrictions on European doctors is both good and bad," says Lewis. "It means they can be more creative and try more products, but they also take bigger risks." She warns against cut-price surgery tourism. "A woman came to see me the other day with a brochure for a clinic in the Mediterranean and said didn't it look nice. I told her, 'If you want to go on holiday, go on holiday. What do you know about this clinic? Nothing.'" Quality is everything. "Most clients," says Lewis, "want to look better, not different."

Jacqueline Dusseaux, 43, a realtor from Montargis, 100 km south of Paris, could relate. She had a face-lift at the end of January. "The wrinkles were starting to become a real problem around my chin and eyes, to the point that when I put on eye-shadow, it would disappear in the creases," she recounts — while admitting that she had to adjust to her "new face." "Just the other day I went to get medicine. Everyone was staring at me," says Dusseaux. "Then the pharmacist came over and said, 'My God, with the other customers it is hard to tell that they have had something done, but on you it really shows.'" And she hasn't told her parents. "In France there is still a taboo," says Dusseaux. "People have certain perceptions of you once they know you have had work. It is perceived as a frivolous thing that rich people do. I don't understand it. Anyone can have plastic surgery now. It has been democratized."

Granted, democracy comes at a price. Alice Kisko, 33, from Aachen, Germany, is still getting used to the breast implants she received earlier this year — and their cost. She and her family went without their usual vacations to help fund the j3,000 operation. Luckily her husband and two children are all enthusiastic about the results. "My 10-year-old daughter was downright excited," says Kisko. "She said my breasts looked 'superwonderful and natural.'" Still, Kisko doesn't plan further cosmetic procedures and wonders about the participants in TV reality shows. "I feel like myself — even though the size of my breasts is still a little unfamiliar — when I look in a mirror. But how can these women do so when they look like entirely different people?" But such disapproval misses the point. If cosmetic surgery has become something that many Europeans — rather than a rich few — now contemplate, it's TV that's responsible.

Makeover!
When Isabelle Dinoire, recipient of the world's first partial face transplant, made her postoperative press debut last month, the scene at the hospital in Amiens, France, echoed the set-piece closing sequences of Extreme Makeover. That TV program uses surgery to transform plain Janes into sultry Suzys. The media applauded Dinoire's entrance and the patient declared, "I now have a face like everyone else. A door to the future is opening."

That's precisely the subtext of many makeover programs broadcast on European TV channels. The absence of beauty, they suggest, precludes a normal existence. In the past, cosmetic surgeons had to rely upon before-and-after shots of clients: you've seen the dowdy mugshot followed by the coiffed glamour-puss look. The genius of the reality television shows was to develop this emotive narrative into multipart series. Their names resonate with promise: The Swan, 10 Years Younger, Make Me Perfect. Poland's first-ever locally produced surgery show, Make Me Beautiful, attracted 100,000 applicants in its first season.

One of the most successful examples of the transformation genre, Extreme Makeover, devised in the U.S., has been sold to broadcasters in 30 European territories; the format has also been licensed to homegrown versions in six European countries. Each episode introduces participants at their lowest ebb, discusses their "defects" and emphasizes their unhappiness in voiceover. Then comes the transformation scene: a surgical makeover, usually involving multiple procedures, new teeth and wardrobe, and industrial quantities of makeup. Finally we arrive at the "reveal," the climax when the transfigured patient is unveiled, à la Dinoire, to the applause of friends and family.

It's a great moment. But Wendy Lewis worries the TV shows have raised unrealistic expectations. "We've created a culture of people who can't afford surgery or aren't stable enough for it. We've made it seem a little too accessible. Having your boobs done won't mean you meet the man of your dreams." Moreover, she challenges the idea that surgery is an option for everyone. "This is a luxury and an elective item. If you can't afford the fee, if you start going into financing, then there's so much riding on the outcome of that surgery that it puts too much pressure on you."

Besides, sometimes surgery doesn't do the trick. Gérard Le Gouès, a Paris-based psychoanalyst and author of a book about cosmetic surgery, Un Désir dans la Peau (A Desire in the Skin), believes that many successful surgical operations are "failures, psychologically speaking — I would estimate about 35-40%. Surgeons aren't psychological specialists."

And sometimes it's more than the psyche that's damaged. In France, Muriel Bessis, 62, has undergone five breast operations, six facial procedures and 11 years of tribulation to achieve her current look. And she says frankly, "I do not recognize myself." In 1985, Bessis, a Parisian speech therapist then in her early 40s, decided her breasts would benefit from a little work. The operation was not a success. She eventually consulted a second surgeon who offered to fix her breasts and to give her an eye-lift. "After the surgery I was unable to close my eyes for almost a year. I looked inhuman. My husband had to put drops in my eyes constantly and I had to sleep with my eyes open. The stitches were put in in such a way that I also lost all my hair." Bessis founded a support group for fellow sufferers and discovered she was far from alone in her experience. But "women were not speaking out because they felt guilty. Why did they feel guilty? Because they had willingly been operated on when there is nothing technically wrong with their bodies."

Bessis does not oppose cosmetic surgery; she just wants the discipline to be as well-regulated as other branches of medicine. Le Gouès, the psychoanalyst, stresses that cosmetic surgery can bring about substantial benefits. "Take, for example, a young woman whose breasts are too large. She can't do sports; she has trouble knowing how to dress well; she has trouble with boys. In other words, it's a sort of handicap for her." A breast reduction, he suggests, will not only solve the practical problems. "There's something more; suddenly her chest is something she's pleased with, that she finds beautiful." Hold that nice thought and add one twist to it. In Europe today, increasingly, that "she" opting for breast reduction is a "he."

The Deadly Male
"We've had a very good january — a phenomenally good January — so I thought, 'I'm going to treat myself,'" says Mark Jennings, who works in the London M&A division of one of Europe's leading banks. A trip to Verbier? A new Porsche? Nah. Jennings, 41, invested part of his bonus in stomach liposuction at London's Harley Medical Group. "I work very long hours — it comes with the territory — but I've been fit all my life so it shocked me when I started to get a midlife belly," he explains. Gym visits did little to beat the small bulge. "So I looked into cosmetic surgery."

Jennings and several other bankers he knows had already had Botox injections — not out of vanity, he says, or even to conceal aging. The bankers want to avoid "frowning or looking stressed. We're in a very, very high pressured environment, we're working 18-hour days, weekends, bank holidays, and it's important to look your best � like you can take it in your stride." Donato Massimi, 60, from Rome, is another male who knows what stress is like. "I have to have a dynamic and youthful image," he says. Massimi's firm, Charme International, equips spas and wellness centers. Gotta look as good as the clients — even if Massimi's 19-year-old son was skeptical about Dad's face-lift. But as Massimi says, "He's had a classical education."

As did Silvio Berlusconi, who turns 70 in September. But Italy's Prime Minister retains a belief in the importance of maintaining his public face. He has admitted to having an eye-lift in 2003, and has followed that up with at least one hair transplant. Last month the French daily Libération claimed that some contenders for the presidency in next year's elections have started polishing their images too. According to its report, Prime Minister Dominique de Villepin no longer sports a mole on his noble brow, and Ségolène Royal, one of the Socialist Party's possible candidates, had her teeth redone. "The French people's favorite Socialist is now endowed with an American smile," wrote Libération, with the characteristic hauteur of heroes of the French left.

Anyway, what's wrong with an American smile? Dr. Jonathan Cole, a professor and a hospital consultant in clinical neurophysiology at Poole and Salisbury Hospitals in southwestern England, has studied the relation between the self and the face, and can explain why it pays to look good. "Before the Industrial Revolution," he says, "your society might extend to 200 or so people. Now you see thousands of people. You see them but you don't interact. The only way people make an impact on each other is through the visible self." Men such as Jennings and Massimi say their cosmetic interventions are helping them to make the right impact; cosmetic surgery, in other words, is as much a professional tool as an indulgence. And unlike many women who came of age before the word post was surgically grafted onto the proboscis of feminism, the majority of men contemplating surgery aren't consumed with guilt. They may worry about what their friends will think. They don't agonize about betraying their sex.

In the end, most men — and women — have cosmetic surgery because they think it will make them look good. Back home in Bordeaux, Thierry Moreau and his new pectorals have been getting acquainted. They aren't bosom pals, as yet. "I think they are disproportionately large," he says, but then, it may be three weeks before all swelling subsides. Then he's sure he'll be pleased — and, if not, he'd consider more surgery. "It's like it's a foreign body, not really part of my physique yet," he says.

Ozlem Avan remembers when her newly reshaped nose was still engorged. But she and the nose "became friends right away because it looked 100% natural," she says. Avan, now 24 and a student in Frankfurt am Main, Germany, was still a teenager in 12th grade when she persuaded her parents to pay for her surgery at the One-Plast clinic in Istanbul, Turkey. Like the majority of the younger patients interviewed by Time, her approach to surgery is buoyed by a good outcome and untainted by guilt or embarrassment. "You remain the same individual, whatever you look like — because ultimately it's your inner values that count," she opines.

Another young patient, Spaniard Virginia Pozas, 27, describes her series of operations as "absolutely necessary." Spain, according to isaps, is the biggest market for cosmetic surgery in Europe, and the one with the greatest percentage of operations performed on the under-21s. Dr. Vicente del Pino Paredes, a Madrid surgeon, first reduced Pozas' stomach capacity; he followed that up by giving her a tummy tuck and a breast augmentation. Why the breasts? Because that's what Pozas wanted. And all went swimmingly; her weight has plunged from 117 kg to 60 kg, and her boyfriend has more than once been forced to deny that he's squiring a new woman. Says his remodeled girlfriend: "I have a lot more confidence now, more self-esteem."

Shapely and blond, Pozas has undoubtedly moved closer to cultural ideals of glamour. Doubtless, that will be good for her career prospects. But if the majority of young Europeans start employing cosmetic surgeons to fix perceived defects, will they begin also to eradicate their individuality and distinctive national traits?

Dr. Jean-Luc Roffé, a plastic surgeon at the Clinique St. Martin in Normandy, thinks not. "My French patients come in wanting small breasts on the cheap that nobody will notice. My American patients come in wanting big breasts that cost a lot of money that everyone will notice," he says. Wendy Lewis isn't so confident that la différence will survive. "Images of beauty are homogenizing," she says. "Brazil used to be the home of the breast reduction because they liked pert, small breasts and big bottoms. That's gone. Now they can't keep silicone implants on the shelves down there. And Korean women come to me with massive big cheekbones a Western woman would kill for that they want shaved down."

So should Europe prepare to bid adieu to Jeanne Moreau and say a big howdy to Pamela Anderson? Not necessarily. The rich, always adept at finding ways to distinguish themselves from others, are already developing a new aesthetic. When the British edition of Harper's Bazaar polled its affluent readers to find whom they considered most beautiful, the top five were all brunets. Sure, there were bombshells like Angelina Jolie, but also more cerebral choices such as Sofia Coppola and Nigella Lawson — a far cry from the Californian blonds who until recently represented the ideal. "Readers wanted beauties that look different. There was almost a reaction against the blond, perfect stereotype," says editor Lucy Yeomans. Being thin and tanned used to be a sure sign of wealth, she adds, but now simply looking different from the clones might be enough to cut a dash.

So will that make ugly the new black? Unlikely. Aesthetics may shift and new ideals take hold, but the premium Europeans place on beauty will continue to soar. It's all unfolding much as feminist author Naomi Wolf predicted 16 years ago in her book, The Beauty Myth. Women, on the cusp of economic parity with men, were being tricked into diverting their energies, said Wolf, obsessing instead about their physical imperfections. But Wolf failed to foresee that men might be ensnared by the same obsessions. Or that, in a faster, flickering, image-rich world, transforming your appearance might be the quickest route to transforming your whole life. After all, as Europeans are learning, it's what's on the outside that counts.

• CATHERINE MAYER
• For the women — and men — of all ages looking to shape up, does cosmetic surgery transform their world?