03/07/2009 05:12 am ET | Updated Nov 17, 2011

Dueling Docs

The Issue
Cosmetic procedures

The Facts
Everyone's doing it (except you, of course). Having their faces cut, sewn and injected so that they, too, can look as young as Jennifer Aniston ten years ago. With all the cosmetic tinkering going on - from stalwart injectables like Botox and Restylane to plastic surgery -- just finding a natural 50 year-old-face in any urban area seems a near impossibility.

Especially in today's non-existent job market where older women, not to mention men, have to compete with someone half their age to find a new job or simply hold onto their current one. But cosmetic interventions are a major expenditure compared to say, groceries, with surgery costing from $2,500 for a cheek implant to more than twice that much for a basic face lift and injectables running upwards of $500 a pop -- all rarely covered by insurance.

In the face of nose-diving portfolios and little disposable income to go around, should ridding the face of wrinkles really be a priority? For that matter, should it ever be a priority?

Two doctors on debate the issue: Dr. Philip Prioleau, dermatologist, and Dr. Cap Lesesne, plastic surgeon, both in private practice on Manhattan's Upper East Side.

The Debate

Dr. Prioleau

"I think it's fine if you want to get these things done, but there's just too much of it. With the financial crisis and less money to spend, things may change, but I see women who are on their third facelift. They come to my office looking so weird. They come in with guppy lips. And then they tell me they haven't had any surgery. It's such a strange thing: women develop these strange looks on their faces and then that's considered the norm."

Dr. Prioleau thinks women should stop focusing on their external appearance and well, get a life. "Women should feel strong and powerful about who they are. Granted, it's really tough out there for women these days. Many need to get a new job or need to hang on to their current job. But they should read a book rather than put money into cosmetic procedures. Women need to start thinking out of the box rather than doing what their peers are doing."

He continues: "Women have been trying to beautify themselves for ages. Take Cleopatra. Yes, she wore makeup, but she probably spoke 7 languages and was one of the most brilliant women who ever lived."

Dr. Prioleau can't overlook the fact that doctors stand to gain from a patient's need to look younger. "The way I look at it, Botox is a gateway drug and then patients move onto Restylane and other injectables and maybe plastic surgery after that. These drugs are perfect for doctors. They're an annuity. They don't last so patients have to keep coming back for more. "

Dr. Prioleau offers up a radical idea: "Let's put a tax on cosmetic procedures. Call it a luxury tax, like the VAT in France. If someone pays $400 for injectables - let them pay $100 in tax. If a facelift costs $30,000 then let them pay a few thousand in taxes, like they would for a Porsche. The average person can't afford a face lift. It's a luxury. Then why is it tax-free?"

He also thinks that the government -- and hence the rest of us -- wind up subsidizing cosmetic procedures because government funds help pay for medical school training. "And the minute the students are trained, they go out and inject Botox. Dermatology is one of the most sought after residencies because people can do Botox and work just two days a week. It's a waste of resources!" Dr. Prioleau suggests another tax "Maybe the medical student who goes in for cosmetic procedures should pay tax on his or her training, too."

Dr. Prioleau doesn't necessarily mind cosmetic surgery if people are aware of the risks, but he still wonders if a surgical candidate shouldn't "talk to a therapist before submitting to surgery. I worry that if at the outset, a woman doesn't have body dysmorphic disorder (a psychiatric problem where a minor body defect becomes a major preoccupation), she may develop it as she gets deeper and deeper into doing these things. I really think women should be getting a psychological evaluation before having these things done."

Dr. Cap Lesesne

"I would strongly disagree. I don't think women need to be evaluated by a psychiatrist to have a face life. These women aren't crazy. The people I see usually have something that concerns them about their appearance and they want to do something about it. It's not the psychiatrist who's doing the surgery -- it's the surgeon and under every state law, the surgeon is responsible for the patient, not a consultant. Tell me, should every psychiatrist patient see a plastic surgeon first?

Dr. Lesesne, who turns down about 5% of the patients who come to him, emphasizes that a plastic surgeon has the tools to assess who's right for surgery. Besides the obvious physical risks, like uncontrolled high blood pressure and diabetes which can make someone a poor candidate for surgery, Dr. Lesesne says: "You kind of know if someone is not in the right psychological condition for plastic surgery. They don't appreciate the risk of complications, they don't understand informed consent and they simply have unrealistic expectations of what surgery can fix and not fix, something you can assess quickly." He adds: "It's perfectly legal to just say no to a patient."

As for considering cosmetic procedures a luxury and taxing them? "That's rubbish," says Dr. Lesesne. "Then add extra tax on all expensive women's handbags and on all expensive restaurants.

"For a lot of people, particularly now, having plastic surgery or Botox is not a luxury. It's a necessity. A lot of people are out of a job and they need the work. It's a competitive world out there now.

"If you have a physical issue, you can read a book until you're blue in the face. Meantime, you're getting older and younger people are taking your job. You're reading your book to feel better about yourself? Good luck."

He continues: "Somewhere on that bell curve between narcissism and self denial, there's normality. My patients are mostly normal. As long as you look at these procedures as taking away a wrinkle and not changing your life and you've rationalized the risk, then you should go ahead and do it."

"I'll tell you, the biggest form of narcissism is not on the Upper East Side of Manhattan. It's on Pennsylvania Avenue because they think they have superior intelligence and the right to control other people's lives. Someone who wants to fix their face is just thinking about themselves, they're not imposing it on anyone else."