By Adriane Fugh-Berman, MD

A friend of mine was informed recently by her nine-year-old daughter, "You know, Mom, you can fix those uneven breasts of yours with plastic surgery." My friend, a physician, sat her daughter down and explained that unmatched sets were the norm, not the exception, and that these uneven breasts kept you alive as a baby, young lady, so have some respect for them.

It turned out that her daughter had been watching a vile show called "Swan." In which women have so-called "extreme" makeovers that involve extensive plastic surgery, and then use their mutilated bodies and faces to compete in a beauty contest. I haven't seen the show (and no one can make me), but my friend had. She was horrified to hear women describe their expectations of increased self-esteem, as though the procedures awaiting them were treatments for depression. And perhaps because the same teams of surgeons, hairdressers, etc. worked on all the contestants, the inevitably buxom and blond results bore an eerie resemblance not only to each other, but to Barbie.

Women have always undergone painful beauty rituals, but cosmetic surgery is a relatively recent phenomenon, and its use among the middle classes is even more recent. Plastic and reconstructive surgeons defend their specialty because some of their work involves restoring normal contours — and functions — in children with cleft palate or other congenital deformities, or people disfigured by burns, trauma or disease. But these surgeons make the most money from cosmetic procedures, which range from facelifts to new facial features. Such procedures are not covered by insurance, and thus aren't subject to price controls imposed by third-party payers. So surgeons can charge large amounts of money, be paid in advance, and avoid paperwork. For that reason, it's not just plastic surgeons who are performing cosmetic procedures. Dermatologists do dermabrasion (sanding or chemically burning a layer of skin off the face). And other physicians, including ob-gyns, are offering Botox injections, laser hair removal and other cosmetic procedures in their offices.

Here's why even those of us who can afford cosmetic procedures shouldn't have them.

·All cosmetic surgery carries risks that aren't limited to bad cosmetic outcomes. Complications of surgery include strokes, blood clots in the lung and death from reactions to anesthesia.

·What is considered attractive is culturally determined. For example, while most cosmetic breast surgeries in the United States involve increasing bust size, in France these procedures typically reduce breast size. In China, where tallness is valued, leg-lengthening surgery is becoming popular: the legs are broken and then attached to racks — I mean devices — that are painfully tightened over months to force new bone to grow where the breaks occurred. Sometimes the process results in deformity and disability. I've found that Americans are shocked by the idea of leg lengthening but are blasé about the insertion of fake breasts.

·We live in a society that encourages us to be dissatisfied with our appearance. Although many of us easily resist the idea of changing our facial features, restoring ones own youthful skin, hair or contours can be more difficult to resist.

A friend and I were looking at some photos of ourselves in our 20s and marveling at how attractive we once were. I'm sure that when we're 70, we will marvel at our 45-year-old faces and bodies! At the time, however, we measured our attractiveness against airbrushed models and came out wanting; we obsessed about acne and unruly hair and "potbellies" that would fit inside a change purse.

At a social gathering, some of my women students, all in their early 20s, were bemoaning their lost youth. These inarguably beautiful young women complained about how their appearance had nose-dived ("Now I have flabby underarms, just like my mother…"), and how they weren't as thin or strong or flexible as when they were 16. I was appalled; but it did make me remember that we didn't know how beautiful we were when we were young either.

Clearly, women's dissatisfaction with appearance is not related to age, or even beauty — nor has it changed over the years. But another thing that hasn't changed is that self-confidence and comfort in one's body have always been attractive. Conversely, bewailing one's imaginary flaws is quite unappealing. Never look at beauty magazines (no one's self-esteem can survive an hour with one), and if you don't like what you see in the mirror, stop looking or throw away the mirror.

Societal standards of what sacrifices must be made in the pursuit of beauty affect all women — and, as my friend learned first-hand — girls as well. Sexy is an attitude. So dress outrageously, flirt shamelessly, don't complain about your appearance and do tell other women that they are beautiful. Above all, those of us who are dealing with graying hair and lines on our faces should model attractiveness based on self-confidence not surgery.