America's Vainest Cities

Pride is supposed to be a deadly sin. When it comes to their looks, however, fewer Americans are seeing it that way.

That's because the advent of safe and affordable plastic surgery has persuaded even the most fearful and cash-strapped patients to go under the knife. Add to the equation celebrities who are candid about their nips and tucks and reality-TV shows that feature ugly ducklings transformed into swans, and it's clear why more and more Americans are seeking to perfect their bodies with the aid of liposuction, implants and injectable fillers.

In 2006, Americans had 11 million cosmetic surgical and noninvasive procedures, a 48% increase from 2000, according to the American Society of Plastic Surgeons. Unsurprisingly, Botox injections skyrocketed by 420% during that time, while breast augmentations and hyaluronic acid injectables, like the lip plumper Restylane, grew by only 55% and 59%, respectively.

Complete List: America's Vainest Cities

As the number of cosmetic procedures nationwide continues to surge, we looked at which cities have most embraced market demand for taut faces, lush lips and flat abs. There were predictable entries like New York, Miami and Los Angeles, but also surprising ones like Louisville, Ky., and Nashville, Tenn. Most shocking of all was the town that ranked first: Salt Lake City.

Behind The Numbers
To rank the cities, we collected the number of plastic surgeons in the country's 50 most populated cities. We excluded residents under the age of 18, leaving out a small number of children and adolescents who undergo reconstructive or cosmetic plastic surgery. While it was impossible to determine the number of reconstructive procedures as opposed to cosmetic surgeries in each city, according to the American Society of Plastic Surgeons, reconstructive procedures account for about one-third of all plastic surgery procedures.

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We obtained the number of plastic surgeons in each city from the American Society of Plastic Surgeons, a membership organization that represents about 90% of all plastic surgeons certified by the American Board of Plastic Surgery. While plastic surgeons often practice without certification from the ABPS--and therefore were excluded from our data--it is recommended that patients seek out physicians with this credential.

Next we calculated the number of surgeons per 100,000 people. Though there are at least 591 plastic surgeons in New York City, there were four per 100,000 people. Salt Lake City had only 45 surgeons but a total of six per 100,000 people. Unexpected entries like Salt Lake City, Nashville and Louisville might rise to the top, given smaller populations and medical or university programs and centers that focus on plastic surgery. An influx of younger, more affluent residents into the smaller cities may also account for the rising number of plastic surgeons.

Dr. R. Bruce Shack, professor and chairman of the department of Plastic Surgery at the Vanderbilt University Medical Center in Nashville, says the city's younger professionals are spending some of their disposable income on cosmetic procedures. He has also noticed an increase in cosmetic procedures for patients who have experienced significant weight loss or undergone bariatric surgery. When we ranked the Most Obese Cities, Nashville entered the list as the seventh heaviest.

A Brief History
Prior to the 1980s, cosmetic plastic surgery was a taboo subject. Now it is conversation material for cocktail parties. While we frequently blame a booming cosmetic surgery industry on the ubiquitous images of actors, models and socialites, we often forget the role of simple economics: cosmetic plastic surgery is a cash business.

In 2006 alone, Americans spent $11.5 billion on face-lifts, chemical peels, butt implants and other surgical and noninvasive cosmetic procedures. Patients pay fees out-of-pocket, sometimes by charging a credit card or taking out a loan, and surgeons are spared the hassle of dealing with insurance companies or other third parties. The allure of guaranteed income has drawn many surgeons, some of whom have wide-ranging specialties, to plastic surgery.

This would have been an unexpected development in the 1970s. At the time, the American Medical Association banned its members from advertising, including for plastic surgery services . The rule, implemented in the early 1900s, was an effort to professionalize medicine, lending it an authority it hadn't enjoyed before. But in 1975, the Supreme Court decided that "learned professions" like medicine were subject to antitrust laws.

As a result, the American Medical Association battled with the Federal Trade Commission, which demanded more competition between medical providers in an effort to lower mounting medical costs. By 1982, the AMA had lost the fight and could no longer forbid its members from advertising. Since then, cosmetic plastic surgery has increasingly entered into mainstream culture.

Satisfied Patients
Though comedians crack jokes about the swollen lips and frozen foreheads that result from overzealous or poorly performed cosmetic procedures and plastic surgery, most patients report being happy with the results and say they would do it again.

Dr. David Sarwer, associate professor of psychology at the Center for Human Appearance at the University of Pennsylvania School of Medicine, cites a "preponderance of evidence that patients benefit psychologically from plastic surgery," including improved self-esteem. Sarwer is also a consultant for Allergan (nyse: AGN - news - people ), a pharmaceutical and medical device company that develops Botox and breast implants, among other products.

He says a number of studies of plastic and cosmetic surgery patients have shown high satisfaction rates up to 85% to 90%. "If patients are saying they're satisfied with the results," he says, "then maybe cosmetic surgery is a good thing for people."

Plastic surgeons Dr. Michael Rose and Dr. Andrew Elkwood, who recently opened Smoothmed, a walk-in Botox boutique in Manhattan, say cosmetic surgery done safely and ethically lends patients a sense of control over aging. "Caring for your appearance is important," says Elkwood. "Trying to maintain a youthful appearance is an admirable thing."

Both surgeons have yet to trade places with their patients and undergo a cosmetic procedure, but say they'd consider it in the future and have treated family members.

The duo felt strongly about providing the public with walk-in Botox services after seeing patients at their New Jersey plastic surgery practice wait for a 10- or 15-minute procedure. At the Manhattan store, customers are served promptly. They are charged $13 per unit of Botox--the forehead requires about 20 units--and are injected by doctors trained to use Botox but board-certified in internal medicine, not plastic surgery or dermatology.

The treatments are effective for up to four months, at which point the patient needs further injections to maintain a creaseless look. More than 30 Smoothmed customers have seen the doctors about invasive procedures not available at the walk-in office. Both bristle at the description of Botox as a "gateway" treatment.

"That has a negative implication," says Elkwood. "[Botox] is often people's first foray into cosmetic therapy. It treats some of the early signs of aging. It's for people looking for a quick fix. You need to make sure their expectations are reasonable."

Changing Norms
Realistic expectations are hard to define in an age where plastic-surgery TV shows minimize post-surgery pain and suffering, and celebrities disappear for days to emerge wrinkle- and flaw-free.

Sarwer is wary when the plastic surgery patients he counsels cite "external" motivations for undergoing surgery. These might include getting a face-lift to save a failing marriage or fixing an imperfect nose to quiet a critical parent. "Internal" motivations, on the other hand, reflect a personal desire to alter one's appearance independent of the judgment or influence of others. Sarwer is more apt to recommend surgery for patients with "internal" motivations.

Regardless of the motivation, plastic surgery largely worries Deborah Sullivan, an associate professor of sociology at Arizona State University and author of Cosmetic Surgery: The Cutting Edge of Commercial Medicine in America.

"I'm really concerned that we are creating these plastic bodies," Sullivan says. "The standard of beauty that we're putting out there is not achievable without intervention. We are changing the norms about what a body should look like."

Sullivan attributes regional differences in the frequency of plastic surgery to warmer climates where the body is often on display, and to pressure to demonstrate social mobility. Cities like Miami, New York and Los Angeles have one or both of these factors. She also cites long-term trends like higher divorce rates, which force people in their 40s and 50s back into dating and greater numbers of women into joining the workforce. Both groups experience increased pressure to look attractive and perhaps face competition from younger suitors or colleagues.

Such is the case for several of Dr. Foad Nahai's patients. The Atlanta-based plastic surgeon is also president of the American Society for Aesthetic Plastic Surgery.

"We live in a youth-oriented society," he says, "and a very large number of my patients come in and say, 'I sell homes, and I can't compete with a woman in her 30s. I need to look young enough.' I've had a lot of salesmen who say they've been told they look angry or tired, so they get a brow lift."

Past studies correlating higher pay with attractiveness seem to validate the fear that an imperfect or aging visage harms one's money-making abilities.

Nahai believes advancements in medicine will eventually yield technology that allows us to not treat aging but actually prevent it at the cellular level. He predicts the plastic surgery industry will continue to grow at impressive rates as it becomes more accessible and innovative. "It's progress," he says of a future in which our bodies don't betray our ages.

Still, he's never fully imagined what that reality might be like. "If I gave it a lot of thought, it would probably concern me," Nahai says. "I haven't sat back and thought, 'Gosh, what would it be like if I showed up to work and everybody looked like they were in their 30s?' "