She was not quite forty, with striking features and the figure of an even younger woman, and this was her first face lift. Now that the skin had been trimmed around her ears and fastened back in place with rows of nylon sutures and gleaming stainless steel staples, she had started to worry about the mole on her nose. Jim Gilmore, however, didn’t think this was the time to remove it. “Let’s set our priorities,” he suggested gently, “We’ve still got to do your forehead.”

Gilmore parted her hair in a continuous line running from ear to ear right across the top of her head, and then he tied up the strands of long blonde hair into two rows of neat little bundles on either side of the part. He took the scalpel and cut swiftly along the path he had created through her hair, and after a few snips with large surgical scissors the quarter-inch-thick layer of scalp parted to reveal a glistening wedge of the membrane that covers the skull. Blood began oozing from the severed vessels in the scalp, and as Gilmore went across the dome of the head with the electrocautery the veins hissed and sizzled and were sealed off. Then the pace of the operation accelerated suddenly, almost violently.

Moving very quickly, Gilmore stuck first one and then two fingers into the incision and began to pull the scalp away from the forehead, making a sound quite similar to a Velcro fastener being torn apart. Within seconds he had worked his fingers down several inches below the patient’s hairline, and then cut with scissors to a point just above her eyebrows, so that a third of her face just flopped away from the skull like some realistic Halloween mask that could be ripped off, discarded, and replaced. The patient looked up at the ceiling, then down toward the purple canvas espadrilles on her feet. “I don’t know when I’ve been more relaxed,” she said dreamily.

That thin, extremely pliable layer of flesh and gristle that covers our skulls can indeed be as shockingly superficial and impermanent as it appears to be during a so-called forehead lift. But for many of us, like the blonde woman, who was put back together the way she wanted, it is becoming increasingly difficult to separate the well-being of the outer mask from our inner well-being, and that is probably why cosmetic plastic surgery is becoming one of medicine’s major growth industries. And like most medical booms, it echoes rather faithfully the tenor of the times. During the fifties and sixties, for example, we plunged so rapidly into affluence and abundance that we ended up glorifying our heart surgeons and enriching our psychiatrists. During the seventies we kept track of aerobic points, took megavitamins, and self-motivated our way towards physical and mental health, and podiatrists and diet doctors started gaining respectability and making money. With the eighties has come the need for icing on the self-improvement cake, as well as a material edge in a world where competition, both economic and social, has suddenly become much more intense. The eighties are going to be the decade of the nose job and the face lift.

The considerable skills of Jim Gilmore, M.D., board-certified otolaryngologist, fellow of the American College of Surgeons and the American Academy of Facial Plastic and Reconstructive Surgery, and a rising star in the firmament of cosmetic surgery, are generally dedicated to making average-looking people look good, good-looking people look better, and beautiful people look nearly perfect. It is a job that he pursues with the sincere commitment and intelligence of a DNA researcher trying to unlock the secrets of life, even though it is a job that is still largely scorned by much of the rest of the medical community. But at a time when a new face can cost thousands of dollars less than a Japanese subcompact, the rich dowagers and aging screen idols who once endured torment and seclusion in their pursuit of eternal youth have been replaced by hundreds of thousands of ordinary middle-class people for whom new, relatively painless, and rapidly healing procedures have made refurbishing the face a more realistic goal than re-decorating a living room. These are the new believers, the ones who know that good looks can contribute to their good works, and their belief leads them to the operating table like pilgrims to a shrine. Like all pilgrims, each has a tale of his or her journey—tales of love and money, success and failure, life and death. And like all pilgrims, they nurture a hope for renewal at the end of their journey.

“Is it Foolish to Have This Done?”

The lady from Minnesota was spending the summer with her niece in Lewisville, and she had come to see Jim Gilmore in his new offices at Concorde on the Creek in North Dallas. Dr. Gilmore had decided to move from his office in Promenade Center in Richardson, which he shared with several other doctors, for several reasons. For one thing, he had his own ideas about cosmetic surgery, about the aesthetics of the face and what it should look like after surgery, and he didn’t want to be associated with doctors who didn’t share his concerns. For another thing, he wanted a comfortable, living room type of atmosphere instead of the clinical environment he had at the old place. So he hired an agent to find an office that he could rent or an office condominium or perhaps even an entire building that he could buy. He also hired someone to go through his files and make a map that would show where his patients were coming from. As it turned out, about one third were from Highland Park, one third from Richardson, North Dallas, and Plano (the triad of affluent northern suburbs), and one third from out of state. Finally Jim decided on a location right at the LBJ Freeway and Hillcrest Road, where a whole cluster of low, gleaming glass office complexes and concrete-covered parking areas had appeared almost overnight. The building in which he would rent space was one of the least futuristic of the half-dozen in the vicinity, its facade softened by liberal expanses of burnished brick surrounding the black reflective windowpanes.

Gilmore and his four full-time and three part-time staffers made the move to the new office in one weekend and never missed seeing a patient. By the first week in August Jim was on his own, and he had his own new image. He had the latest, highest-quality equipment in his operating room; sumptuous, tastefully upholstered sofas in his reception area and consultation rooms; a new logo for his cards and announcements; and even a little room with a specially designed basin where patients could have the blood and goo washed out of their hair after an operation. The fact that the oriental rug and Ming vase for the reception area had not yet arrived, and neither had the art for the walls, did not seem to bother the lady from Minnesota at all. She very desperately wanted Jim Gilmore to do her face, which put her a step ahead of most patients at this stage.

Ordinarily, when patients come to Gilmore for their first visit, or consultation, they are surgeon-shopping, and since their health or life is not in direct peril—and since they aren’t obligated to pay for the consultation—they can afford to be finicky. Often a patient will mention something he or she didn’t like about a previous doctor, like the woman who became disenchanted with one highly reputable surgeon because he kept glancing at his watch during her visit. A surgeon is undergoing a subtle and often psychologically penetrating sort of trial during this first visit. But at the same time he must consider the patient’s suitability for surgery, because a dissatisfied patient is nothing less than a walking, talking billboard that says Dr. So-and-so doesn’t do good work. And that was what worried Jim about the lady from Minnesota.

She was the first in the day’s round of consultations, so Gilmore, in a brief break following the morning’s surgery, had had a moment to review his game plan. His concept was simple, but the execution would be difficult. He had to get her to talk about her weight. He pulled her chart out of the Plexiglas holder mounted on the wall, entered the second of the two small consultation rooms, and pulled the sliding wood-panel door closed behind him.

The lady from Minnesota and her niece were sitting in armchairs on either side of a small round table covered with a bone-colored linen tablecloth. The niece was middle-aged, trim, and well groomed and wore black trousers and lots of gold and diamonds on her wrists and fingers. Auntie, as she called the aged lady from Minnesota, was also wearing slacks and lots of jewelry, as well as a billowing floral blouse that could not conceal the fact that she was very large indeed. Gilmore, still in his blue surgical scrub suit, came in and sat on the end of the sofa, close enough to reach out and touch the lady from Minnesota. He pulled several black and white photographs from her file, warned her that they were excessively sharp and made her look worse than she really does, and pointed out the great folds of skin that were encircling her eyes. “Let’s decide on our priorities,” said Jim, almost as if he were prompting a child to choose any two candies in the box, but only two. “What do you want?”

“I want to look good,” fumbled Auntie, seemingly taken aback by his solicitation of her amateur opinion. Then, recovering, she began talking about the ponderous sagging of skin just beneath her eyebrows. “Why don’t you take off your glasses so that we can see?” suggested Jim politely. She removed the glasses—enormous structures of black and gold—and her eyes appeared as two slits amid bulging blue-purple expanses of eye-shadowed flesh. Her face began to twitch like some ultrasensitive night-dwelling organism that had suddenly been exposed to daylight. Gilmore reached forward and started drawing his fingers across the skin at the corner of her eyes as carefully as if he were placing decorations on top of an elaborately frosted cake. He moved down to the cheeks and neck and pulled at the jowls and folds with the same delicacy. His fingers confirmed what he already knew to be the case: there was too much fat under the skin for her to have successful surgery. Not only would the surplus fat prove a poor sculptural material for the “contouring of the face” but the fatty tissue would promote bleeding, prolong the operation to untenable lengths, and cause the skin to sag back into its original position rapidly.

Auntie provided Gilmore with his opening. “Is it foolish to have this done at eighty?” she asked rather hopefully.

“It would be foolish if you can’t get your weight down,” replied Gilmore.

That soured things immediately. “I can’t lose weight,” mumbled Auntie stubbornly.

“She loses inches, not weight,” offered her niece. And with that, the battle was joined.

Gilmore began to suggest formulas for weight loss. Walking. Reduced caloric intake under medical supervision. Weight Watchers. He hammered away at the theme like a diet doctor promoting his latest book on a talk show. Gradually he drew the women into his discussion of weight loss, and gradually the niece began to offer evidence that Auntie perhaps could reduce her intake of food and beer. But the real turning point was when Jim suggested a physician to supervise her weight loss program. “Yes, he’s the one who does the stapling-off of the stomach,” said the niece happily. “My daughter-in-law had that done.” The ladies agreed to set up an appointment with this physician, perhaps hopeful that some internal surgical magic could pave the way for the external transformation. It was agreed that Auntie could return for her eyelid lift when she had lost ten pounds, and that her face could be done when she had lost another ten.

“You’re not mad at me?” asked Gilmore, with what seemed to be genuine contrition.

“I’m not mad at you,” said the lady from Minnesota.

Looking, Then Leaping

There is something deeply rooted, almost primal, that is aroused in someone when he goes into a doctor’s office and decides to change whatever God, nature, or personal fate gave him in the way of looks. Yet most cosmetic surgery patients are not obsessively introspective or guilt-ridden individuals. They tend to be positive, success-oriented people who are comfortable with material reward, and they have a determined faith in their ability to shape their world. But when they come into the realm of the magic knife that can alter even the person who looks back at them in the mirror every morning, all sorts of strange things start coming to the surface.

No one has ever done any kind of documented study of the self-image changes that patients go through before and after cosmetic surgery, although such an analysis would be invaluable to surgeons in the field. As it is, each surgeon must proceed on the basis of experience and intuition in order to handle a crucial aspect of his practice. Gilmore tries to ease the emotional turmoil from the minute the patient walks into his waiting room, relying on the living room ambience and a friendly staff who he says “have good vibes for people” to put the prospective patient at ease. When he sees the patient he tries to demystify his own prowess, stressing the limits of cosmetic surgery and making conservative forecasts of the expected result. He makes sure that the patients realize that they are not going to get a different face or become a different person. He also establishes a sense of security and conveys concern with his touch, which many patients describe as unusually sensitive and gentle, softer than anything they have ever felt before. And once he has established a sort of bond with the patient, he starts reading back information from him. He thinks that he has a sort of sixth sense, a “shining,” when it comes to reading people. Sometimes he doesn’t like what he sees. “If I get negative vibes from a patient,” he says, “then I try to back off from the surgery.”

Muriel Hughes, however, was what Dr. Gilmore likes to call an excellent candidate for surgery. She had been into middle age for a while, but she was tall, slender, and active. Her divorce had occurred seven years ago. “It was an ugly marriage,” she didn’t mind saying. “I knew that I’d made a mistake two weeks after I got married.” She had been supporting herself for thirteen years as a realtor and now had her own commercial real estate firm, so she wasn’t one of those problem patients going through a divorce and trying to stick her husband with a face lift bill before the settlement could become final. A hardworking—“People say I have only one speed,” she said, “and it’s not fast. It’s overdrive”—wisecracking, likable woman, Muriel was not the type to be neurotic about her looks. But there was this cruise coming up—her first vacation in some time—and Muriel all of a sudden got to thinking that she wanted to look better than her best. She didn’t know Jim Gilmore at the time, but she did know Sara Munroe, who was an old family friend.

Sara’s position in Jim’s office is unique. She is a patient relations specialist, and everyone who wants to see Dr. Gilmore has to talk to Sara first. She tells the patients what they can expect from surgery and how much they will have to pay for it. When they come in for the first time, she takes their “before” pictures, which Gilmore will use to plan his surgery, and then escorts them back to her nicely appointed office and discusses the surgery, tells them about insurance and financing alternatives, and maybe even gets into a little talk about postoperative makeup. Since all cosmetic surgery is cash in advance, Sara also has to tactfully collect at the last preoperative consultation. She calls the patients the night before surgery to reassure them, and with those intent on concealing their surgery from their spouses or families, she will make a special note not to mention “Dr. Gilmore’s office.” Sara also makes sure that all patients get cards on Christmas and their birthdays.

An elegantly attenuate, pretty woman with college-age daughters, Sara Munroe was a University Park housewife and a friend of Jim Gilmore’s before she came to work for him two years ago. She has a natural, ebullient rapport with most patients, and because of that they confide a great deal in her. Sara has heard enough to attribute the rise of both male and female interest in cosmetic surgery to that essential characteristic of the American system—competition. To middle-aged women suddenly thrust into single life by divorce, or perhaps just worried about all the young, pretty women their husbands work around every day, the surgery offers a better chance of competing. For the men—30 per cent of Gilmore’s patients—a younger, healthier look shows that they can still keep pace with the young bucks in their firm. And nobody wants to merge with a guy whose eyes are so puffy that they are almost closed.

Sara’s insights are perhaps sharpened by the fact that she, too, is a believer. Jim has done her nose, chin, and face, and Sara wants her youngest daughter to have a chin implant as soon as she gets her braces off. Sara feels that the attention she devotes to her appearance is a form of self-discipline that promotes excellence in other areas of her life and that a face lift is simply an ego boost that creates an easily transferable feeling of achievement. “It’s all totally inward,” she says. “It’s a sense of self-confidence that says, ‘I can do anything I want to do better.’ But you’re still exactly the same person.” And of course, she is always glad to let patients examine her, as living proof that the scars don’t show.

So when Muriel Hughes called, she talked to Sara for some time about her divorce, her business, and the cruise and then made an appointment for that afternoon. By the time she arrived, Gilmore had already performed and eyelid lift on a business executive, given injections of collagen—a new compound made from cowhide that can be injected under the skin to plump out lines and depressions—to a male model with acne scars and a forty-year-old woman with wrinkles at the corners of her mouth, seen a half-dozen pre-op and post-op patients, and examined one man with a growth in his nose that needed to be biopsied. Then he went into the consultation room where Muriel was waiting. “Well,” he begun casually, “what’s on your mind?”

“I’m running scared,” said Muriel only slightly facetiously. “I brought my daughter in for moral support.” Lyn Lowery, an attractive, fashionable woman in her mid-thirties, sat on the sofa across from Muriel. “You know,” said Muriel, again half seriously, half in jest, “I’d like to turn into a beautiful thing overnight with no pain.” At that Gilmore, sitting in the armchair on the other side of the table from her, pulled his chair up and began to touch her skin very softly.

As Jim examined her, Muriel began to describe her own face as if she were appraising a not-so-choice piece of real estate. Her nose, she said, was ugly. Her jowls were too pronounced. Her upper lip was wrinkled, as was her forehead. Her mirthful demeanor had crinkled the corners of her eyes. Worst of all, her eyelids—which were at the moment behind two enormous designer-frame-mounted lenses that served more to magnify them than to conceal them­—had the characteristic hooding and sagging of old age. “I guess you’d just like to tear me up and start all over from scratch?” she drawled rhetorically.

With that Gilmore pulled his chair even closer and looked her in the eye. “Is it important to you at this time in life?” he asked. “If it isn’t, don’t do it.”

It was obviously important enough for a protracted discussion of procedures by Jim, Muriel, and Lyn, who was coaching her mother the way Tom Landry handles the Dallas Cowboys. What the women were discussing was essentially a collection of products—face lift, eyelid lift, brow lift, forehead lift, nose job—that could be purchased singly or in any combination. And what principally concerned them about those products was how good they were. How long would they last? Would a chemical peel—one solution to the minor wrinkles above the lips and at the corners of the eyes—be too painful? Would Muriel be away from her business for too long? Could there be damage to the facial nerves? And most important, would the scars be visible? Addressing his remarks to both women, Jim went down their shopping list point by painstaking point.

Finally Muriel seemed to come to a conclusion on at least the quantity of her order, should she decide to make it. “It’s just like making repairs to a house,” she said with the laconic self-confidence of a head of state who might know nothing of the complex technical subtleties of an issue but who will nevertheless make the right decision due to some unerring leadership instinct. “If you just do a partial job, it doesn’t do any good. You might as well not do it at all.” That meant that she would go for the eyes, forehead, and face, and if she liked the results she might come back for a go at the nose. But she still wasn’t sure about the quality. “How long have you been doing this?” she asked. And the matter of the scars still bothered her.

Just when it seemed that the dialogue would never get anywhere, Gilmore suggested that they set a date—about two weeks away—for surgery; Muriel, like every patient, could retain the option of backing out until the second the knife went to work. This proved to be a satisfactory compromise. Muriel could contemplate and question at her leisure, but should she decide to go through with the operation, she wouldn’t have wasted her valuable time. And while she was at Gilmore’s office, she might as well let Sara take her pictures. When Sara came into the room, both Lyn and Muriel took a look at her face and rubbed their fingers along the junctions between her ears and her face. All three women seemed to glow at the touch, and at that moment it seemed that some of the belief passed like a current between them. They went off to have the pictures taken and then back to Sara’s office to formalize the dates and the fees.

Broad Palms, Long Fingers

Jim Gilmore was born outside Lufkin in 1937, a third-generation Texan. His father had grown up on a farm, never earned a college degree, and moved from job to job with regularity. An intelligent man, skilled with his hands, he simply never seemed to be satisfied with anything, so he worked variously as a printer, florist, banker, and oilman. One thing he made clear to Jim was that if a man really wanted to be successful, he needed a vocation or profession he could stick with.

There were forty students in Jim’s graduating class at Grapeland High School, and more than a few of them—Jim included—had their lives indelibly marked by Mrs. Lorena Schoultz, their speech teacher. Mrs. Schoultz taught her small-town students that there were no limits to the human mind and that with sufficient will and effort anything was possible. She inculcated in Jim a passion to excel and a tenacity in pursuit of his goals. But at the time Jim wasn’t sure what he wanted to excel in. He knew that he didn’t want to spend the rest of his life in a small town, but he still had small-town ideas of what constituted an honorable profession. He thought he would like to be an engineer or a military officer.

After spending his freshman year studying chemical engineering at Texas A&M, Gilmore lost his appointment to West Point when he flunked the physical because of an old football injury. He had soured on the military routine at A&M anyway, so he transferred to Stephen F. Austin College in Nacogdoches and entered the pre-med program. He finished the next three years’ worth of work in two, reasoning that since he was paying for it he might as well get it done as quickly as possible. He worked on road gangs, in the oil fields, in the labs, and as a teaching assistant to pay his tuition and living expenses. And by the end of his second year he had gotten pretty well locked into the pre-med program. He wasn’t sure what medicine would be like, but it sounded like an honorable profession.

Jim worked his way through Southwestern Medical School as well, primarily by assisting in surgery, and while doing that he learned a very important thing about himself. His big, broad-palmed hands with the long, sensitive fingers, the kind of hands that looked like they could handle a plow or palm a basketball or play a piano with equal facility, were very, very dexterous in the operating room. Jim Gilmore could do things in surgery much faster and with greater precision than just about anyone else.

But when he graduated from medical school in 1962 he experienced a definite sense of depression. The goal he had worked so hard for was behind him, but he couldn’t be sure that he was doing exactly what he was meant to do. He assumed, however, that he wanted to be a general surgeon, and when he went into the military in 1963 he became a surgeon in the Strategic Air Command at Grand Forks, North Dakota. His case load was varied, but what really began to interest him was reconstructive, plastic, and cosmetic surgery. He even did a few noses. And when he came back to Parkland Hospital in Dallas for his residency in general surgery, he began to focus on reconstructive surgery of the head and neck. When he finished up, he was a certified otolaryngologist—or ear, nose, and throat man.

Gilmore hung out his shingle as a private otolaryngologist and set himself up in his own office, although a little later he had to go in with a group of doctors to cut his overhead. He did lots of reconstructive work and general surgery on cancer and trauma patients, but he also started doing a good bit of purely cosmetic work. Gradually the cosmetic surgery began to involve him more and more—he liked having an aesthetic aspect to his surgery—and by the mid-seventies he reached the point where his work was about half cosmetic.

Gilmore’s evolution wasn’t unusual. He was just one of thousands of ophthalmologists, dermatologists, general surgeons, dental surgeons, and ear, nose, and throat specialists who were being lured by the burgeoning demand for cosmetic and plastic surgery. Their crossing of professional lines was facilitated by the Federal Trade Commission, which in 1978 took a somewhat controversial “if you can do it, you can advertise it” position against anti-competitive practices in Yellow Pages listings. What this mean was that, for example, a dermatologist who performed scalp transplants or other cosmetic surgical procedures could bill himself as a plastic surgeon in the Yellow Pages without board certification as a plastic surgeon. The only thing that he had to exhibit was an ability to do the surgery itself.

This didn’t sit well with the board-certified plastic surgeons. Each of them had earned his board certification—just as Jim had earned his otolaryngology—by completing a residency or training program in plastic surgery that met the standards of the academicians who constituted the national board. What this meant (and still does) was that as far as board certification goes, a doctor was pretty much restricted to the specialty in which he had done his residency. So while an oral surgeon might do the best jaw resectioning in the business, he could never be a board-certified plastic surgeon. Under the FTC ruling, however, the consumer wouldn’t have to know the difference.

The board-certified plastic surgeons and the converts have formed competing factions. The American Society of Plastic and Reconstructive Surgeons represents the board-certified doctors, and the American Academy of Facial Plastic and Reconstructive Surgery is largely drawn from the ranks of maverick otolaryngologists, with representatives from other specialties. Along with the converts has come the tendency of plastic surgeons to specialize in certain regions of the body or even certain features. Gilmore specializes in the head and neck, and he feels that his background in otolaryngology has given him more familiarity with the anatomy of those areas than a plastic surgeon would ordinarily acquire in his training. On the other hand, he also feels that he could learn something from even more narrowly focused specialists. He thinks, for example, that ophthalmologists should be able to do the best—and safest—eyelid surgery. “I welcome the chance to learn from these people,” he says. “And I think that the competition is driving the quality up.”

Today Jim Gilmore lists himself as both plastic surgeon and otolaryngologist in the Yellow Pages, but his practice is almost entirely limited to cosmetic facial surgery.

“We Need to Get Away From the New York Nose”

The operating room in Gilmore’s offices has $50,000 worth of the latest surgical equipment, including a complete emergency unit with a cardiac defibrillator. In the middle of the room is a padded, contoured recliner that can be stretched out full length or adjusted to various angles and heights in order to bring the upper body and head into the right position. Gilmore prefers to operate in his office with a local anesthetic because the work goes faster and the patients don’t bleed as much as they would under a general anesthetic; both are factors that lessen swelling and speed recovery. And a rapid recovery was definitely important to this morning’s patient.

She was a fashion model, and although she was still an ingenue—her picture had just come out in Seventeen magazine—she was savvy enough to know that her nose just wasn’t right. It was a smidgen too long, and instead of plunging straight to the tip, or perhaps even displaying a hint of graceful concavity, the profile was marred by a slight hump. “People tell me that I have such pretty skin I should do face modeling,” she explained. “But I can’t do it with my nose.” What she needed was a few subtle alterations, and then she needed to get back to work. “Maybe I’ll go to New York and become famous,” she said as she waited for the knife.

The nose job, or rhinoplasty, as it is known to surgeons, is the speediest and most economical of all cosmetic surgical procedures from the patient’s point of view. The average surgeon’s fee is $1500 to $2000. When done in a doctor’s office, the operation is no more expensive than a ski trip or five days in Cancún. It takes about 45 minutes to an hour; it requires a small, superficial protective cast that comes off in a week; and although it is usually about a year before what is referred to as the final result is visible to the expert eye, from a layman’s point of view all of the swelling and bruising vanishes within about two weeks. But for the surgeon, rhinoplasty is an invitation to disaster.

Cosmetic surgeons rarely reach unanimity on a technical issue, but one thing they invariably agree upon is that rhinoplasty is by far the most difficult procedure to perform and, they will admit, the easiest to botch. “Noses,” says Gilmore, “are unforgiving. This is where we separate the men from the boys.” This is also where he feels he does his best work. Because he thinks it is a challenge equal to his skills, the perfect nose job is Jim Gilmore’s obsession.

The model was already in the twilight zone induced by Valium and intravenous Sublimaze—rhinoplasty patients are generally taken deeper than face lift patients because of the sensitive nerves in the nose—when Gilmore stuffed her nostrils with cotton soaked in a cocaine solution. Then he took a large syringe full of Xylocaine—the local anesthetic—and began injecting up, down, and inside the nose. Wearing a blue fiber-optic light on his head, Gilmore pulled the right nostril open with a small retractor and with the scalpel in his other hand made a quarter-inch long, curving incision on the inside of the nostril. The model’s feet twitched and a single tear ran down her cheek, but she remained calm. Then Gilmore inserted a small pair of scissors into the incision and created a narrow tunnel along the length of her nose between the skin and the underlying bone and cartilage. At this point the model mentioned that Eileen Ford of New York’s Ford agency was going to be in town and she wondered if she might be able to see her today. And at this point all that stood between her and the perfect nose were a few millimeters of bone and cartilage, a surgeon’s judgment, and any one of a number of things that could go wrong.

For a structure that is primarily an air conditioning, humidifying, and filtration duct for the air that enters the body (smelling is really a secondary function), the nose is fairly complicated. At the top the nasal bones give the nose its definition by coming together above the septum (the cartilage that partitions the nostrils) to form a sort of tent shape. The lower two thirds of the nose is shaped by a set of cartilages that allow the nose a convenient flexibility and resistance to impact. In addition to the septum, there are the paired upper lateral cartilages, which slightly overlap the nasal bones, and the paired lower lateral or alar cartilages, which slightly overlap the upper lateral cartilages. The alar cartilages have a graceful U-shape, and they extend from the outer rim of the nostrils, next to the face, to the tip of the nose and then loop around under the septum to give firmness to the columella, the bridge of flesh that divides the nostrils at the very bottom of the nose. The alar cartilages are where the surgeon has to start worrying.

When Jim Gilmore sees nose jobs by other surgeons he is frequently critical. “We need to get away from the ‘New York nose,’ the mass production nose,” he says. “We need to strive for the aesthetic nose.” Gilmore believes that the nose and the rest of the face are a sort of ecological system and that any changes have to be in harmony with the whole. You can’t put the same perfect nose on everybody’s face. So what Jim had done with the model, as he does with every patient, was to study her face very carefully. He watched her as she talked and moved around. He studied her pictures on slides and Polaroid prints taken from the slides. He studied the pictures in her modeling portfolio. And then he decided how to sculpture her nose so that it would be the perfect nose for her face, and for what she wanted to do with that face. And that would all begin with the alar cartilages.

Inserting a pair of scissors into the incision, Gilmore snipped through the skin enveloping the right alar cartilage. He probed the incision with tweezers and found the upper edge of the alar cartilage (where it abuts the upper lateral cartilage), then pulled the cartilage over and out of the incision so that it was exposed and inverted. Then he repeated the procedure in the left nostril. Through experience he had learned to think of the alar cartilages as a sort of tripod, with the two wings under the columella forming one leg and the two wings running to the face on each side of the nose forming the other two legs. If he shortened the two side legs by clipping off a section from the surgically exposed top of each cartilage, then the tip of the nose would shorten and move up toward the upper lateral cartilages just like a camera tripod with sections of two of its legs suddenly collapsed. The only problems were figuring out just how much to shorten those two legs and making sure to shorten each exactly the same amount.

Cosmetic surgery texts are full of gruesome pictures of nose jobs that have been bungled by “inexpert” handling of the alar cartilages; secondary repair, the undoing of botched nose jobs, is a common enough procedure to have entered the medical vernacular. In severe cases the nose can crinkle up like a piece of aluminum foil, a condition that is substantially irreparable. More commonly, the tip can end up uneven, with unsightly bumps caused by scar tissue, or simply too upturned— the “bobbed nose” of lore and legend. Gilmore, however, was confident that he could avoid disaster; the only thought that nagged him was whether this would be the best he was capable of, the best of all possible noses for this patient. The decisive moment upon him, he took his small surgical scissors and snipped off a triangular portion of each cartilage—about seven or eight millimeters on a side—then let them spring back into the incisions. Allowing for the tendency of the columella to swell under local anesthetic, he judged the angle and height of the tip to be correct. Now he had to make sure that everything that followed would harmonize with what he had done to the tip. And from here on out he would be working almost entirely by touch.

The next step was getting rid of the hump. Working inside the tunnel he had already created between the nasal bones and the skin, Gilmore inserted a saw that looked like a miniature table knife with serrated edges. Pulling the saw vigorously toward himself several times, Gilmore cut a series of grooves in the nasal bones. Then he inserted a similar tool that had a flat, toothed surface for rasping the bone. Drawing the rasp out every couple of strokes so that the blood and bone fragments could be washed off, Gilmore brought down the hump. That done, he used a scalpel to shave the upper lateral cartilage until it once again merged with the bone in a continuous slope. The only problem that remained was the width of the nose, which now had to be adjusted to the new profile.

This time a long, thin, spikelike chisel called an osteotome went up the tunnel along the nose. Gilmore held it tightly against the base of the nasal bone while Betty McFarling, the scrub nurse, gave it two sharp raps with a big stainless steel mallet. The osteotome was moved up twice, and each time the two blows were administered. The procedure was repeated on the other side of the nose. After removing the osteotome, Jim took the nose firmly between his thumb and forefinger and began to twist it very slightly from side to side. After fifteen or twenty seconds there was a muffled click like the sound of a wet Popsicle stick breaking. This sound signified that the nasal bones, already ringed with a line of fine cracks made by the osteotome, had broken loose from the face. Once again applying pressure with his thumb and forefinger, Gilmore squeezed the nasal bones together like an accordion or a bellows, and found just the width he was looking for.

In what he calls the fine tuning, Gilmore rubbed saline solution on the nose to help him feel any imperfections in the contours. He made a few minor adjustments with the rasp and knife, removing still more tiny fragments of bone and cartilage. Then he sutured the incisions, used a suction device to remove the blood from the back of the model’s nose, stuffed her nostrils with self-dissolving oxidized cotton, and put a small plaster patch on top of her nose. The operation had taken him 45 minutes; it would have taken a novice three hours.

“Do you think I can see Eileen Ford tomorrow?” asked the model.

“I don’t think that would be a good idea,” counseled Gilmore. “Remember that when you first meet people, they form their image of you.”

“You’re My Advertisement”

In the two weeks since her first consultation with Jim Gilmore, Muriel had been doing some research. She had talked to all the people she could think of who had had cosmetic surgery, quizzing them on the quality of their results as well as any complications they may have had. She had talked with five other doctors, inquiring about their fees and recommended procedures. She had read articles in books and magazines. She had communicated frequently with Sara Munroe. She had even intended to cancel her surgery once, because she was working on a multimillion-dollar deal and needed to be on the West Coast, but at the last minute she decided that she could send an associate. Now her surgery was once again scheduled for tomorrow morning, and she was very, very worried.

First and foremost, Muriel was worried about nerve damage. She had called Kim Dawson—whom she didn’t know—of the Kim Dawson talent agency, because she had been worked on by Gilmore and a couple of other surgeons. Dawson had told Muriel that she might expect the same kind of occasional numbness that she had experienced for a couple of months after surgery, and Muriel had naturally been alarmed by that report. “This is not no-risk surgery,” she concluded. She was worried that she wouldn’t be able to get out in the sun during her cruise. She was worried that the collagen injections planned to smooth out her upper lip and the corners of her eyes were still in the experimental stage. She was concerned about the location of her scars. She was concerned that Gilmore’s anesthetist was a nurse rather than an anesthesiologist with an M.D. Worst of all, she was worried about Jim Gilmore’s competence. She had a stack of old Yellow Pages at her office, and she had checked up on Gilmore’s listings. What she had found really agitated her. Gilmore had been listed under “Plastic Surgery” for only two years. “He’s an ear, nose, and throat guy who recently specialized,” she explained. “I like him personally, but I don’t think he has the experience some of the others do. And when you’re paying top dollar, you want the best.”

Jim was late for his final pre-op consultation with Muriel Hughes. A businessman in Gilmore’s office complex had thought he was having a heart attack, so the doctor had rushed to the man’s aid with his cardiac defibrillator and EKG monitor. The interruption had put him a half-hour behind schedule for the afternoon, and by now Muriel was loaded for bear. Impeccable in his light gray suit, light blue shirt, blue and gray tie flecked with red, and gold-rimmed glasses, Jim entered the consultation room where he had previously met with Muriel and shook hands with Muriel and Lyn, who was once again advising her mother. “This scares the devil out of me,” said Muriel right off the bat.

“I think we need to talk about that,” said Jim smoothly.

First Muriel discussed the problem of her cruise, which was about seven weeks away, and Gilmore assured her that there would be no restrictions on her activities. Then she got down to the real bugaboo. “I’d feel awfully foolish if I ended up with some kind of lingering nerve damage,” she said. But just then one of Dr. Gilmore’s assistants knocked on the sliding wood-panel door and reported that the stricken businessman, a CPA, had had chest pains, not a heart attack. The reporting of this incident sidetracked the issue of nerve damage, which allowed Gilmore to begin at his intended beginning. He switched on the slide projector that sat on the round linen-covered table. The projector had a built-in screen, so that when Muriel’s face came on in full color, it look like she was on TV. “That looks like the morning after the night before,” said Muriel.

Jim ran through the various views of her face and then went back to the eyes and stopped. A ten-minute discussion of various alternatives—eyelid lift with brow lift, eyelid lift with forehead lift, eyelid lift with collagen and chemical peel—ensued. “We don’t want to do too much at one time,” warned Gilmore. Finally it was decided to do the upper and lower lids, forgo the forehead lift, and attack the crow’s-feet with collagen.

“How safe is collagen?” wondered Muriel.

“The FDA has studied it for five years,” Gilmore said. “The worst that can happen is an allergic reaction. That’s why we give you a skin test before we start treatment.”

“What about cancer?”

“They’ve run those tests, too.”

“Shouldn’t that be over a period of twenty years?” suggested Lyn.

“They told us silicone was safe once, too,” Muriel added.

Jim explained that silicone is the basis for almost every prosthesis or artificial device that can be implanted in the body. The only problems with silicone arise when it is injected by amateur or inexpert physicians using it indiscriminately to build up breasts or fill out facial depressions. “The problems don’t come from the substance,” he concluded, “but with its usage.”

“Well, what is collagen?” rejoined Muriel.

“It’s a solution made from cowhide.” With this Muriel gave a startled look and then dropped the subject of collagen as if mollified by this frank disclosure of its constitution.

The eyes decided, Jim went to a profile view. With a purple felt-tip marker, he began to draw lines on Muriel’s projected face. Three arrows moving across the cheek toward the ear represented the direction of the lift, while lines around the ears showed the placement of the incisions. Gilmore also pointed out that although the lines at the corner of Muriel’s mouth would become less pronounced, they would not be eradicated. “I want to give you a realistic picture of your result,” said Gilmore.

“Yes, that’s what we like about you,” Lyn said.

Next, Jim explained how he would pull up the sagging muscles in Muriel’s cheeks and suture them into place. “We call this a bilevel face lift,” he said. “A lot of doctors still aren’t doing this, but I think it gives you a longer-lasting result.”

“I don’t want to be experimented on,” interjected Muriel nervously.

“It’s not experimental,” explained Gilmore.

Then Muriel got down to the serious business. “How long have you been doing this cosmetic surgery?” she asked him directly.

Gilmore explained that he had been performing cosmetic surgery as part of his regular practice for ten years, and during the last five years he had begun to specialize in it at the expense of his practice in reconstructive surgery of the ear, nose, and throat. Now his practice was almost exclusively devoted to cosmetic surgery.

“Why did you give up the other?” probed Muriel somewhat suspiciously.

“Quite frankly,” Jim said, “because it didn’t look good for the cosmetic surgery patients to see the cancer cases. It’s not fair for somebody coming in for a nose job to have to come into my waiting room and sit next to a guy with a hole in his windpipe.”

Again the candid response seemed to satisfy Muriel. “If all this works out, I want you to fix this terrible nose that God gave to me. Give it to someone else.”

Jim took the turning of the tide as an opportunity to reassure her. We’re in this together, he told her. He was optimistic. He had every reason to want a good result in her case. For one thing, he always wanted to do his best. For another, he liked Muriel personally. “And finally,” he said, in another appeal to her pragmatism, “you’re my advertisement.”

With that, the discussion of procedures and complications proceeded anew, but on a more casual note. Incision placement and scarring were brought up, and Gilmore explained how he would hide the scars alongside the ear and in the hair When Muriel mentioned a D Magazine article about a recent spate of deaths during surgery in Fort Worth that criticized the use of nurses as anesthetists, he pointed out that in at least one of the cases the anesthetist was a doctor and that those surgeries were performed under general rather than local anesthetics. “You have to differentiate between the types of anesthetics rather than the people who administer it.” Bleeding under the skin, or hematoma—an infrequent complication—was brought up. And then facial nerve damage. “I’ve never had facial nerve paralysis,” said Jim, and he knocked on the table three times. “Permanent damage is very rare. A doctor has got to stray badly to injure the facial nerve.” Then he explained the difference between temporary numbness and serious nerve damage and discussed the 1-in-20,000 chance of visual damage during eyelid surgery.

“I think you’re prepared for it now,” Lyn said to her mother, signaling the end of the interrogation.

“I want a good job, a complete job,” said Muriel, like a speaker beginning the summary of a lengthy dissertation. “I can’t see doing it partially.”

“We won’t do it half-ass, if I may use that word,” said Gilmore.

“I use it all the time,” said Muriel, who then added a final question. “Do you think I need everything I’m having done?”

Jim brushed his hand lightly along the skin at her chin. “You need it.”

Gilmore rose then and took Muriel’s hand. “I beg you to do the best you can,” she said as he made his leave. As he walked out the door Sara swept in, a vision in silky pale gray and white skirt, blouse, hose, and matching shoes, and Muriel wrote her a check for $5250, saying the numbers out loud as she wrote them down.

Muriel on the Table

At one-thirty on the morning of her surgery Muriel awakened and decided that she was going to have only her eyes done. She was able to go back to sleep, however, and when she awoke again at five-thirty and took the prescribed ten milligrams of Valium—she had never taken Valium before—she changed her mind. Now it was seven-thirty, rain was pouring down outside, and Muriel was stretched out under the bright fluorescent lights waiting for the touch of steel on her skin. She was covered with a green plasticized-paper sterile sheet and a blanket, and she had an IV tube hooked up to her arm and her hair pulled straight back behind her head. Four color Polaroid prints of her face were taped to the wall over the cardiac monitor.

Muriel chatted spontaneously with Betty McFarling and Ann Coan, the anesthetist. “This is the first time in my life that I’ve done anything crazy like this,” she said.

“It’s not crazy,” laughed Betty, who has had her eyes done by Gilmore.

But apparently Muriel still felt the need for some personal exegesis. “I’m young at heart,” she said. “My youngest daughter is twenty-three and I have kids in and out of my house all the time. Those kids keep me young.” Then she went farther back in time. “I’ve always taken pride in my appearance,” she explained. “My father was director of the church choir, and I was the pianist. I was always in the public eye.”

Ann applied some greenish gel to a six-inch-square metal plate—the ground for the electrocoagulator—and put it under Muriel’s back. Then she hooked Muriel’s arm up to a blood pressure measuring device and mentioned the deaths in Fort Worth, which she attributed to “double and triple posting,”—the practice of having one anesthesiologist supervise two or three operations simultaneously. That was the real problem, not the use of nurses as anesthetists. A few minutes later Lyn popped in to take an Instamatic picture of her mother on the operating table, and right after that Dr. Gilmore came in and put a big plasticized smock over his blue scrub suit while Betty helped him into his pale yellow latex gloves.

“You absolutely don’t want to do the forehead today?” asked Muriel.

“Not when we’re doing your eyes,” he replied.

Jim sat down on a little stool right next to Muriel’s head, and he took out a purple felt-tip marker and began to draw lines on her face, lines that would show him not only where to make his incisions but also the boundaries beyond which he could not go without risking nerve damage. Then he warned Muriel that the injections of local anesthetic that would follow were the most painful part of the operation. “I’m really tough,” said Muriel. “I can stand whatever I have to stand.” Then she became very quiet, and Gilmore injected Kylocaine around her eyelids, her ears and cheeks, and finally her neck.

The various skin lifts that are done on and around the face are rather different in concept from a nose job. Rhinoplasty involves removal and alteration of structural materials—bone and cartilage—while a face lift, or rhytidectomy, involves only the removal of parts of the exterior shell—the skin—and perhaps some insulation—fat. A nose job is somewhat akin to architecture or structural engineering, while a face lift is more like fine tailoring. But unlike a tailor’s usual materials, the amazing waterproof, breathable, stretchable, heat-dissipating skin can also mend itself when it is cut or torn. It does this by forming scar tissue, which makes the cosmetic surgeon sweat a lot more than a tailor does. The surgeon must consider the placement of scars, and he must ensure that there is not too much tension on the skin in order to prevent widening of the scars as well as discomfort and immobility for the patient. He must also be very careful not to trim away too much skin, because he can replace it only by grafts, with horrendous scarring as a consequence. Such concerns are particularly important in the case of the eyelid lift, or blepharoplasty.

Using a small scalpel, Gilmore made a single punch in the skin near the outside corner of Muriel’s left eye. Sticking a fine pair of scissors into the incision at a point right beneath the lower lashes, he cut all the way along the lower eyelid. He pulled the flap of skin back with a picklike instrument, cauterized a few spurting blood vessels, and began peering intently into the area around the corner of the eye. He poked with scissors. He pulled with the tweezers. He frowned. After about five minutes he made his decision, pulled up a few millimeters of muscle at the corner of the eye, and sutured it into place with two quick loops. This tacking of the muscle, rather than the skin removal, would be the most important factor in eliminating the sagging in Muriel’s lower lids. Then Gilmore pulled the flap of skin up over the rim of the lower lid and spent some time patting it into place with the blunt edge of his scissors. He asked Muriel to look up, open her mouth, look down, open her mouth again. Satisfied that he had a natural, unstrained look to the lower lid—it is possible to make the eyes look like they are going to bug right out of the head by being overly aggressive at this point—Gilmore then sliced off a sliver of lower lid about an eighth of an inch wide and sutured the flap back along the line just below the lashes.

The upper lids began in the same fashion as the lower, except that this time the incision was made inside the natural fold that occurs at about the midpoint of the upper lid, and this time scissors cut through both muscle and skin. With the scissors, Jim dissected away the stringy muscle fibers from the upper flap, pulled it down over the lower flap, made a single vertical quarter-inch-long cut in the middle of the upper flap, and tacked the upper flap to the lower flap with a single suture. Moving toward the outer corner of the eye, he made another vertical cut and tacked the two flaps together in the same fashion. Then he began trimming off quarter-inch-wide sections of upper flap and suturing the shortened upper flap to the lower. After painstakingly working his way to the outer corner of the eye, he started at the middle and followed the same procedure as he headed toward the nose. When he was done, Muriel’s left eye was about three decades younger than her right eye. Her lids were disconcertingly parted so that about a third of her blue iris showed, but Jim said that this was normal. He had done a very conservative eyelid lift. Then he brought his little stool around to the right side of Muriel’s head and did the same thing to her right eye.

An hour and a half into the operation, Muriel’s fact lift began. Again Gilmore went around her ears, cheeks, and neck with the syringe full of Xylocaine. With the scalpel he cut swiftly around the entire ear and along two horizontal lines: one extending forward from the top of the ear to just under the sideburn and the other from the middle of the back of the ear into the hairline. He pulled at the edges of the flap that he had just created with several picklike skin hooks similar to the ones he had used on the eyelids—the tiny blood vessels in the skin can be crushed if the surgeon touches them with his fingers, resulting in skin loss—and then he began to cut the skin and a thin layer of subcutaneous tissue away from the face with the large scissors. When the skin had been separated from most of the cheek and part of the neck, Betty and Jim pulled it up so that he could peer into the red cavern between the skin and face. The skin, laced with tiny red blood vessels, glowed yellow from the light behind it.

Gilmore took the scissors again and dissected a second, several-millimeters-thick layer of the facial or platismal muscle, known to surgeons as the SMAS (for subcutaneous musculoaponeurotic system). This would be the basis for the bilevel face lift. After separating the layer of SMAS all the way down into the neck, Gilmore pulled it up to a point just below the earlobe and tacked it into place with several permanent nylon sutures. The excess SMAS, a triangular flap about an inch on each side, was trimmed off and thrown into a big plastic trash can. When the skin flap was subsequently laid back in place, it concealed about a third of the ear. Gilmore cauterized some blood vessels, packed gauze between the skin flap and the facial muscle, and went over to the other side of the head and did the same thing all over again.

Now it was closing time. First, Gilmore removed the packing and began carefully cauterizing any oozing blood vessels, until the SMAS was dry and covered with tiny black dots. He injected the SMAS with Marcaine, a long-lasting anesthetic, in order to reduce postoperative pain. Then he pulled the skin back over the ear, cut about a one-inch-long slit for the earlobe, and began tailoring the skin. Working in much the same fashion as he had with the eyelids, Gilmore made cuts perpendicular to the main line of the incision, tacked up the flaps, trimmed them, and then sutured everything back together. Even with Gilmore’s nimble, quick hands, it was an excruciatingly tedious process of gradual adjustment, with lots of big one-inch flaps of Muriel, followed by smaller slivers, making their way to the trash can. It began behind the ear, where most of the tension is put and where staples can be used to close parts of the incision, and ended along the crazy contours at the front edge of the ear, which were sewn with the finest needle and thread. And it had to be done again on the other side of the face.

When it was finished, Muriel’s face had been transformed. Her eyes had started to swell and turn purplish, but her face had not yet begun to react to the trauma it had just endured. This was a temporary lull, however, the eye of a physiological hurricane, and three hours after he began the surgery, Gilmore began to swathe Muriel’s face in cotton packing bound with cotton bandages­—he insists on doing this part of the procedure himself and considers it an art that can contribute greatly to the patient’s comfort and recovery after surgery—until she looked like a Siberian peasant woman preparing for a winter outing.

Muriel began to emerge from her Sumblimaze twilight world. “How does the mouth look, Jim?” she asked, concerned about the extent to which the face lift would eliminate the lines around her mouth.

“It looks real good,” replied Gilmore. “How are you doing?”


“I Love the Compliments”

Jim Gilmore performs more than four hundred operations a year. At an average surgeon’s fee of about $1800 each, his gross income approaches $1 million a year, which is about as much money as one person can make by working every day with his own two hands. Jim, however, maintains that the money is unimportant; if he didn’t love his work it would never be worth it. “I could make just as much money in real estate,” he says with implacable self-confidence, “and with a lot less stress.” Like many doctors, he is incorporated, and the sum of his overhead and the salaries he pays his assistants is enormous. Unlike many doctors, he pays himself a relatively modest salary, lives in a less than opulent section of North Dallas with his wife, Gay—an ex nurse—and his three children, and drives an older Datsun 28OZ, which is hardly a status car for a successful doctor. His life is totally controlled by his work. He never stays out late or drinks the night before surgery; he runs four to six miles most mornings because he feels that it builds him up to a mental and physical peak before surgery, abstains from coffee or soft drinks on the mornings when he is operating, and will even see patients and remove stitches on Saturdays and Sundays. His daily routine is an unrelenting cycle of psychological sparring, critical surgical and aesthetic judgments, and sheer manual drudgery. He pushes himself through it like an athlete trying to break a world’s record every day of the year. “My life is goal directed,” he says. “I can’t afford slumps. I can’t afford to be mediocre even once.”

Not everyone approves of Dr. Gilmore’s goals, including many other doctors and nurses. Gilmore is aware that many physicians think that cosmetic surgery is a retreat from the classic standards of medicine, and because nurses at many hospitals resent cosmetic surgery patients so much, he makes it a point to perform all of his in-hospital surgery at a small hospital in Richardson, where the chief of surgery is a plastic surgeon and the climate is generally more receptive. But he also feels that his critical colleagues are shortsighted. He thinks that doctors need to turn more toward preventive medicine rather than just concerning themselves with diseases. He thinks that it is necessary to treat the whole person, and in that context cosmetic surgery is the finishing touch. He cannot say, however, that there was ever a moment when he made a conscious philosophical decision to begin focusing on cosmetic surgery. It was really a sort of aesthetic seduction, something growing out of a lifelong but generally subordinated interest in painting and sculpture. “Had I had the opportunity,” he says, “I might have become an artist.”

Aside from surgery and art, Jim’s intellectual passions run to ecology and humanitarian causes. “I see myself,” he says, “as a very small part of a much greater whole.” He belongs to the Sierra Club and Midway Hills Christian Church, which is active in a number of liberal social issues, and he donates medical services from time to time to church-supported causes. But most of Gilmore’s fellow parishioners are unaware of the nature of his practice, and he does wonder how many of them would admire the use to which he has put his skills. On a day-to-day basis, however, such questions don’t disturb him. “When I’m at work,” he says, “there’s so much positive feeling around me that I never think about things like that.”

Muriel Hughes attributed her extraordinarily rapid recovery to several factors, giving approximately equal credit to the surgeon’s skill, her own active lifestyle and good eating habits, and the fact that once she finally decided to go through with it, she became completely confident that everything would turn out well. Whatever the reasons, Muriel was doing business on the phone the day after her operation. On the third day the heavy bandaging and some of the stitches were removed, and while Muriel’s face was somewhat swollen and her eyes slightly purple, it was obvious that she was coming back very fast. That Saturday—the fourth day after surgery—she put on some dark glasses and went out to show a building to a client. On Sunday more stitches were removed, and on Monday she put on makeup and went back to work. By the end of the week all of her stitches were out, the women at the beauty shop were agog at the almost total absence of bruising and swelling, and an executive with an elevator company was already giving her the heavy rush. “I love the compliments,” said Muriel. “I just feel a new burst of energy.” And she couldn’t say enough about Jim Gilmore. “I guess,” she mused, “that I just got in with the best in the business.”

Two weeks after her surgery Muriel came in for the first collagen injections in her upper lip. By then her “result” was dramatic. She was still Muriel, her face still had character and some of the wrinkles and none of the stretched, taut look of a face lift, but she looked measurably better, more vital, more beautiful. Her face really was a kind of masterpiece, and Muriel was thrilled with it. She had some of the predictable feeling of tightness, but there was no evidence of the once feared nerve damage, and her incisions were already virtually unnoticeable lines of pale pink.

Three weeks after her face lift Muriel Hughes had Jim Gilmore do her nose. She was worried that at her age the broken bones would ache from time to time, but other than that she was strictly upbeat about the whole thing. “I hear,” she said as confidently as a track handicapper betting on a race he knows is fixed, “that noses are what he does best.”