This story is from The Pulse, a weekly health and science podcast. Subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts.

Find our full episode on mental health and appearance here. 

Carla Papas was 13 years old when she realized she had a big nose.

“I was in the canteen line at school and I was with one of my good friends,” she said. “And in front of us there was this boy and he turned around sharply and looked at me and he said, ‘Get your big nose out of here!’”

Startled, Papas turned to her friend.

“And I asked her, ‘Do I have a big nose?’ And she said, ‘Well yeah, kind of.’  And that was the moment where I thought, ‘Oh my gosh, there’s something wrong with my nose. My nose is so big.’”

That moment in the lunch line was the birth of an insecurity that would haunt Papas for the rest of her adolescence. Looking back, Papas says she had a “nose of character” — a nose with a high bridge that curved outward. But back then, she saw it as huge, defective — ugly.

Soon, Papas was doing everything she could to hide her nose. Whenever anyone was taking pictures, she always made sure to face the camera, so it didn’t capture her profile. When she met new people, she became convinced they were staring at — and judging — her nose. It even affected her driving.

“When I would stop at traffic lights, I would make sure that I turned my head away from anyone if they were next to me in their car, so they couldn’t see my profile,” she said. “And these were strangers. I was even worried about what strangers thought about my nose.”

It didn’t help that around that time, the early 2000s, there was a trend in the world of reality TV of shows featuring often drastic plastic surgery makeovers. Even then, shows like “Extreme Makeover” and “The Swan” prompted a good amount of public horror — but all Papas saw was the hope and transformation they represented.

“I would wish that I could get on one of those shows because I wanted to change my face,” she said. “Because when I change my face, my nose, then I’ll be happy. Then I’ll be beautiful.”

A chance for a new face

Papas’ opportunity for a new face finally arrived when she was 21, and met another young woman who’d recently gotten a nose job. She asked the woman for the surgeon’s name, and within a few weeks, found herself sitting in his office for an initial consultation. There, on Photoshop, the surgeon showed Papas what her new nose would look like.

“I saw it all happen right there so easily with a little bit of Photoshop magic,” she said. “And he said, ‘This is what we’ll do. This is what we’ll make you look like.’ And I was so impressed and I couldn’t wait to get it done.”

Papas’ memories of the rest of the visit are fuzzy. She knows the doctor must have reviewed information about the risks and recovery, but his tone was easy-breezy. “There’s an X% chance to such-and-such could happen… but if it does, we’ll just bring you back in for a revision! No big deal.”

“But of course a 21-year-old who’s just really excited to get their nose changed because this is going to change their life and make them finally beautiful skims over that as well and doesn’t think too much,” she said, “doesn’t think that could happen to me.”

So Papas scheduled her rhinoplasty, put down her deposit, and two months later, was back in the surgeon’s office, ready for the procedure that would usher in her beautiful new life. She had no doubts about her decision — until just before the procedure.

“I was waiting in the room and the surgeon came in and he was describing again what we’re going to be doing today. And then you know what he said? He was like, ‘Oh, would you like your breast done as well?’ And I was, like, mortified,” Papas said. “It was maybe a moment where I could have — should have — questioned, ‘What am I doing here?’ And I think maybe I did. But because it was booked in, because I’d paid the $2,000 deposit, I kind of was like, ‘No, I’ve got to go ahead with it. Like, I’ve told everyone I’m doing this. I’ve got to go ahead with it.’” 

The rhinoplasty went smoothly, and Papas went home to recover. It was then that she realized that nose jobs were a bigger deal than she had thought. 

Papas had what’s called an open rhinoplasty, in which the surgeon makes an incision near the base of the septum, and essentially peels back the skin and soft tissue to expose the cartilage underneath. The surgeon can then cut away slivers of cartilage from the tip or bridge of the nose, or file down the nose bone in order to remove a hump. Once the internal structures are arranged and stitched together the way they want, they pull the skin back down and close the incision.

It’s a complicated, invasive procedure, and even small missteps can lead to noses not looking the way the patient had hoped, or even problems with breathing. 

As Papas discovered, recovery can also hurt — a lot.

“The recovery was way more painful than I thought it would be,” she said.

Papas was pretty much bed-ridden those first few weeks. She wasn’t allowed to exercise, as increased heart rate and blood pressure can cause bleeding and swelling that slows down the healing process. She also had to avoid swimming, bending, pulling, pushing, sunlight, spicy foods, even blowing her nose.

Recovery complications

Still, Papas was happy with the results — at first. But as the months went on, scar tissue began forming around her nose, beneath the skin. And soon, her nose began to look distorted.

“My nose got really wide,” she said. “I look at it now and I joke around; I call it a Play-Doh nose, because it looked like someone put a bit of clay, a bit of Play-Doh, on my face because that’s what it looked like. So it was six months after that where I realized, ‘This is not what I wanted it to look like.’”

Throughout the whole recovery process, Papas had been making monthly visits to her surgeon so he could check her progress, and give her cortisone shots to reduce the swelling. On her second visit, the surgeon suggested she might need a slight revision — a “retweak.”

“In my head I’m just thinking, ‘You’ve got to be kidding me — I have to go through this all over again?’” she said. “Well, not I have to, but I went through this, I put myself through this, and now this is the result that I have. This sucks.”

More pain, more time stuck in bed, more life she would miss out on. Worse, she was going to have to pay another $4,000 to get the revision done, on top of the $9,000 she’d already paid. 

Rhinoplasty revisions aren’t rare – but they’re not all that common either, at an estimated rate of 5-15%, and they certainly aren’t desirable.

As she contemplated having to go through one of her own, Papas was flooded with anger and regret — and shame. Shame about her decisions, and the self-hatred that had driven them.

“It felt a bit selfish and … vain,” Papas said. “This wasn’t a surgery that was required for my health; I chose to do this to myself.”

Papas also worried that the complications might have been her fault. She’d been instructed to avoid working out for at least a few weeks. But at the time, Papas suffered from an exercise addiction, and eventually anxiety over her weight pushed her off the couch.

“I remember there was this one day where I was recovering and I went for this really long walk,” she said. “And I remember my nose throbbing just with pain. I knew it was not a good idea what I was doing, but I just felt so guilty for not doing anything.”

Ultimately, it took Papas two years to save up enough money to get the revision done — two years of not being able to breathe through her nose because of the swelling, and of debilitating self-consciousness that had grown even worse than before.

“I felt just so ugly — I felt disgusting,” she said. “I felt like, I hate myself. And to say that out loud is so sad, to think that past me felt that.”

The mental health impact of cosmetic surgery

These feelings — the regret, the anger, the fear and shame — are more common with plastic surgery than the reality shows and before-and-after pictures might have you believe.

Few understand the complexity of those feelings better than David Sarwer, a psychologist who, for the past 30 years, has led a research program at Temple University in Philadelphia looking at emotional and mental health issues surrounding cosmetic procedures. 

“Most patients have a very positive psychological result with regards to satisfaction and desire to do it again,” he said. “But certainly there are cases where people are challenged to appreciate and adapt to the changes in their appearance.”

This can be especially true for rhinoplasties, which have one of the higher regret rates among cosmetic procedures,  ranging from 5% to more than 15%. And regret doesn’t just happen when something goes wrong — even successful rhinoplasties can elicit regret, emotional turmoil, and even identity issues when patients see how different their faces look.

One of the bigger sources of regret, however, has to do with patients’ unrealistic expectations about how a procedure will change their lives.

“I often think that almost all patients probably have some kind of daydream of how very different their lives may be after they undergo these procedures,” Sarwer said. “For people who expect that their social relationships are going to fundamentally change, or a failing romantic relationship is suddenly going to rekindle, I think they sometimes discount the idea that our interpersonal relationships, whether in the workplace or our social relationships, are influenced by countless different factors, and our appearance is only one of them. And so we may change that one little element of our physical appearance, and that may lead people to look at our faces or our bodies slightly differently. But their total experience of us as a human being isn’t going to necessarily change just because of that cosmetic procedure.”

And then there are expectations regarding the results themselves.

“A lot of the art of plastic surgery is the decision-making, and what is achievable and what we’re going to try to achieve,” said Scott Hollenbeck, a longtime plastic surgeon who currently serves as president of the American Society of Plastic Surgeons. “And that starts with, first of all, talking to the patient.”

Plastic surgeons, Hollenbeck says, should take the time during initial consultations to get a full and accurate picture of what the patient is looking for, and to explain what they’re realistically able to deliver.

“If you hear something that doesn’t seem realistic, or at least in your hands is not technically possible, then you have to have a discussion with the patient and let them know that you really don’t suggest that or advise that,” Hollenbeck said. “That can be a difficult conversation though, because patients can feel like you’re withholding care from them or you’re refusing to treat them in some way. But really it all boils down to, at the end of the day, we don’t want to harm patients.”

The same, careful process of informed consent should also be applied to discussions of potential risks — which, as in Papas’ case, can not only affect patients’ health and finances, but also their final result. In fact, the American Society of Plastic Surgeons code of ethics prohibits surgeons from issuing advertisements or private communications that contain “a guarantee that satisfaction or a cure will result from the performance of the member’s services.”

“Some people, for example, heal in a way that leads to tremendous scarring and that would change the outcome of the procedure such that guaranteeing 100% satisfaction would be unrealistic and would almost be deceitful in some ways,” Hollenbeck said. “I think you have to notify patients that there are certain things that are a little bit out of everybody’s control. Infection, for example, can occur.” 

Likewise, surgeons should be preparing patients, early and comprehensively, for the realities of the healing process. For instance, in some people, the swelling from a rhinoplasty can last as long as a year, and it can take just as long for their new nose to “settle” into its final shape. But not all patients know — or remember — those facts, which can lead to freakouts weeks or months into the recovery process, when they’re not happy with how their nose looks.

“I find that patients just do so much better when you’ve explained to them the possible things that can happen,” Hollenbeck said. “Even if they don’t happen, they’re more prepared and they handle those ups and downs of the recovery process much better. So that preoperative period, that preoperative consent, the preoperative information that they gather [are] extremely important for setting expectations.”

But one of the most important steps to avoiding disappointed expectations, both Sarwer and Hollenbeck say, is screening patients for body dysmorphic disorder, a mental health condition in which a person becomes obsessed with perceived physical flaws in such a way that it begins disrupting their everyday lives. It’s a condition that only affects around 2% of the population — but anywhere from 5-15% of plastic surgery patients.

“Now, that might not seem like a lot,” Sarwer said, “but when you think about the number of physicians who practice just cosmetic procedures in this day and age, and may see 20 new patients in a week, that means they’re seeing one or two patients a week who may have features of, if not this actual, diagnosis.”

Screening for body dysmorphic disorder is important, Sarwer says, because plastic surgery can significantly worsen a patient’s symptoms — and, in extreme cases, can lead to self-harm, or even to the patient harming their surgeon.

While Hollenbeck says plastic surgeons are advised to watch out for signs of body dysmorphic disorder when evaluating potential patients, he admits that they aren’t equipped to make mental health diagnoses, nor are there standard screening tools that are universally used by surgeons.

“There are very few cosmetic surgeons out there that I’m aware of who ask patients to go meet with a mental health professional before a cosmetic procedure,” Sarwer said. 

Although he doesn’t think mental health evaluations are necessary for every patient, he says they can be important for the occasional patient who is suffering from body dysmorphic disorder. In those cases, he says, patients should be referred to a mental health professional, in the same way your primary care physician might refer you to a specialist.

“ I think that the cosmetic surgeon should be in the habit of doing the same thing with their patients with mental health issues as well.

Finding peace

In the end, Papas’ revision surgery went well. Her nose finally looked like the image her surgeon had shown her on Photoshop. But now, more than a decade later, at the age of 34, Papas still has regrets. She says her nose is still sensitive; it still swells whenever it’s hot out or she’s on a flight.

But more than that, she regrets the feelings that led her to getting the nose job in the first place. In the years just after the rhinoplasty, Papas got really into yoga, and one of the mantras her instructor used was about acceptance: Acceptance of all that has been, acceptance of all that is, and acceptance of all that will be.

“And when I heard this for the first time, I realized, wow — I don’t accept myself just as I am,” Papas said. “I’m always thinking that I need to change something; I’m always thinking — and this is a big one — that I need to lose weight, that I need to be thinner. And then I realized that this was the same thing with my nose, that it needs to be smaller. I was always thinking I need to take up less space in order to be accepted. And in my head, I think what I thought was that it was acceptance from others — but what it really was, was that I didn’t accept myself.”

These days, Papas is pretty good about accepting herself as she is. In fact, she and her sister/business partner have built their professional lives around the concept of self-acceptance, which is at the heart of a fitness app they released called Merrybody, which focuses on developing a healthy relationship with your body and exercise.

Even so, Papas still has regrets about her decision to get a rhinoplasty.

“I accept that I went through that journey — however, if I could go back and change it, maybe I would,” Papas said. “I’ve just had a baby and I’m pretty sure he has my nose, because if I look at me as a baby, it looks like the same nose. I would call it the ‘Papas nose,’ because it’s a very Greek nose. And this excites me that he has it, but it also makes me a little bit sad that I don’t have it — that I got rid of it. I got rid of a part of my history and a part of my family’s history, a part of where I came from, and that makes me regret the decision and makes me a little bit sad when I think about it.”