It all began with hands. Mutilated hands with complicated anatomy and so many moving parts. Hands that needed surgery, required tendons and nerves from other parts of the body.

It was during his third year of medical school at the University of Western Ontario that Dr. Ryan Neinstein had his first glimpse into the potent power of plastics. “The more time I spent, I realized that plastic surgery can reconstruct any part of the body,” he says. “That was what drew me towards the specialty.”

I met Dr. Neinstein at an Upper East Side Le Pain Quotidien on a Wednesday, surgery day. Mondays he does education training at Lenox Hill Hospital, Tuesdays he sees patients for pre- and post-operation meetings, and he spends Wednesdays through Fridays either assisting in or overseeing surgeries. He seems tethered to his patients and colleagues via phone, text or email, and devotedly responsive.

Neinstein, thirty-one, is a board certified plastic surgeon in Canada, currently doing an aesthetic surgery fellowship in New York City where he works at the Manhattan Eye, Ear and Throat Hospital, on the Upper East Side. When we met recently, after a day swimming in scrubs and other people’s body parts, he looked sharp—extremely handsome, with a warm smile, and impeccably dressed in an open-collared white shirt, gray blazer, black dress pants and leather loafers. His shirt pocket was playfully stuffed with a pink handkerchief and he had perfectly styled dark brown hair. Neinstein’s Twitter bio says he is “Bringing a modern approach to the age-old quest for beauty and refinement.” Born in Toronto, he spent three years studying genetics in college, four years at medical school, another five years training in plastic surgery, and has now embarked on the yearlong fellowship in New York. Neinstein likes the action; he thinks it’s fun. “If someone comes in with a problem into the operating room, they [leave] with the problem fixed,” he says. “As opposed to ordering tests, taking medication for weeks and months before you could see what happens, I like doing it and moving on to the next one.”

I, on the other hand, have always seen cosmetic surgery as many others do: a decoupage of vanity, superficiality and an unnecessary meddling with natural gifts. Just last week, as I stood in Penn Station waiting to take the Long Island Rail Road, I noticed a young woman meticulously sculpting and poking a male companion’s nose, telling him he needed plastic surgery. Something wasn’t “right” with the shape, she said; she knew a great plastic surgeon. I was shocked by her tenacity, her callous judgment, right there in public under the track listings.

But then, I was used to that sort of thing. For over a decade, I had an eating disorder. What began as anorexia at age eleven morphed into bulimia at thirteen, which continued for the next seven years with hints of binge eating disorder and over-exercising sprinkled throughout. Today, eight years recovered, I’m a painfully low-maintenance twenty-nine-year-old woman who only uses lip-gloss and Burt’s Bees Wax for make-up. And I’ve become a public guru on all things body empowerment, speaking to groups about my struggles with eating disorders and hosting, for the past four years, a YouTube series called “Body Empowerment.”  “Love your body,” I say over and over. “Let go of shame.”

Yet, I jumped at the chance to write about a young, hip plastic surgeon. If I’m preaching self-love, urging my YouTube followers and spoken word poetry fans to embrace every aspect about their selves, don’t plastic surgeons—and their patients—deserve the same sort of treatment? I met with Neinstein partially because I wondered whether I could overcome my own judgment of plastic surgeons’ work and patients’ choices. I wanted to myth-bust myself.

*   *   *

Dr. Neinstein was inspired to become a doctor after volunteering as a medic in Israel. He chose surgery early on in his medical training, drawn to its dramatic and quick results, which fit his personality. Dynamic, yet focused and thorough, Neinstein liked how surgery—with its team-oriented atmosphere—activated the inner athlete of his youth. “There’s not a lot of things in life that kind of give you a rush every day,” he says.

Overachiever that he is, Neinstein visited many medical specialties during his free time, and discovered plastic surgery in his third year of med school. He volunteered as a researcher for a hand surgeon and, the following summer, worked at a children’s hospital where he discovered clef palate surgery, skull remodeling surgery, surgery to separate attached fingers. Here he solidified his future in plastics.

Dr. Ryan Neinstein
Dr. Ryan Neinstein

During Neinstein’s five-year plastic surgery residency, he became intrigued with cosmetic, or aesthetic, surgery, even though his training had focused largely on reconstructive surgery. “I thought it was imperative that I go out and seek more training,” he says. “I might have done five hundred hand cases and maybe five cosmetic cases, so I wouldn’t feel as confident doing those cases on my own.”

He applied for and was accepted to the prestigious one-year fellowship he currently holds at Manhattan Eye, Ear and Throat. “It’s the most well-established training program,” he said. “This is where you want to be…Not only do we learn the surgical techniques, but we also learn how to approach patients—who to operate on, who not to operate on. The thing about our program is we learn it from some of the masters of plastic surgery in this country.”

I was surprised to learn that a patient’s physical and mental health are both taken into serious consideration when clearing them for elective cosmetic surgery. Getting a nose job or a boob job isn’t as easy as TV shows can make it seem. Patients must be physically healthy: no bleeding disorders, no lung or heart disease, no nutritional issues, no iron or protein or vitamin or mineral deficiencies, all of which could interfere with healing. All prospective patients get blood work, and breast surgery patients undergo mammograms. And patients need to be above a certain body mass index in order to avoid complications.

Already, my assumptions about cosmetic surgery were slowly melting away, like layers of fat sucked up through a surgical tube. I figured that anyone who got liposuction had to be tremendously overweight. Not so. “People get confused with plastic surgery,” Neinstein told me. “Really heavy people come in and they think you can make them skinny. We’re looking for people who have close to their ideal body weight with extra skin and fat…body contouring is not a weight loss operation.”

“People have to have the right motivations for having cosmetic surgery,” Neinstein went on. “You want to make sure there’s not a specific goal they have in mind that’s unrealistic that surgery would attain for them.”

Plastic surgeons, Neinstein explained, have to ensure an individual isn’t getting pushed into a procedure by a partner, and they must beware of psychological conditions, like body dysmorphic disorder, which causes a person to be excessively concerned with an aspect of their body and appearance, whether real or imagined. “Some of the time, no matter what you do, you’re not going to be able to treat that and that could go down a bad road to depression, suicide,” Neinstein tells me.

He says his fellowship training is most effective in terms of what he learns from his mentors, whom he describes as “so slick.” “These guys, within like twelve seconds of talking to someone, they know whether or not they should operate on them,” he says.  “We spend a lot of time, we talk about it a lot and we think about it a lot. An operation is not going to treat a psychological issue.”

Now Neinstein is speaking my language, one brimming with terms like body dysmorphia, body image, mental illness. Eating disorders, a form of mental illness, wreaked havoc on my entire life. In high school, I went from straight As to straight Cs. I ultimately spent a year and a half at boarding school in Switzerland, leaving my tremendously competitive and elite public high school in the Chicago suburbs to academically and emotionally redeem myself and leverage a shot at my Ivy League dreams. It worked, sure. I went to the University of Pennsylvania for college and Columbia University for a master’s in journalism. I’ve been recovered for eight years, since my junior year of college. But there were so many hours spent in anguish, the minutes suffocated by my inner pain, the seconds drowned by this despicable voice yelling at me to hate myself. That this doctor, this plastic and cosmetic surgeon, and all of his colleagues take the time to make sure potential clients are not enmeshed in this same horror—what a gift.

But I was still skeptical that, mental health evaluations or not, patients are seeking plastic surgery for the right reasons. So I asked Neinstein if one of his patients would be willing to speak with me. I wanted to find out if they indeed had thought long and hard to electively let an incision redirect the shape of their body, if they were truly willing to pay the price, financial and otherwise, to become more “perfect.”

*   *   *

Anna punctuates her speech with witty humor, playful laughter, arm gesticulations and conviction. She is effervescent, filled with fresh energy and without a hint of the narcissistic decoupage I’d previously ascribed to cosmetic surgery patients. She wears a gray sweatpant and sweatshirt outfit, a pink T-shirt, and a leopard print scarf, and has a cute haircut layered to her shoulders.

I meet Anna (who asked that her real name not be used) at a Wendy’s in Brooklyn where the J train nears Queens. Mother to a four-year-old son and a seventeen-year-old daughter, Anna, thirty-three, was born in Panama and moved to Brooklyn when she was eight. A trained pastry chef, she owns her own business: a half-party-supply store, half-bakery in south Williamsburg.

She doesn’t miss a beat of vulnerability. Within minutes, she jokes that her son pushed her into plastic surgery. His ten-pound weight at birth left what she describes as thick stretch marks nearly half-an-inch wide on her petite frame. So a few months ago, she had a tummy tuck and a breast augmentation with Dr. Neinstein.

In 2011, breast augmentation was the top cosmetic surgery for women in the United States, with  316,948 surgeries, followed by liposuction with 293,669. That year, women had nearly 8.4 million plastic surgery procedures, which was 91 percent of all cosmetic procedures, according to the American Society for Aesthetic Plastic Surgery.

Anna had thought about cosmetic surgery for years after her son’s birth. “As soon as I came home from the hospital, I was putting money in the bank,” she says with a lightness of acceptance and cheer. “Once I’d seen my body, I was like, ‘I have to do something about it.’” For Anna, there was no other option but cosmetic surgery, despite the toll it would take on her body. “It’s a trade-off…between the scar and the beauty. It doesn’t come at no cost,” she tells me.

What about “the beauty” was important, I ask—I ask Anna if the surgery was for herself or someone else. “For myself,” she immediately says. “Because my husband has said, ‘You don’t need that.’ Every time something came up in our lives or in the business he would call my surgery off.” Immediate laughter. He’d tell her she looked beautiful; she’d think, “Um, hello, no!”

Yet, Anna does feel society plays a big part in women’s insecurities. She mentioned all the women getting butt implants lately. Butt implants? I missed this memo. I tell her I’m shocked and make a joke about how big my butt already is, and she giggles, and I giggle, and we giggle together, and I keep thinking about how despite the pressure we women face, at least we have each other to laugh with.

“But when you’re ethnic,” she continues, “It’s difficult. You’re, like, expected to be built that way. Ethnic men look for that extra something…I can only speak about ethnic because I’m Latin and that’s my culture, but I think society in general is very hard on women, very hard.”

The sisterhood beckons. I can’t help but chime in, break the journalism rules and start making a conversation, not an interview. I’m a twenty-nine-year-old white, upper-middle class Jewish woman, eight years recovered from a decade-long eating disorder. I was a size four at my Bat Mitzvah when I was borderline anorexic. I now live on the threshold of a size fourteen. I’m voluptuous—oftentimes told I am fat. Maybe I am. But I don’t care anymore—really, I don’t. I love my body.

But the pressure. Despite my advocacy and activism work, I still can’t miss any opportunity to talk about the pressure.

It’s fascinating, I tell Anna, how for her community and many other communities of color, the idealized body is often voluptuous—big boobs, big butts, big hips; yet in white culture, the idealized body is waif–thin, toned, almost verging on withdrawal. I mention the rampant eating disorders in Orthodox Judaism—the women who starve themselves to appeal to future husbands with whom they will have an arranged marriage.

She says that her husband, a biracial fireman, works in a highly Caucasian environment. He tells her how a lot of his white colleagues talk about preferring Hispanic and black women who are voluptuous, but then when it comes down to marrying, they go back to white women.

I ask Anna about her body image before she had her son. “I felt very good about myself,” she says. “I went to the gym all the time…I had a four-pack. I ran all the time. I was in good health and good condition. For me, [the pregnancy] was hard. It hit me really hard. That’s why I went to the extremes of getting surgery.”

Anna tried returning to the gym, but her physique, she said, “just never came back. My muscles were damaged and I had a hernia. It doesn’t matter how many crunches, it doesn’t matter how much I ran. It didn’t matter. My body wasn’t responding. Giving birth to this child took a toll on me.”

She mentions a near fatal car accident she had seven years ago, how her arm was broken. How she “had to be fixed.” Just like her arm, her stomach, after the pregnancy, had to be fixed.

So she searched for the right surgeon, had consultations, saved money, had more consultations, saved more money, and joked with one unforgiving surgeon about where she could get a coupon. From doctors on Park Avenue to Jersey to famous Hispanic doctors who speak on Spanish-language television she saw close to fifteen different doctors, in her search for the perfect surgeon with the right price, the right approach, and the right rapport.

Then she researched teaching hospitals, where the price tag is cheaper, and the surgeons are dedicated to honing their skills. She found Dr. Neinstein. As someone who works with her hands making custom-made cakes and tiny details out of sugar, she liked Dr. Neinstein’s hands-on approach.

Anna wanted her breasts done, too, which she says Dr. Neinstein initially discouraged her from doing. “He felt that there was nothing wrong with them because thanks to genetics, and my mother, they were very youthful,” she says. “But I felt, you know, I’m doing this so let’s just do it all in one shot. It’s only downhill from here!”

She learned that his technique was to place drainage incisions for the breast surgery on the tummy tuck incision—no extra scars. He would even repair a hernia—also a result of her pregnancy—for free. An affordable total, compared to most cosmetic surgery, of $6,000 for the tummy tuck, breast augmentation and bonus hernia repair. She was sold. “It didn’t seem like he was selling me a dream,” Anna told me.

Dr. Neinstein says he helped Anna with every decision, that he went over the pros and cons of every aspect of every procedure—saline or silicone for the breast implants, the options of implant sizes, where to make the incision (through the armpit, areola, or under the breasts), ways to ensure she wouldn’t lose nipple sensation, ways to keep the scars and incisions to a minimum. She ultimately went with saline—less expensive, smaller incision, since if there was a rupture (of which there is only a one-percent chance of happening) she’d know immediately.

Speaking with Anna about “customer service” and “dreams,” my preconceptions about plastic surgery started to unravel a little more. I had no idea cosmetic surgeons took so much time and care to accommodate their patients. Maybe it was for the money. Maybe it was so good results from happy patients would turn into referrals and more money. But I got the sense that this was actually genuine, on a level I don’t remember experiencing even with some of the doctors who were supposed to help me recover from my eating disorder. I had an eating disorder specialist in high school who once wouldn’t see me after I was a few minutes late to my appointment. He made me feel like I was such a failure, that even the man who was supposed to help save my life didn’t want to help me. I was too broken. Too bad. Too unworthy of help. My mother remembers that day vividly—maybe even better than I do—how unconscionable it was to treat a teenage bulimic with such a lack of “customer service.”

*   *   *

Anna calls Dr. Neinstein an artist. Says his perfect line across her stomach on October 17, the day of the surgery, was flawless, ultimately resting below her bikini line across her stomach. She mentions RealSelf.com, where patients post their experiences with cosmetic surgery: before and after pictures, fears, concerns, triumphs, successes, doctors ratings and more. She has seen images of surgical pens gone awry, incisions run amok. “Some of these women pay ten or fifteen thousand dollars for these jobs and one side is higher than the other one and it’s because they’re all freestyling it,” she says. “I’ve seen some scars there that you realize, ‘Whoa, my scar was so neat from the very beginning.’ It’s like, that’s why I’m sitting here with you because I really think that this guy has like a…he has what it takes.”

Anna imitates Dr. Neinstein drawing on her body, stepping back, looking forward, drawing, stepping back, reviewing. Her own physical animation represents her inherent confidence. I think about something Dr. Neinstein said when I asked if he felt his work empowered his patients. “A lot of them are pretty empowered people,” he said. “To be able to walk into a room with a stranger and take your clothes off and tell them what you don’t like about your body takes a lot of guts.”

Anna went into the operation around 3 p.m., wrapped in warmed blankets, her daughter sitting in the waiting room, having canceled her coveted after-school extracurricular activities. Like Anna’s husband, her daughter had also been against the boob job. “She was like, that’s just so unnecessary,” Anna begins, “but that’s because she’s seventeen and flawless…what does she know?!” We both laugh.

Just before the surgery, Anna was nervous. “It’s like I’m going to do something so shallow,” she says, “And you could maybe lose your life…This is not a surgery that is needed to save my life. More like to save my ego, my self-esteem. How do you explain it, if something happens, to your children?”

Since the surgery, Anna has barely experienced post-operative pain. But she feels discomfort. For the first few months it was hard to stand up straight, she lost a lot of weight, she felt stiff, and it was hard to move. When we meet at Wendy’s, two months after her surgery, she’d only just started to feel the swelling go down. “Your body’s just like, ‘What the hell just happened to me?’” Anna says.

*   *   *

Dr. Neinstein won’t go so far as to say that cosmetic surgery is empowering. It’s a quality-of-life field, he tells me. His patients are not asking to be someone different, he says. Maybe their bodies have taken a beating from childbirth, or their nose doesn’t quite fit their face, or they just want to go back to looking how they once did. Sometimes it’s about helping the body heal from trauma, about helping women after breast cancer. “To be able to give a woman their breasts back, that’s a big quality-of life-reconstruction,” he said, adding, “I’m content and satisfied with making people happy and improving their life.”

The only time I ever considered cosmetic surgery was in middle school when I worried my long, pointed Jewish nose was responsible for all of my body image insecurities. It wasn’t. It was my stomach. It’s always been about my stomach. My stomach makes me feel ashamed. Makes me feel alone in an isolated box of hypocrisy as I post bi-weekly episodes of my YouTube video series; as I stand on stage in front of hundreds of college students and perform spoken word poetry about being recovered from an eating disorder; as I facilitate writing workshops for both youth and adults and ask them to write love letters and thank you notes to the part of their body they like least. Every time, I write a letter to my stomach.

When I was bulimic, I used to think about chopping my stomach off with a huge, sharp knife. Wouldn’t it be so much easier if I just chopped it off? And then I could go to the emergency room and they could sew it up as if nothing happened. Or maybe I should consider liposuction. Maybe I should just “go there,” I thought, and be “that shallow” with my “superficial” thoughts. An eating disorder is a mental illness. It’s not about vanity. It’s not about weight. It’s not really about body image. The crux of the disorder is something much, much deeper and far more painful than looking in the mirror and loathing what you see.

I ask Anna how she feels in relation to all of the reasons she had the surgery. “At some point I was like, ‘Oh my god, what did I do?’” she tells me, “Because you think that you’re going to go in there and they’re going to fix everything. And then you come out and then the reality hits you that they did the best they could, and it’s never going to come back. That’s it. It’s gone. You exchanged the stretch marks for a huge scar. So it’s never going to be the same.”

“That hits you,” she says.

She became depressed, though that dissipated as her body healed. Now, she feels much better. “My scar looks amazing…for a scar!” she jests. “The job that [Dr. Neinstein] did was so neat.”  Her boobs, she says, “look un-be-liev-able—they look natural!” And Anna’s husband, who originally thought the breast augmentation wasn’t necessary, has switched camps. She laughs through it all, and reads a text from her husband directed to me about giving Dr. Neinstein a shout out, and his loving her boob job. And we laugh together.

Yet emotionally, Anna is still recovering. The problem, she now knows, will never go away. “Women don’t talk about that,” she tells me. We don’t. We women (and, of course, some men, too). We need spaces to share our insecurities, explore the pressures we feel to be these perfectly sculpted, molded structures of clay. We women, we need to talk.

So Anna and I talk. As she lists all of the friends she’s now recommended to Dr. Neinstein, I pause; she has a lot of friends getting plastic surgery. While I knew plenty of people who got nose jobs and breast reductions in high school and college, I don’t have any friends—as far as I know—in my diverse and large social network currently getting cosmetic surgery in our late twenties and early thirties.

Anna admits that she used to look down upon women who had cosmetic surgery—“not the tummy tuck…but the boobs and the butt. I can’t talk about them anymore. And I find myself having to catch myself.” She continues, “The one thing I think about is: how can you walk around being a complete fraud?”

“Do you think you’re a fraud?” I ask.

“I’m feeling like one at times,” she says. “And I think that’s what’s going to stop me from doing other procedures.”

I pause for half a minute, which is an eternity during an interview. I want to tell Anna that she’s gorgeous, that she’s aesthetically stunning and has a great sense of humor, and personality, and wit, and confidence. I could sit here with her for hours. I can’t help it. I have to cross the line. I have to say something.

“There’s no need to feel like a fraud,” I tell her. “You did something you chose to do. And that’s okay. Why should you be ashamed for making that choice? Right? I know I’m changing the journalism rules here, but woman to woman.”

“You know why you’re changing the rules like that?” she says. “Because you’re a woman and you know how hard it is to be one.”

*   *   *

As Anna recaps her experience, repeats what it physically feels like to heal—how it feels wearing shape wear, how breathing feels different—I watch her hands continue to so viscerally and vividly punctuate her storytelling and voice. I think to myself, ‘This is a woman who is so tremendously connected between her body and voice. This is a woman who has a relationship with her whole self. This is a woman who listened to her body, who made a decision that was sound and empowered.’ Even if she feels overwhelmed by cultural pressures, even if she’s changing her natural assets, she’s making those choices authentically. She’s still listening to herself. And ultimately, isn’t that listening, hearing, and honoring of the self all that matters?

I don’t have lingering judgments about Anna and her surgery, only empathy and concern for the pressure she feels. I know that pressure. While I know my eating disorder was caused by trauma and emotional struggles, I would be lying if I said it had nothing to do with body image, if I said I never struggled—especially before I recovered—obsessively comparing myself to women in magazines, on television, and around me.

But as for cosmetic surgery—Neinstein, his colleagues, their field—I’m not sure. I am deeply moved by Neinstein’s words about reconstructive surgery, his epiphany while watching hand trauma reconstruction, and his desire to continue in plastics beyond his fellowship. But aesthetic surgery, choosing to change one’s body to enhance quality of life? Part of me feels that combating the pressures suffocating all of us, regardless of gender, means shifting what quality of life means, making it start from the inside out with self love and empowerment, letting go of shame. Isn’t that the key to permanent change? Isn’t that more lasting than an elected incision?

I tell Anna about my own experience. She’s been so giving. I want her to know I understand.

“It’s really important for women to share,” she tells me. “We can’t change the way men look at us and the way society’s going. We can’t do that. It is what it is.” We talk like this for several minutes until, finally, my heart is in my throat; I have chills. “That’s the least we can do,” I say. “At least we can share with each other and support each other.”

“Yes,” she says and puts her fist up, “Be sisters.”

*   *   *

Caroline Rothstein is a New York City-based writer, performer, and eating disorder recovery advocate. She hosts the widely viewed YouTube video-blog “Body Empowerment” sharing her own recovery story to promote positive body image worldwide.

Courtney Dudley is a freelance photographer based in New York.