What's behind Hollywood's plastic surgery obsession? Radar spoke with industry insiders—from casting directors to A-list doctors—for the truth about the insane pressures, the elaborate subterfuges, and the costs of playing the perfection game

See before-and-after shots of Angelina Jolie and others

FOR MERE MORTALS, the holidays are a chance to congregate with loved ones, rationalize gluttony, and exchange unwanted gifts. For Hollywood celebrities, they're traditionally a time to sneak off to one's surgeon's office for some urgent nips and tucks. With only weeks remaining until awards season—the series of televised events that kicks off with the Golden Globes on January 13—planning is everything. By Thanksgiving, anxious stars are already discreetly arranging to have their palms Botoxed (to avoid sweaty red-carpet handshakes), their laugh lines rendered mirthless with Juvederm injections, and their droopy eyelids carved away. As the ceremonies draw nearer, last-minute earlobe plumpings are not unheard of.
Recently, Rose McGowan lost out on a role in the upcoming film Speed Racer, reportedly because her overstretched eyelids had begun to evoke those of an alien kitten

Each time major celebrities alter their bodies, they're risking millions of dollars in potential earnings and the livelihoods of their entire teams. With the stakes so high, the effects must be subtle. No one wants to be the next Meg Ryan, whose 2001 misadventures in lip enhancement left America's erstwhile sweetheart looking like a duck, a lapse in judgment at which Hollywood still shudders. "She basically installed a vagina on her face," says producer Clifford Streit (American Psycho), adding helpfully, "When your lips get that big, your eyes look too small." More recently, Rose McGowan lost out on a role in the upcoming film Speed Racer, reportedly because her overstretched eyelids had begun to evoke those of an alien kitten.

Even minor procedures are performed in grim secrecy. For A- and B-list stars, admitting to any plastic surgery is only slightly less taboo than admitting to a taste for sodomy. "Everybody lies about it," says actress Julie Bowen (Boston Legal, Ed, Lost). "The men I know are a bit more open, but the girls will lie and lie and lie, even though you're staring right at their scars." Bowen, 37, one of the most defiantly flat-chested successes in the business, has no need to fib: "I haven't had any surgery," she insists, "but I'm totally fascinated with the idea."

She's not the only one. Although much of America has grown blasé about plastic surgery and sees little wrong with a self-esteem-boosting nose job (or three), Hollywood's lies perpetuate our national fixation with its frozen faces. In the tabloid era, editors at InTouch and Star endlessly examine renowned noses for telltale nostril changes, and paparazzi stake out the offices of high-profile doctors like Arnold Klein, a Beverly Hills dermatologist who somehow survived his association with Michael Jackson to become one of Hollywood's elite injectors. Meanwhile, awfulplasticsurgery.com, a website run by a Los Angeles customer service representative, draws more than one million hits a month, exposing the stars' scalpel antics with tantalizing (if sometimes dubious) photo evidence.

Still, thanks to patient confidentiality and stealth tactics, some of the harshest aspects of the industry's bizarrely conflicted relationship with plastic surgery go unreported.

To uncover the real truth about daily life inside this collective neurosis, Radar talked to dozens of entertainment-industry insiders—casting directors, talent managers, actors, and agents—many of whom insisted on anonymity. Several others declined to talk even off-the-record. "You've got to understand the desperation," says Streit. "Hollywood is a sea of desperation surrounding the Beverly Hills Hotel."

This is a town, after all, where stars meet their surgeons for whispered face-lift consultations on the sidelines of their children's soccer games, and use underground parking garages to skulk into opulent "recovery retreats" after surgery. It's a place where Lionel Richie's estranged wife, Diane, anxious to sustain her plastic surgery habit, explicitly demanded $20,000 a year in annual upkeep in her 2004 divorce filing. (Which is arguably a bargain: Some doctors charge that much per day to clear their schedule for a marathon fix-it session, and Demi Moore allegedly dropped some $330,000 for her pre–Charlie's Angels body makeover.) Even high-profile Scientologists, so famously opposed to pharmaceutical self-improvement, have their own plasticizers, such as Edward Terino, M.D., who reportedly performs church-sanctioned "silent" nose jobs in the belief that any music or chitchat in the operating room might subconsciously taint the anesthetized believer.

The fetish for looking generically ageless is by no means confined to on-screen talent. "Actors aren't the only ones to feel the pressure," says Greg H., who spent 23 years in Hollywood as a top casting director, agent, and talent manager before decamping for Seattle. "It's everyone: producers, writers, assistants ... the executives' wives are easily the worst."

"Actually," says producer and manager Douglas Urbanski (The Contender), who's repped stars such as Gary Oldman (his current producing partner) and Isabella Rossellini, "the realtors are probably the most plastic-surgerized people going. L.A. is such a fucked-up place. Where else do you have to look flawlessly sexy to sell a house?" As the Los Angeles Times recently observed, perfection has become the city's requisite standard of grooming: "Walking around with a furrowed forehead ... has become the equivalent of going out with dirty fingernails. It's possible to fix that."

Photos: Kidman, Matthew Salacuse; Ryan, Evan Agostini, Getty Images; Carrot Top, Carlo Allegri, Getty Images; Digital Art: Kidman, Planet Hiltron

BUT EVEN IN a city where plumbers' cracks are suspiciously tanned and hairless, actors still inspire the most intense scrutiny and the wildest rumors. If you've been paying attention to recently published gossip, you'll know that David Arquette has forbidden his wife Courteney Cox from getting surgery; Paris Hilton's droopy left eye is the result of a botched 2001 eye lift; John Cusack so hated the way his neck sagged in 1408 that he had it lifted; and Robert Redford is enjoying the benefits of a "scrotum lift" (sack-tightening is an allegedly hot procedure).

"You'll get an e-mail like, 'Oh my God, don't call actress X in. She just had her lips done. She looks like a freak.' So you don't." Unless you're bored. "Then you might call her in anyway, just to see how freaky she looks"

But, according to the actors we interviewed, before you're celebrated enough to inspire gossip about your testicles, you have to survive the Hollywood "feedback loop," an unofficial system designed to target and correct your physical flaws. Some actors resist surgery for decades; some yield too quickly (and eagerly); but either way, it's easy to get screwed. Too much surgery and you're unemployable. Too little and you're, well, unemployable. The process starts with your first auditions.

"I think I was 20 or 21 when a casting director told me I had too much hip and thigh," confesses an indisputably attractive 27-year-old Latina actress who's still searching for the elusive big break. "I was shocked. I mean, I was very thin. What do you do? Go home and starve yourself—or do you get the lipo?" After six years of feedback, the critique she's received most often is that she's too "ethnic," she says. "They'll tell you they love your look and originality. But then they slowly classify you and compare you, and try to get you to look more like everyone else. It's bizarre. Sometimes I'll be at an audition and realize that the actresses all look exactly the same."

Though she won't discuss the specifics of her own surgery, she concedes that "[a]nyone who comes out to L.A. will eventually get something done. Their teeth, the breast implants, the lips ... if you're really striving to be a part of this business, at some point you succumb." While A-listers will only gossip about people's surgeries, in less exalted Hollywood circles, one's own nipple flaws and cheek-implant anxieties are appropriate small talk. "They all want knee work now, since Demi Moore had it, so that becomes one more thing to do," she says, adding wistfully that she can't afford to contemplate more expensive procedures: "If you can't get the surgery, you can't get the mainstream jobs, the big-money deals everyone wants."

If that sounds like a rationalization, says Greg H., the former casting director, it's not entirely: "TV writer/producers, especially, are notorious for picking actresses with the bigger breasts. I'd bring in amazingly talented, beautiful women to read for a part, and the feedback would be: She's not pretty enough. Which basically meant they didn't want to fuck her."

Actresses who've successfully secured decent film roles counter that appearance is not always a deciding factor. "I've never felt that if I had bigger boobs, I'd get the job," insists an increasingly high-profile film actress in her early 30s. "I've always felt it's more about your talent than the way you look."

The truth is somewhere in between, says Julie Bowen. She likes to tell the story of her first wardrobe tests as the schoolteacher on Ed. Ten outfits failed to pass muster with the producers. "They were always vaguely dissatisfied," she says, "like they couldn't quite put their finger on what was wrong." On a whim, she popped her "chicken cutlet" silicone enhancers into her bra and returned in the very first outfit, a demure twinset. "Suddenly, they're like, 'Now, that's good, that's perfect.'"

THOUGH CASTING DIRECTORS are often blamed for Hollywood's plastic surgery addiction, they deny responsibility for anyone's decision to go under the knife, and most insist they would never suggest surgery to actresses (or actors) directly. "I've been doing this a long time," says veteran casting director Steve Jacobs (Arrested Development, Roseanne), "and that's never come up in a room I've been in." It's not in his interest to promote rampant plastic surgery, he says; the more unreal actors look, the harder it is to cast them.

If any "suggestions" are made, says Greg H., they're conveyed privately to the actor's agent when he or she calls for feedback, in a codified manner that's both frank and veiled: "There's very little editing in that discussion. There's no taboo in mentioning that an actress's eyes look really 'tired,' which is code for 'she could use an eye lift.'" (Similarly, "I don't know what we're going to do with her during the beach scene," means, "Look, she needs implants if she wants bimbo roles.") More than 80 percent of casting directors are women themselves, he says, and many of them are among the most unsparing: "Believe me, they love delivering that kind of news."

Satisfying Hollywood's exacting demands is no easy task, however. Bad work is often more damaging than no work at all. When casting directors confront obvious disasters, says a veteran, they're not above warning one another not to waste their time: "You'll get an e-mail like, 'Oh my God, don't call actress X in. She just had her lips done. She looks like a freak.' So you don't." Unless you're bored. "Then you might call her in anyway, just to see how freaky she looks."

If negative feedback about an actor (especially from major casting directors) starts piling up on the agent's end, it's his job to delicately broach the topic of surgery with his client. "No actor wants to feel they're being treated like a piece of meat," says a former talent agent. "The diplomatic way is to hope that the actor asks you about it. If not, you gently float the idea. Eventually, you might have to say, still very chattily, 'The feedback I'm getting is that your neck is an issue.'"

Actors bring such criticism on themselves, he says, by insisting on auditioning for roles they lack the talent or physical attributes to get: "When you meet a prospective client, you always ask about career goals. Nine times out of 10, she's going to say films. But nine times out of 10, you're thinking soaps."

Of course, it's easy for an established actress, who no longer even has to audition, to start seeing herself as inadequate thanks to the relentless scrutiny of the tabloids: "My women clients complain to me that it's no longer enough just to be beautiful [from the neck up]," a prominent female talent agent says, "because, one way or the other, the tabloids are going to trash them ... their thighs or their cellulite." Increasingly, technology is causing panic, too. With the growing market for high-definition TV—up to 10 times crisper than analog—stars' suddenly glaring imperfections have become so gossip-worthy that HDTV-obsessed websites are issuing best and worst lists exposing the vulnerable, like Brad Pitt ("no gift to women in high-def") or Britney Spears ("looks like she belongs in a biker bar"), while lauding stars like Katherine Heigl, 29, merely for withstanding magnification. "My actor friends pretend they don't notice the difference, but they do," says Bowen. "And, of course, my husband has to have the 60-inch TV. ... God forbid he should miss a single wrinkle. It's enough to make anyone go out and do something with her face."

That's when the real madness begins.

Photos: Rourke, Gustavo Caballero, Getty Images; Rogers, Paul Hawthorne, Getty Images

While there are no stats available specifically for Los Angeles, evidence suggests that nipping and tucking is on the rise nationwide. The total number of cosmetic procedures jumped nearly 10 percent from 2005 to 2006. The level of insanity among famous patients appears to be rising, too.

The insistence on anonymity threw one Santa Monica doctor's office into chaos after a book detailing all his star clients' various aliases went missing; the fake names had been used to label the celebrities' charts, so no one could remember whose was whose. Star-courting surgeons like Dr. Frank Ryan (something of a narcissist himself—his website features a photographic timeline of his journey from child to man) must offer "secret" back doors and house calls to resolve Botox emergencies.
One Hollywood partygoer claimed of Nicole Kidman: "I heard she no longer has expression in her face, so she had to change her acting style, and now she has to act more with her body"

The paranoia surrounding exposure can make Hollywood friendships a little strange, too, says Bowen. "I have several friends who've had implants ... they'll admit it to you only after you get very close to them. Some didn't tell me for years." Half the time, she says, she can't even detect the change. "I knew a girl who'd had her upper lids done. Apparently, she was horribly conflicted, and felt like she'd yielded to her vanity. So she finally comes clean and I was like, 'Oh, I can kinda see it.'"

Hollywood being what it is, not even the utmost discretion or the most exacting precautions can protect a celebrity from post-op gossip. Streit says that the RN who cared for him in his home after his own eye surgery claimed she'd just come from tending to Elizabeth Taylor in her mansion, and had been monitoring Michelle Pfeiffer's recovery the week before that. Curiously, the nurse seemed most scandalized by Pfeiffer's substandard decor. "You see," says Streit, "I had a small Pissarro in my bedroom, and we got to talking. The nurse said she was shocked that Michelle had no art on her walls. This was, of course, pre–David Kelley."

"Hollywood is a little gossip factory," one casting director says matter-of-factly. "And surgery comes up all the time during the workday. It's almost always about making fun of someone, like, did you see what Marcia Cross did to her face? Oy, this business!"

Parties, says Streit, provide another opportunity for stars to dissect their peers. "In New York, people check out the shoes and the bags. In L.A., they start with surgery. For guys, it's the teeth and the hair. For women, it's the boobs and the Botox."

Experienced gossips are highly selective though, says an actress in her early 40s. "There's so much bad work in L.A., it's not even worth discussing. But if people see someone famous who's 50 years old and looks mysteriously phenomenal, that's when they start leaning in at the parties and whispering, desperately trying to figure it out." The latest focus of such awe, she says, is ... Michelle Pfeiffer. "After Hairspray and Stardust came out simultaneously, I don't know anyone who wasn't saying, 'How the hell does she look like that?' Now everyone thinks they can do it, too." If only they knew the secret recipe.

Abrupt changes in younger actors who normally show surgical restraint are also cause for immediate speculation. "As soon as the second season of The West Wing debuted," a casting director told Radar, "everyone in the industry started talking about Rob Lowe's eye lift. He looked completely bizarre. Of course, if you ran into any of Lowe's representatives, you'd ask them. You knew they'd lie, but half the fun of asking is watching the agent squirm."

The bigger the star, the louder the rumble. In 2005, the New York Times sent an undercover reporter to Hollywood gatherings to record the guests' surgery speculations verbatim. Nicole Kidman and her "ubiquitous and strangely frozen forehead" inspired the most fervent conjecture. The partygoers' theories ranged from an alleged brow lift to a "liquid nitrogen peel." One claimed to be uniquely well-informed: "I heard she no longer has expression in her face, so she had to change her acting style, and now she has to act more with her body."

Whatever she may have done or not, Kidman, now 40, has come to represent a certain threshold: the precise moment when a star will either allow herself to age or become a casualty of blind narcissism. "I think Nicole is starting to get it wrong," says a prominent talent agent. "She's starting to look like someone else. Maybe it's the people who surround her. The hair people, the stylists ..." When a star's entire team is getting surgery, too, says the agent, they all start to live in a bubble of artificial reality.

Sooner or later, actors who've crossed that threshold—the Burt Reynoldses, the Chers—are labeled "uncastable." As casting director Steve Jacobs says, "In extreme cases, it becomes impossible to light them because they've taken all the lines out of their faces." Richard Hicks, a top casting director (Hairspray, Curb Your Enthusiasm) goes further: "There's no way to light them so that they don't look hideous. For the most part," he says, "what I find moving is the truth. And once you've had your face worked on, it's often not the same thing. There's an integrity to someone who doesn't get the face-lift."

Recently, the Wall Street Journal reported that major studios like Warner Brothers have doubled their casting staffs in Canada and England, places where actors tend to look more real. In the same piece, the Journal asserted that an actress who was up for a series this past spring was told she could have the job on the condition that she "lays off the injectables."

To escape the "damned if you do, damned if you don't" dilemma, some actors have begun to go public. "It's not as bad as the old days, when everyone was completely in the closet," says Linda Klein, a Nip/Tuck medical adviser. George Clooney has admitted he's had his eyes done, explaining, "I think it's important to look awake." (Though his publicist insists he was kidding.) Patrick Dempsey has copped to Botox. Men have a better chance, says Bowen, of pulling off the whole "It's just shit you have to do, what's the big deal?" bravado. But for most of Hollywood, the subject remains taboo.

Recently, however, a new solution has surfaced that some believe will make the whole plastic surgery debate moot. When Robert Zemeckis's latest movie, Beowulf (starring Angelina Jolie and Ray Winstone), debuted on November 16, audiences got the best look yet at Digital Enhanced Live Action, a new computer-graphic system that uses special body suits and more than 150 facial sensors per actor to manipulate thespians' on-screen appearances, making them look thinner, bustier, younger, or fuller of calf. The scrawny Jolie, for instance, becomes a voluptuous creature with a distinctly larger butt. All atwitter, Hollywood Reporter columnist Martin Grove has gone on record saying that with this technology, "plastic surgery can become a thing of the past."

This is, if you think about it, ridiculous. How many stars will want to attend the Oscars with 150 sensors stuck to their faces instead of a few scars?

See before-and-after shots of Angelina Jolie, Victoria Beckham, and others

Photos: Young, Bruce Gifford, Filmmagic; Jackson, Frazer Harrison, Getty Images