Twenty years ago South African-born billionaire Jocelyn Wildenstein was seen as a rare example of extreme plastic surgery.
Dubbed "Catwoman" because her multiple injections, implants, fillers, tighteners and surgeries were intended to morph her into a human version of the big cats back in her homeland, she was deemed a standout case of cosmetic surgery obsession.
These days, not so much.
Excessive plastic surgery by celebrities or those seeking fame by becoming known for it – such as "human Barbies" – is becoming more common.
Whether it's Hollywood-style pressure on retaining a youthful appearance, or something darker in the person's psychology, obsessive plastic surgery is on the rise.
According to one psychology report, Body Dysmorphic Disorder (BDD) occurs in 1 per cent of the general population, but in 7 to 15 per cent of cosmetic surgery patients.
And these people also tended to have high rates of major depression, substance use disorders, social phobia, eating disorders and obsessive-compulsive disorder.
At the very least, psychologists say patients can become addicted to the thrill they feel having a procedure which they believe enhances their attractiveness.
But it can relate to troubling issues such as low self esteem, and the boost they feel may press them into more procedures which begin to dismantle the structure of their faces.
Not only does excessive plastic surgery ruin the appearances of an increasing number of people, they look as if they belong to the same race of space aliens.
Celebrities re-emerge after a trip to Turkey, Brazil or a Beverly Hills clinic with the same puffy lips, identical square chins or strangely-shaped foreheads.
Actor Mickey Rourke could be fashion designer Donatella Versace's American brother, and actresses Meg Ryan, Daryl Hannah, Kim Novak and Melanie Griffith could be quadruplets.
Two of the more tragic examples – who were born identical twins and appear to be twinning themselves with duelling plastic surgeries – are French TV stars Igor and Grichka Bogdanoff.
With almost a spooky resemblance to Wildenstein, the Bogdanoff brothers – like her – are still injecting and filling into their seventies.
Back in the 1970s, there were just handsome
The French TV stars. who have noble Russian ancestry and a shared interest in science fiction and cosmology, were known for their programs about extraterrestrial phenomena and robots. The pair looked vastly different in their early screen appearances back in the 1970s, prior to their obsession with cosmetic surgery.
By the late 1990s, when the Bogdanoffs were headed into their fifties, they began having surgery and implants.
Regulars at the Cannes Film Festival, the twins now look like a cross between Kirk Douglas and Buzz Lightyear.
Igor has more bouffant hair and darker fake tan, while Grichka's cheek implants are so massive they must hurt and have scrunched his eyes into slits.
According to US statistics, the number of males having plastic surgery has steadily increased.
The American Society of Plastic Surgeons' annual report for 2019 says 18.1 million surgical and minimally-invasive cosmetic procedures were performed in the United States alone last year.
This compares with 13 million in 2011, and the top five procedures were breast augmentation followed by liposuction, eyelid surgery, nose reshaping and facelifts.
The top five nonsurgical procedures were Botox (7.7m procedures), hyaluronic acid or soft tissue fillers, chemical peels, laser hair removal and photo rejuvenation (IPL).
The American Society for Aesthetic Plastic Surgery's plastic surgery predictions for 2020, released before the COVID-19 pandemic back in January, was it would be a "landmark" year.
It predicted a "return of the facelift", as more patients realised injectable treatments do not last.
"The most effective, most natural, most long-lasting and overall most cost-effective treatment for facial ageing remains a well performed cheek and necklift," the ASAPS report said.
It also foreshadowed a continuing increase in facial procedures by men, and the rise of "Baby Botox", targeted micro injections of a neurotoxin to achieve a more natural, subtle look.
"Generation Z, people born in the late 1990s and early 2000s will seek out aesthetic procedures earlier in life as a preventive measure and in non-surgical ways," ASAPS said.
Some plastic surgeons are willing to keep operating on extremely altered people, such as 37-year-old Brazilian-British TV personality Jessica Alves.
Until recently Jessica was Rodrigo Alves, or the "human Ken doll", but after more surgery which included breast implants has now re-emerged as a woman.
The top five countries for plastic surgery are the US, followed closely by Brazil, Japan, Italy and Mexico
Statistics from all those countries show eyelid surgery was the most-requested procedure in the facial and head treatments category.
Most plastic surgeons rarely encounter patients wanting extreme plastic surgery.
David Wreath, MD, a plastic surgeon in Knoxville, Tennessee told WebMD that initially it is hard to recognise a burgeoning plastic surgery addict.
"Sometimes you start working with someone who is reasonable, and the more you work with them, you begin to realise you will have to extricate yourself," he said.
California women's studies professor Dr Natalie Wilson said many plastic surgeons would turn away a client once they were being pressured to do more work on a person's face than was warranted.
"But that is how they make their money – by doing surgery," she said, and some people became hooked on the positive feedback that came from the results.
"It makes us feel better and want that high again," Wilson said.
According to a paper written by Ohio psychiatry professor Randy Sansone and physician Lori Sansone, patients with Body Dysmorphic Disorder had higher risk factors.
These included higher levels of anger and hostility, lower self esteem and higher levels of perfectionism, higher frequencies of childhood abuse and neglect and more frequent suicidal ideation and attempts.
The Sansone's paper, Cosmetic Surgery and Psychological Issues, published in Psychiatry MMC compared patients without BDD seeking cosmetic surgery to those with the disorder.
Those with BDD also had significantly higher rates of "borderline, avoidant, paranoid, schizotypal and obsessive-compulsive personality disorders", the paper found.
A sad example of an obsession with plastic surgery to the point of disfigurement is Korean actress Hang Mioku.
She had her first procedure aged 28 and moved to Japan to have more operations.
When doctors refused to work on her any further, she injected some black market silicone into her face, then cooking oil.
Mioku has since had surgery to remove the silicone, oil and other foreign substances, but now in her 50s is permanently scarred.
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