The close of the twentieth century marked the centenary of modern surgical intervention to alter the image of the body. A list of the most common operations which were developed over the past century and are understood as ‘cosmetic’ procedures today are shown in the table.
| Operations on the face |
| Forehead lift: tightens the forehead and raises the brow |
| Facelift (rhytidectomy): tightens the jowls and neck |
| Eyelid tightening (blepharoplasty): tightens the eyelids |
| Rhinoplasty (nose job): changes the appearance of the nose |
| Otoplasty (ear pinback): brings the ears closer to the head |
| Facial implants (chin, cheek): makes the cheek or chin more prominent |
| Hair transplantation: treats male pattern baldness |
| Scar revision: improves the appearance of scars |
| Skin resurfacing (laser, peel, dermabrasion): smoothes the skin |
| Operations on the body |
| Breast enlargement: enhances the size of the breast |
| Breast tightening (mastopexy): tightens the skin of the breast |
| Breast reduction: reduces the size of the breast |
| Breast reconstruction: rebuilds the breast after cancer |
| Abdominoplasty (tummy tuck): tightens skin and removes extra fat |
| Mini-abdominoplasty: removes the lower abdominal pouching |
| Liposuction: removes extra fat |
| Arm lift: tightens the skin of the upper arm |
| Gynecomastia resection (large breasts in men): reduces breast size |
It is, of course, evident that virtually all procedures which could be conceptualized as cosmetic or aesthetic can also have a reconstructive dimension. Breast reconstruction, which used the same type of implant as breast augmentation, was the focus of a major debate within both medical and feminist circles in the US in the 1990s, as to whether it was reconstructive or aesthetic surgery. During the closing decades of the twentieth century these procedures, and also aesthetic orthodontics, came to be a common undertaking. Aesthetic surgery became a focus of interest — being patient-initiated, and non-reimbursable by private or state third-party payers.
While aesthetic surgery is related in many ways to other physical interventions, from hairweaving to tattooing and body piercing, it is performed in the quite different context of the institution of medicine. The surgical interventions are understood by doctors and patients alike as aesthetic rather than reconstructive. Even though the term ‘aesthetic surgery’ was acknowledged only recently, the practice of surgical interventions devoted to making people ‘beautiful’ rather than to any direct reconstruction of physical anomalies is relatively recent. There is a necessary if rather arbitrary distinction between reconstructive (plastic) surgery and aesthetic (cosmetic) surgery — between not having a nose and having a nose that you dislike. The first represents a functional fault. There is something wrong with the body as well as an unfortunate appearance — a hare lip, a missing jaw, a lost ear — and your desire is to repair the function of the body. Part of that function is, of course, an aesthetic one. Cosmetic surgery, which is part of, and grew from, reconstructive surgery, stresses the latter, subordinate, but essential aspect of the reconstruction. We imagine our bodies as intact and read our intactness as ‘beauty’. You may have a functional nose, a jaw, a breast, but it does not represent your self-image of the beautiful nose, jaw, or breast. It inhales, chews, or lactates, but it is not appropriate. The distinction between reconstructive and aesthetic surgery is an arbitrary one. Certain interventions have been labelled as inherently different — such as breast reconstruction vs. breast augmentation, even though the procedures are similar. The former are understood as a means of restoring physical completeness to the body image and therefore of restoring the psyche to a ‘happy’ state; the latter can be dismissed as ‘vogue fashions’ (R. V. S. Thompson, Kay-Kilner Prize Essay, 1994). Feminists in the 1990s, such as the American poet Audre Lorde, who underwent a radical mastectomy, argued against breast reconstruction as a refusal to acknowledge the realities of the woman's body. In the Middle Ages, Guy de Chauliac, perhaps the most important surgeon of his time, defined the role of surgery as being threefold: solvit continuum (separating the fused), jungit separatum (connecting the divided), and exstirpat superfluum (removing the extraneous). There is no discussion in his or other texts of that period about the creation of new body parts or their augmentation or reconstruction, although it is evident that virtually all primarily reconstructive surgical procedures also had an aesthetic dimension, even then. As early as the Edwin Smith Surgical Papyrus (3000 bce), surgeons were concerned about the cosmetic results of their interventions. The Egyptians were careful to suture the edges of facial wounds. Even fractures of the nose-bones were dealt with by forcing them into normal positions by means of ‘two plugs of linen, saturated with grease’ inserted into the nostrils. The Roman physician Aulus Cornelius Celsus stressed the ‘beautiful’ suture. This approach can be followed through to the late nineteenth and early twentieth century, with plastic surgeons such as Erich Lexer stressing the cosmetic ends of an operation as ‘an always more appreciated requirement of modern surgery’. Such a stress on the neatness and beauty of the closure was part of the image of the return to function following the operation, for the beautiful was a sign of the healthy — but of the healthy body, not the healthy mind.
Yet even as we understand aesthetic surgery as a means of altering our body's ‘image’ it becomes a means not only of changing our bodies but of shaping our psyches. Aesthetic surgery remains rooted in a presumed relationship between the body and the mind. Sculpting the body comes to be a form of reshaping the psyche.
The central assumption of aesthetic surgery is that if you understand your body as ‘bad’ you are bound to be ‘unhappy’. And in our day and age, being unhappy seems to be identified with being sick. And if you are sick, you should be cured! The idea that you can cure the soul by altering the form of the body became commonplace in the twentieth century. It is the other side of the coin from the argument that to cure specific bodily symptoms you need to ‘heal’ the psyche.
Elaine Scarry has remarked in her classic work The Body In Pain (1985),
… at particular moments when there is within a society a crisis of belief — that is, when some central idea or ideology of cultural construct has ceased to elicit a population's belief either because it is manifestly fictitious or because it has for some reason been divested of ordinary forms of transubstantiation — the sheer material factualness of the human body will be borrowed to lend that cultural construct the aura of “realness” and “certainty”.
It is this realness and certainty ascribed to an imagined as well as the real body which is operated upon by the aesthetic surgeon.
During a period of revolutionary change in science, from the mid nineteenth to the early twentieth centuries, two major developments took place which enabled surgeons to introduce aesthetic changes, and patients to overcome their anxiety and undertake such procedures. Antisepsis and anaesthesia became central to the practice of surgery, following the discovery of ether anaesthesia in 1846 and the development by the 1880s of local anaesthesia. The movement toward antisepsis paralleled the development of anaesthesia: the model for antisepsis provided by Joseph Lister in 1867 became generally accepted by the end of the century. Aesthetic surgery became a context in which the ideology of the medical alteration of the body (and its state) was accepted by both the patient and the physician. All of these concerns can be understood as concerns of ‘hygiene’ in the broadest nineteenth-century sense, a hygiene of the state of both the body and the psyche. This set the stage for the development of the procedures used today. Take the case of Jacques Joseph, a young German-Jewish surgeon practising in fin-de-siècle Berlin. In 1896 Joseph undertook a corrective procedure on a child with protruding ears (otoplasty), which, although successful, caused Joseph to be dismissed from the staff of the orthopaedic clinic at the Berlin Charité. One simply did not undertake surgical procedures for vanity's sake, he was told upon his dismissal. The child was not suffering from any physical ailment which could be cured through surgery. Yet, according to the child's mother, he had suffered from humiliation in school because of his protruding ears. It was the unhappiness of the child that Joseph was correcting. The significance of protruding ears was clear to Jacques Joseph and his contemporaries at that time. There is an old trope in European culture about the Jew's ears that can be found throughout the anti-Semitic literature of the fin de siècle, and it is also a major sub-theme of one of the great works of world literature, Heinrich Mann's Man of Straw (1918). In that novel, Mann's self-serving convert, Jadassohn (Judas's son?) ‘looked so Jewish’ because of his ‘huge, red, prominent ears’ which he eventually went to Paris to have cosmetically reduced; his ears signified his poor character. Jacques Joseph went on to pioneer the intranasal procedure for the reduction of the size of the nose and came to be known among the Jewish community in Berlin as ‘Nose-Joseph’.
The social and psychological significance of the introduction of aesthetic surgery is relevant to other external markers of difference, from ageing (face lifts), to sexuality (transsexual surgery), to notions of beauty of face (orthodontics) and of body (liposuction). The norms of the acceptable change with time, but the desire to become invisible, to become a member of a class or group to which one does not naturally belong, maintains itself over the entire history of aesthetic surgery.
— Sander L. Gilman
Bibliography
- Gilman, S. L. (2000) Making the body beautiful: a cultural history of aesthetic surgery. Princeton University Press, Princeton.
- Maltz, M. (1946). Evolution of plastic surgery. Froben Press, New York.
- Wallace, A. F. (1982). The progress of plastic surgery: an introductory history. Willem A. Meeuws, Oxford
