JUDGING BY APPEARANCES
What Is Aesthetic Surgery?
In a world in which we are judged by how we appear, the belief that we can change our appearance is liberating. We are what we seem to be and we seem to be what we are! All of us harbor internal norms of appearance by which we decide whom to trust, like, love, or fear. We act as if these internal norms are both fixed and accurate. But we constantly redraw these visual maps as we negotiate the world with all of its complexities. And as we see the world, the world is also seeing us, judging us by our appearance. To become someone else or to become a better version of ourselves in the eyes of the world is something we all want. Whether we do it with ornaments such as jewelry or through the wide range of physical alterations from hair dressing to tattoos to body piercing, we respond to the demand of seeing and being seen. Such visual judgments are ubiquitous and perhaps even necessary. But they also trap us. In the past hundred years we have increasingly turned to those whom we believe can permanently alter the way we look to othersto the aesthetic surgeons.
As we come to the close of the twentieth century, modern aesthetic surgery is celebrating its centenary. Most of the modern procedures employed in aesthetic surgery date to the 1880s and 1890s. Since then, the rise in the number of aesthetic surgery patients and procedures has been spectacular. The past two decades alone show startling growth. In the United States in 1981, 296,000 such procedures were undertaken; in 1984 there were 477,700 "aesthetic" operations; in 1996 the American Academy of Facial Plastic and Reconstructive Surgery's (AAFPRS) survey stated that 825,000 plastic and reconstructive procedures had been performed on the face alone in 1995, an increase of 9 percent since 1993. And the line between "reconstructive" and "aesthetic" procedures, as we shall discuss, is blurry. Moreover, as testimony to the popularity and growth of aesthetic surgery, in 1994 65 percent of these procedures were done on people with family incomes less than fifty thousand dollars a year, even though neither state nor private health insurance covers aesthetic surgery. To provide some sense of the relative scope of these statistics: during 1993, one out of thirty-five surgical procedures was "aesthetic," and of those, one in twelve was a nose adjustment; one in thirty, a face-lift; one in 1,992, a buttock implant. Surgery of the eyelid and hair transplants both enjoyed big increases from 1993 to 1995. Eyelid surgery (blepharoplasty) increased 37 percent and hair transplants increased 61 percent. (It remains to be seen whether the new over-the-counter pharmaceutical treatments for hair loss will put a dent in the hair transplant business.) The most frequently performed aesthetic surgery for women in 1995 was eyelid surgery (blepharoplasty); for men, nose jobs (rhinoplasty).
Such surgery is elective by definition. Elective procedures are unnecessary, or at least not immediately necessary. National health schemes or private insurers in basic coverage rarely cover them. And aesthetic surgery patients are seen as not really sick. Indeed, according to the definition of the "patient's role" by the influential American sociologist Talcott Parsons (1902-79), aesthetic surgical patients are not really patients at all. (This is another reason why insurers do not want to cover them.) Among the central qualities Parsons ascribed to the role of the patient was a "gain from illness." What do we get from admitting we are sick? The attention of a loved one or employer, a day off from work, flowers delivered to the sick room? There is little "gain from illness" for aesthetic surgery patients. Indeed, many of them keep their treatment a secret and thus forfeit all of the sympathy one gains from being ill. In addition there is none of the sense of mortality that defines Parsons's normal patient. For aesthetic surgery patients, the prognosis in terms of morbidity and mortality is almost ideal: people rarely are incapacitated or die from such procedures. There is little anticipated pain, and it is the patient, not the physician, who is supposed to judge the success of the procedure. Although consumer activists may urge us all to think of ourselves in relation to our doctors as clients rather than as patients, aesthetic surgery is the one area of medicine that makes widespread use of the term client rather than patient. I shall refer to these "clients" as "patients" throughout the book, although I am well aware that this is problematic. In spite of health coverage limitations, the expansion of the number of procedures understood as aesthetic surgery at the close of the twentieth century is immense. Aesthetic surgery has clearly become a potent force in contemporary attitudes to the body.
The growth of aesthetic surgery may also be gauged through the increased professionalization of aesthetic surgeons. In North America in 1997, three different "professional" groups invested colleagues with special credentials for aesthetic surgery: the plastic, aesthetic, and reconstructive surgeons, ear-nose-throat (otorhinolaryngologic) surgeons, and eye (ophthalmologic) surgeons. This credentialing is called "board certification"; the first of these boards for aesthetic surgery was the American Board of Plastic Surgery, which was organized in 1937 and admitted to the American Board of Surgery the next year. A board-certified surgeon is eligible to join one of the professional organizations of aesthetic surgeons. A number of professional groups of "board-certified" surgeons exist today. The oldest such association for aesthetic surgery in the United States, the American Association of Oral Surgeons, was founded in 1921. It became the American Association of Plastic Surgeons in 1942, and today is known as the American Society of Plastic and Reconstructive Surgeons, comprising 97 percent of all plastic surgeons certified by the American Board of Plastic Surgery. In addition there are the American Academy of Facial Plastic and Reconstructive Surgery, an organization predominantly made up of otolaryngologists; the American Academy of Cosmetic Surgery, an organization of a wide variety of medical specialists who are boarded either by the American Board of Medical Specialties (ABMS) or by the American Osteopathic Association; the American Society for Aesthetic Plastic Surgery, the self-acknowledged organization of aesthetic surgeons, which was founded only in 1967; the American Society for Dermatologic Surgery, an organization of ABMS-boarded dermatologists; the American Society of Ophthalmic Plastic and Reconstructive Surgeons; and the American Association of Oral and Maxillofacial Surgeons. But, of course, any physician, whether acknowledged as a specialist by his peers or not, can undertake aesthetic surgery. More and more non-"board-certified" physicians undertake aesthetic procedures every day, even dentists doing hair transplants.
Aesthetic surgeons of every description do a truly astounding number of procedures. In 1996 the total number of all aesthetic surgical procedures such as "nose jobs, tummy tucks, and other improvements" exceeded 1.9 million, up from 1.3 million in 1994. This is about one procedure for every 150 people in the United States every year; those who have had such a procedure are still a minority, but one that grows extensively each year. Part of what is so astonishing about this growth is the range of surgical procedures now offered under the rubric of aesthetic surgery. A list of common aesthetic procedures today would include the following operations on the face:
* Cheek implants, which use malar implants for the augmentation of the face
* Chin augmentation (mentoplasty), which uses implants
* Collagen and fat injections, which enhance the lips or plump up sunken facial features
* Ear pinback (otoplasty), which brings the ears closer to the head
* Eyelid tightening (blepharoplasty), which tightens the eyelids by cutting away excess skin and fat around the eyes, eliminating drooping upper eyelids and puffy bags below
* Face-lift (rhytidectomy), which tightens the jowls and neck
* Forehead lift, which tightens the forehead and raises the brow to minimize creases in the forehead and hooding over the eyes
* Hair transplantation, which treats male pattern baldness with a variety of techniques, among them scalp reduction, tissue expansion, strip grafts, scalp flaps, or clusters of punch grafts (plugs, miniplugs, and microplugs)
* Nose job (rhinoplasty), which changes the appearance of the nose
* Scar revision and the removal of common birthmarks (such as capillary nevus and port wine nevus), tattoos, and scar tissue (such as keloids, thick scar tissue that forms on an otherwise normally healing wound)all now undertaken by means of surgery or laser treatment
* Skin resurfacing (laser, chemical face peel, and dermabrasionsanding of the skin), which smoothes the skin, removing fine wrinkles, minor skin blemishes, and acne scars
and operations on the body:
* Arm lift (brachioplasty), which tightens the skin of the upper arm
* Breast augmentation, which can either increase the size of existing breasts or replace breasts removed through mastectomies
* Breast implant removal
* Breast reduction (mammaplasty), which reduces the size of the breast
* Breast tightening (mastopexy), which tightens the skin of the breast
* Buttock-lift and thigh-lift, which tighten the buttocks and thighs
* Calf and other implants, which shape the body
* Foreskin reconstitution (epispasm or posthioplasty)
* Liposuction (as well as lipectomy), which removes fat
* Male breast reduction (gynecomastia)
* Penile enlargement and implants
* Transgender surgery, which alters the form of the primary and secondary sexual characteristics
* Tummy tuck (abdominoplasty), abdominal apronectomy, or dermolipectomy, which reduce body size due to obesity, tighten skin, and remove fat (adipose tissue)
This is certainly not an exhaustive list, but it does give the reader some sense of the wide range of such procedures available today.
But this is not simply an American phenomenon. People all over the world are having aesthetic surgery in greater and greater numbers. The globalization of aesthetic surgery has spawned numerous centers that link surgery and tourism. North Americans have long gone to Mexico, the Dominican Republic, and Brazil; now the United Kingdom has started to offer "aesthetic surgery" tours for Americans as well. People in the United Kingdom still flock to Marbella in Spain for discreet face-lifts, but Poland and Russia are now competing for this market. For medical tourists in the Middle East, Israel has become the country of choice for many procedures, even for citizens of countries that do not have political ties to Israel; Germans visit South Africa for breast reductions and penis enlargements as well to see the Kruger National park; South Korea and Singapore are important for the Asian market; and Beirut, Lebanon, is the place to go for quick, no-questions-asked transgender surgery. Medical tourism has become big business, and aesthetic surgery, because of its elective nature, is a large part of the action. For every procedure recorded in one country, similar procedures are being undertaken on that country's citizens elsewhere. The International Confederation for Plastic Surgery and Aesthetic Surgery, which had its first meeting in Uppsala in 1955, comprises seventy-eight national societies, ranging from the Argentinean Society of Plastic Surgery to the Yugoslavian Society of Plastic and Reconstructive Surgery. Aesthetic surgery has become a worldwide phenomenon in the past few decades.
Why Is It Aesthetic Surgery?
From these statistics, the burgeoning popularity of "aesthetic" surgery is evident, but why is it called "aesthetic surgery"? The name aesthetic surgery seems to be a label for those procedures which society at any given time sees as unnecessary, as nonmedical, as a sign of vanity. "Aesthetic" surgery is the opposite of "reconstructive" surgery, which is understood as restoring function. In the Middle Ages there was no discussion of either type of surgery. And yet noses and other body parts were certainly lost to war, accident, and disease in the Middle Ages. Only with the Renaissance did surgeons begin to speak of aesthetic or beauty surgery. The Renaissance distinction between the "reconstructive" and the "aesthetic" reappears in the course of the nineteenth century.
The rise of aesthetic surgery at the end of the sixteenth century is rooted in the appearance of epidemic syphilis. Syphilis was a highly stigmatizing disease from its initial appearance at the close of the fifteenth century. The role of the new chirurgia decoratoria was to rebuild the noses of syphilitics so that they could become less visible in their society. An early historian of aesthetic surgery, Otto Hildebrand (1858-1927), himself a reconstructive surgeon, noted the relationship between the new aesthetics of the Renaissance, the outbreak of syphilis, which caused defects of an "unaesthetic" nature, and the rise of aesthetic surgery. But the innovations in aesthetic surgery that were developed in the sixteenth century vanished in Europe until the late eighteenth century, when a new age of syphilophobia began in Europe. After that point, surgeons began to seek a new name. Philippe Fredéric Blandin (1798-1849) suggested the term autoplasty for procedures in which skin is taken from the same individual for grafting purposes. Such grafting procedures to alter the form of the body were clearly understood as reconstructive in nature.
It was plastic surgery, not autoplasty, that became the dominant label for all featural and reconstructive surgery by the early nineteenth century. Pierre Joseph Desault (1744-95) proposed plastic surgery (from the Greek plastikos, meaning "fit for molding") in 1798 as the label for those procedures that repaired deformities and corrected functional deficits. Such surgery was to restore the body to its ideal prior state; it was understood as reconstructive. The term plastic became commonplace after Carl Ferdinand von Graefe (1787-1840) entitled his monograph on reconstruction of the nose Rhinoplastik (1818). Plastic surgery was initially understood as surgery on the nose. Following Graefe, there was a surge in the number of "... plasties," such as blepharoplasty, surgery on the eyelid. To avoid a plethora of such terms, Eduard Zeis (1807-68), in his 1838 survey of the state of the field, disavowed the continuous labeling of specific procedures after the model of "rhinoplasty." He wanted a single category for all reconstructive procedures on the face and body, and adopted Desault's term plastic surgery to encompass them.
Nevertheless the explosion of "... plasty" terms following Graefe did not and does not let up. I shall refer to the various categories and labels employed by the surgeons I will be discussing without giving any specific weight to them. Many of these terms are attempts to create priorities for specific techniques through the creation of new "plasties." At least one contemporary American aesthetic surgeon has commented that "the evocation of Greek roots is indicative of insecurity, frequently unconscious, among many cosmetic surgeons. In my presence, the head of a prestigious plastic surgery service chastised a resident who listed the procedure as a face-lift instead of a rhytidectomy, which the chief said `would look better to our colleagues.'" As with the proliferation of technical terms in clinical psychiatry, the status of the medical subspecialty determines the nature of the field's discourse. The lower the perceived status of a field within the general culture as well as within the culture of academic medicine, the more complex and "scientific" the discourse of the field becomes.
The Renaissance label beauty surgery was resurrected as early as the 1840s by the innovative German facial surgeon Johann Friedrich Dieffenbach (1792-1847). He used it with evidently pejorative overtones in order to contrast it with "real" reconstructive surgery. Dieffenbach, the "father of plastic surgery" (as most histories of reconstructive surgery consider him), again draws the line between reading a procedure as having a "real medical" as opposed to merely an "aesthetic" function. The history of aesthetic surgery evolves from a conscious or unconscious juxtaposition with reconstructive surgery. This juxtaposition is often (as with Dieffenbach) seemingly arbitrary, but always meaningful.
Certainly the most widely used popular designation for aesthetic surgery today is cosmetic surgery. (In the database of general newspapers and magazines for the past two years on Lexis-Nexis, reconstructive, plastic, and cosmetic surgery each have more than the maximum of one thousand citations; aesthetic surgery occurs only 126 times.) The term cosmetic in medicine has its origin in the subspecialty cosmetic dermatology. This field developed at the close of the nineteenth century and dealt with the improvement of "abnormal" appearance resulting from pathologies or trauma, including the use of corrosive cosmetics (such as lead compound face powder). Its antecedents can be found in the conflation of medicine and cosmetics in classical Egyptian and Greco-Roman medical texts, which will be discussed throughout this volume. The development of medical cosmetics in the late nineteenth century had its own specific form. Growing out of the popular racial ideology of lay writers such as Hermann Klencke (1813-81) during the 1860s, it was clearly intended to improve or preserve the attractiveness of the individual and thus improve the breeding of the race. This racial tradition maintained itself through the beginning of the twentieth century within the ideology of bodybuilding. This is closely related to cosmetology through the bodybuilder's emphasis on "sensible skin care." The racial view was an intrinsic part of the discourse used by medical dermatologists at the end of the century. This field quickly developed into a major part of what physicians were supposed to doand beauticians were not!
Aesthetic or cosmetic or beauty surgery began to appear sporadically in the course of the nineteenth century as labels for an alternative model of therapy, first within the tradition of reconstructive surgery, and then as its antithesis. Those who used these labels were aware that "cosmetic" or "beauty" or "aesthetic" surgery bore the pejorative overtones used by Dieffenbach. During and following World War I, there was a movement to expand the patient base by using for "aesthetic" purposes those techniques evolved in the treatment of soldiers. Even though early twentieth-century "reconstructive" procedures, such as the rebuilding of the "harelip," had been understood as "aesthetic" in the mid nineteenth century, the division between "plastic" and "aesthetic" surgery was made to seem absolute.
The self-conscious rise, during the closing decades of the nineteenth and the opening decade of the twentieth century, of surgeons who saw themselves as "beauty" surgeons was challenged by the postwar reconstructive surgeons, who saw aesthetic surgery as incidental to their practice. The best-known Allied reconstructive surgeon, the New Zealander Harold Delf Gillies (1882-1960), advocated seeing "aesthetic surgery" as a natural subordinate extension of "reconstructive surgery." In 1934 he called the field: "aesthetic, reconstructive surgery." He also condemned the "poorly qualified and very well advertised surgeons [who] have adopted the term, plastic surgery, without any true training in surgery and without any other surgical ability than to remove a few folds of skin or a small hump of the nose.... It is so easy to agree to do some cosmetic operations which may in fact not be justified, and it is so troublesome, sometimes, to decide whether in a particular patient the proposed operation will give that pleasure and satisfaction which it would in another." Many of the surgeons involved in rebuilding the fractured faces of soldiers came out of the newly developing world of aesthetic surgery, and they continued their practices following the war.
As a "positive" label, beauty surgery had begun in earnest in the opening decade of the twentieth century, but this term evidently was soon tainted, as Gillies's comments showed. The "beauty" surgeons were often simply denounced as quacks by the medical profession. In 1934 Jacques W. Maliniak (1889-1976) attacked the "brazen quackery that has attended the development of modern plastic surgery." This "quackery" was, however, not much different in its approach and success from the procedures developed and used by physicians within the medical establishment. The label quack was used to limit the investiture of those permitted to undertake "serious" interventions. The relationship of quacks with beauty surgery has a long history, stretching back into the eighteenth century, to the rise of anxiety about disease and its disguise.
In the eighteenth century, the Edinburgh "quack" John Taylor (1703-72), according to his own account, removed scar tissue from the lower lid of a burn victim's eye. The pain was excruciating, and the patient repeatedly shouted, "You hurt me, you hurt me!" to which Taylor replied, "Remember, Lady, Beauty! Beauty!" When he was finished, the woman's friends "were astonished and it looked as if the business had been done by some miracle." Taylor performed a number of aesthetic procedures, including removing part of the upper eyelid in a patient who suffered from a drooping eyelid (ptosis), using a procedure that would become commonplace a hundred years later in the age of Dieffenbach. Despite his evident skill, Taylor was a "quack" according to the Edinburgh Royal College of Physicians, which excoriated him in print. This was to no little degree because his stated goal was "beauty." For "beauty doctors," as William Hogarth showed in his Marriage à la Mode, offered the means of masking illnesses such as syphilis as well as restoring beauty. They provided the means by which diseased faces could "pass" as healthy. "Natural" beauty was a guarantee of the health of the individual as well as the health of the state.
The term beauty again became pejorative in American feminist rhetoric against aesthetic surgery in the 1980s. Beauty doctors and the beauty industry were not terms of endearment. In order to maintain the idea of the "beautiful" without using the terms beauty or cosmetic, the profession turned to the classical label aesthetic. The term aesthetic surgery, although used in 1903 to describe paraffin therapy, which shall be discussed in detail later, came into more common use only after 1934. This term, which differentiates the field from "reconstructive" surgery, is most commonly used today to describe elective procedures that alter the surface and shape of the body. The stress on the spelling aesthetic (rather than the less "literary" esthetic) has been noted by one commentator as helping to establish the "seriousness" of the field: "The `a' that precedes `esthetic' in most communications from official organizations of surgeons doing this type of operation also serves to upgrade the image by conferring on it a classical lineage." The irony is that over the past few years beauty parlor workers in the United States, earlier called cosmeticians, have begun to call themselves "estheticians." The classical lineage, with its conflation of health and beauty, is indeed part of the complex history of aesthetic surgery.
The debate about "priorities," which haunts most realms of modern science and medicine, takes on a special meaning in the case of aesthetic surgery. Who undertook the first modern facelift, nose job, tummy tuck, and so forth? This is not an "academic" question of who gets mentioned in the histories of the discipline. No medical subspecialty except psychiatry has spent as much time and effort documenting its own history. In creating an archaeology that places modern "aesthetic" procedures in historical line with (and parallel to) "reconstructive" procedures, aesthetic surgeons and their historians attempt to provide a "serious" medical context for aesthetic procedures. This is analogous to the creation of medical terminology. Within surgery, aesthetic surgery may well be unique in its concern for its own history. This concern parallels the modern creation of the field, certainly as far back as Dieffenbach and Zeis in the mid nineteenth century. The priorities debate among the historians of aesthetic surgery often turns on moments of transition from a self-consciously "medical" model, which does not acknowledge "beauty" as one of its goals, to a competing model of "aesthetic" surgery, in which the creation of a "beautiful" face and body is asserted as a legitimate medical goal. Such a movement takes place in the Renaissance and again in the nineteenth century. In the latter period surgeons not only tried to correct the ugliness that results from diseases such as syphilis, but they also tried to correct the "ugliness" of nonwhite races. Medicine's job became correcting the appearance of illness as well as its pathology. Racial science used appearance as a means of determining who was fit and who was ill, who could reproduce and "improve" the race and who should be excluded and condemned. In a world based on Enlightenment ideals of "disciplining the body and of regulating populations," to cite Michel Foucault, aesthetic surgeons began to offer ways of altering the body to make it appear "healthy" by making it appear racially acceptable. This took place in the 1880s and 1890s, in operations on the ear, the nose, and the breast. Only after this possibility of correcting the "ugliness" of disease and race had been established did other forms of "beauty" surgery begin to be a conceptual possibility. Once you can change what a society understands as unchangeable, such as racial markers, then it is possible to imagine altering other aspects of the body that seem permanent, such as signs of aging. The historical development of specific procedures mirrors the unique double face of aesthetic surgery as parallel to and different from reconstructive surgery.
Remaking the Self
Central to the growth of aesthetic surgery at the close of the nineteenth century was the ability of physicians to eliminate the pain of the operations and reduce the risk of infections. These changes emboldened patients to undertake such procedures more frequently. They could now cease to be mere patients and create the new and different role of medical client. Anesthesia became generally accepted and central to the practice of surgery after the discovery of ether anesthesia by William Thomas Green Morton (1819-68) in 1846. By the 1880s, the further development of local anesthesia, in the forms of cocaine for surgery of the eye, spinal (subarachnoid) anesthesia, and epidural anesthesia, meant that the greater risk of dying under general anesthesia could be avoided. Local anesthesia has played a central part in the development of aesthetic surgery as a widely practiced specialty. It is one of the primary factors in the successful outcome of the patient, who can follow the procedure and, unlike the patient under general anesthesia, does not morbidly fantasize about the opening of the body while unconscious. Under local anesthesia, aesthetic surgery can be experienced as a procedure a patient actively chooses, not a cure to which he or she passively submits under general anesthesia, giving up all control of the self. The patient's perception of autonomy is central to the popularity of aesthetic surgery.
The movement toward antisepsis paralleled the development of anesthesia. In 1867 Joseph Lister (1827-1912) provided a model for antisepsis that became generally accepted by the end of the century. The potential avoidance of infection meant that patients' anxiety about cutting the skin was lessened. The acceptance of antisepsis was relatively slow, but was strongly encouraged by aesthetic surgeons. On November 26, 1877, Robert F. Weir (1838-94), one of the major figures in the creation of American aesthetic surgery, said in a talk before the New York Medical Association that the acceptance of antisepsis in Britain and Germany had outpaced that in the United States. He urged that the smallest detail of the cleansing of patient, surgeon, instruments, and surgical theater be carried out so that the patient not be placed at needless risk. Once this was done, the risks attendant on aesthetic surgery decreased sharply because of the reduction in the high incidence of infection.
With pain and infection removed or reduced, aesthetic surgery came into its own. Yet anesthesia and antisepsis were necessary but not sufficient to mark the beginning of the modern history of aesthetic surgery. It was the Enlightenment ideology that each individual could remake him- or herself in the pursuit of happiness that provided the basis for the modern culture of aesthetic surgery. Indeed, it is remarkable how often aesthetic surgeons cite "happiness" as the goal of the surgery. "Happiness" for aesthetic surgeons is a utilitarian notion of happiness, like that espoused by John Stuart Mill (1806-73), who placed the idea of happiness within the definition of individual autonomy. You can make yourself happy through being able to act in the world. This was mirrored in the rise of modern notions of the citizen as well as the revolutionary potential of the individual. Autonomy stands as the central principle in the shaping of aesthetic surgery. "Sapere aude!" wrote Immanuel Kant (1724-1804), "'Dare to use your own reason'is the motto of the Enlightenment." The ability to remake one's self is the heart of the matter.
The Enlightenment self-remaking took place in public, and was dependent on being "seen" by others as transformed. This extended to the reshaping of the body, even within the world of fashion: "At home, one's clothes suited one's body and its needs; on the street, one stepped into clothes whose purpose was to make it possible for other people to act as if they knew who you were. One became a figure in a contrived landscape; the purpose of the clothes was not to be sure of whom you were dealing with, but to be able to behave as if you were sure." The rise of aesthetic surgery required the physician and the patient to accept an ideology of the medical alteration of the body and the state. And yet, as we shall see, there is an inherent tension between the Enlightenment promiseYou can become one of us and we shall be happy togetherand the subtextThe more you reshape yourself, the more I know my own value, my own authenticity, and your inauthenticity. You become a mere copy, passing yourself off as the "real thing."
Happiness, the central goal of aesthetic surgery, is defined in terms of the autonomy of the individual to transform him- or herself. Thomas Jefferson famously included the pursuit of happiness in his Enlightenment list of the ideal goals of the autonomous citizen. Happiness in this context is a "peculiarly modern, Western idea," as Richard Sennett comments. By the late nineteenth century the belief that the surgeon can cure unhappiness is entrenched in aesthetic surgery. A generation later, in 1929, the Portland, Oregon, "beauty" surgeon Adalbert G. Bettman (1883-?) took it as given that aesthetic surgery "has been perfected to such a degree that it is now available for the improvement of patients' mental well-being, their pursuit of happiness." The Enlightenment debate about the individual's autonomy to remake him- or herself is linked to the power of the institutions of medicine and to the new role of the aesthetic surgeon, not just to heal illness but to fulfill the patient's desires.
All of these changes in aesthetic surgery took place following the most wrenching political revolutions (from the American and French revolutions to those of 1848 and the American Civil War). The revolutions continued, however, in the fields of "science" from Louis Pasteur (1822-95) to Robert Koch (1843-1910) to Thomas A. Edison (1847-1931). The transformation of the Enlightenment notion of self-improvement moved from the battlefield of liberalism to the laboratories and surgical theaters of the later nineteenth century. This is the further context of aesthetic surgery. This age prefigures the revolutionary movements of the late nineteenth and early twentieth centuries. All of the destabilization that had been experienced and repressed following mid-century came to be experienced again in a sea change in imagining who we are and what our bodies are. It is not that the reconstructed body was "invented" at the end of the nineteenth century, but rather that questions about the ability of the individual to be transformed, which had been articulated as social or political in the context of the state, came to be defined as biological and medical. The political "unhappiness" of class and poverty, which led to the storming of the Bastille, came to be experienced as the "unhappiness" found within the body. In each case, the body was the location of the "unhappiness." In the former, it was revolutionary change that would cure the body; in the latter, it was the cure of the individual by which the unhappiness would be resolved.
In the great political movements of the late nineteenth and early twentieth centuries, these dynamic patterns again merged. George Mosse has shown that the revolutionary movements of the late nineteenth century, Zionism, Communism, and Fascism, also reworked the notion of the body as one of their core beliefs. Each wanted to create, for its own purposes, new bodies, which represent the potential of the new system. This political transmutation of the body is also central to the culture of aesthetic surgery. You can become someone new and better by altering the body. In liberal societies it is often imagined as the transformation of the individual, such as the immigrant, into a healthy member of the new polis. The individual can be transformed and made happy. Aesthetic surgery accepts this premise, and adds that such happiness also can be the result of medical practice.
The happiness of the physician parallels that of the patient. The surgeon's happiness comes to be a sign of his ability to transform himself. The rise of aesthetic surgery marked the professionalization and organization of modern medicine. The increase in the social status of the physician/surgeon in the Enlightenment meant an increase in the financial rewards associated with becoming a medical professional. If you were a "real" doctor, you had status and money. Not being a real doctor meant you were a "quack" and were economically marginalized. One could simply not risk being called a "quack," a term often used for the early aesthetic surgeons as well as the syphilis doctors, because it marked one as beyond the boundaries of social and professional status. By the middle of the nineteenth century, the reconstructive or aesthetic surgeons and the syphilologists were all elbowing their way into the medical establishment. They did not want to be seen as doing the work of the beautician or "quack," but that of the medical practitioner. But their ability to enable people to "pass" as different made their position marginal. Passing was the nineteenth century's pejorative term for the act of disguising one's "real" (racial) self. It was also the ultimate articulation of the Enlightenment notion of transformation. The transgressive act of "passing" showed how tenuous the boundaries in the social order really were. The newly enfranchised physicians derived their status and income from escorting patients across these boundaries.
When the successful American surgeon Maxwell Maltz (1899-1975) remembered deciding to become a "plastic surgeon," he set his memory in a dialogue with his Jewish mother in New York City in the 1920s. "What was a plastic surgeon anyway? ... From what I told her it seemed nothing more or less than a beauty doctor, a movie-picture kind of doctor, not a real doctor like the man who pulled out tonsils and cured scarlet fever. So you don't like your nose so you cut it Off?" That Maltz in 1953 imagines such a conversation (accompanied by "steaming golden soup") set before World War I is an indicator of how racial models of "passing" accompanied the stigma of the "aesthetic quack." Quackery lay not in being a "beauty" doctor, but in making it possible for others to disguise themselves through surgery. Such a role put the aesthetic surgeon, no matter how skilled or how well trained, beyond the pale of the new field of reconstructive surgery.
But in the Enlightenment ideology of nineteenth-century medical science, the hygiene of the body became the hygiene of the spirit and that of the state. A concern with "hygiene" in the broadest sense and aesthetic surgery's role in the physical alteration of the "ugliness" of the body led the aesthetic surgeon to become the guarantor of the hygiene of the state, the body, and the psyche. He (with one exception, all of the early aesthetic surgeons were men) provided a type of surgical eugenics, a means of improving the individual and, through the individual, the state. Daniel Kevles defined a tension between the "old eugenics" of selective breeding and a "new genetics" of genetic manipulation. Aesthetic surgery is, as we shall see, more closely allied to the latter than to the former. Eliminate or transformthis was and is the dilemma of nineteenth- and twentieth-century biological science and its cousin, medical practice. Aesthetic surgery could transform the body into a new and happier one, one that fulfilled the expectations of a new society and changed as these expectations changed.
The pursuit of happiness through aesthetic surgery presupposes decisive categories of inclusion and exclusion. Happiness in this instance exists in crossing the boundary separating one category from another. It is rooted in the necessary creation of arbitrary demarcations between the perceived reality of the self and the ideal category into which one desires to move. It is the frustration or fulfillment of this desire that constitutes "unhappiness" or "happiness." The patient and the surgeon know that there is a group that the patient wants to join, and that the surgeon can help him or her to do so. The surgeon can enable the patient to "pass" as a member of the desired group. The categories defining such groups seem to be "real." They seem not to be invented, and thus appear to be quite separate from the imaginations of both patient and surgeon. Yet they are as much a product of the desire of both as any reality beyond them. The nineteenth-century "Jew" who desired to be a "German" assumed that "German" was a real category defined in nature rather than a social construct. "Passing" is thus moving into and becoming invisible within a desired "natural" group. The model of "passing" is the most fruitful to use in examining the history and efficacy of aesthetic surgery. Taken from the history of the construction of race, not gender, it provides the most comprehensive model for the understanding of aesthetic surgery.
The patient believes that there is a desirable category of being from which he or she is excluded because of reasons that are defined as physical. The results of this exclusion are symptoms of psychological "unhappiness." Other signs present in the external world may well mark the exclusion, but they are seen as corollaries of physical difference. The individual desires to join a new community defined economically, socially, erotically (or in all three ways), but this group is primarily defined physically. The surgeon believes that with ever more innovative medical interventions, the patient can be enabled to "pass." The surgical techniques must constantly evolve so as to perfect the illusion that the boundary between the patient and the group never existed. The individual must seem to have always been a member of the cohort. Each set of procedures enables individuals to "pass." The problem with this is that beauty is culturally constituted, and so that which made you (in)visible in one generation or in one place marks you as visible in another.
Each physical category must be so constructed that it has a clearly defined, unambiguous antithesis (hairy/bald, fat / thin, large-breasted / small-breasted, large nose / small nose, male / female). These categories are all socially defined so as to make belonging to the positive category more advantageous than belonging to the negative category. The advantage of each constructed category changes as the society that recognizes it changes. "Fat" has a positive value in certain societies at certain times, for example, as a sign of prosperity. In other societies at other times "fat" has a negative value as a sign of ill health. Indeed, definitions of "fat" and "thin" change from time to time and place to place. What remains constant is the idea that the external body (with whatever qualities are ascribed to it) reflects the values of the soul. To "pass," one must be able to move from a negative category (bald) to a positive category (hairy), which means moving from a negative character to a positive one. Although such categories are subject to continual change, surgeons and patients act as if they are permanent. Indeed, in the construction of ever finer differentials (such as we shall see in the creation of "ethnic appropriate aesthetic surgery" in the 1980s) the antitheses are simply made more specific.
Since the early nineteenth century these categories of inclusion/includability and exclusion/excludability have been defined in terms of "pariah" groups constructed in categories such as race, gender, and class. At any given moment we each know to which group we belong and to which we do not. The gendering of aesthetic surgery is only one aspect of these social constructions of ideal (read: beautiful) groups. Its importance lies more with the nature of the category than its gender specificity. The dichotomy between the "large-nosed" and the "small-nosed" presents an analogous antithesis to the constructions of gender as in male / female, butch /fem, gay / straight, and so on. Within the history of aesthetic surgery the categories are initially those of "pathology" (healthy / diseased) and "race" (Jew / Aryan, Irish/English, black/white). Operations on ears and noses are pejoratively labeled aesthetic in the late nineteenth century because they enable individuals to "pass" as "normal," that is, as neither Irish nor Jewish. The initial operations to mask pathological and/or racial signs are only then followed by the development of other "aesthetic" operations to remove signs of aging or to transform the structure of the genitals. These enable individuals to pass into other cohorts, to become young or female. Many of these categories, such as breast reduction, become "aesthetic" when they are tied to the alleviation of perceived racial "stigmas." The alleviation of these sources of perceived unhappiness is undertaken so that the individual can "pass" and become "happy." Categories of unhappiness such as looking too old are tied to class or at least economic definitions of happiness. These all (in complex ways) are defined by and define the bipolar notions of "beauty" and "ugliness, "happiness" and "unhappiness."
American racial literature of the turn of the last century asserted that "a face can be said to be indisputably beautiful only when it unites features befitting the bearer's age, sex, and race, with the signs of blooming health, and if it be disfigured neither by deformity nor by the traces of some or other impairment nor by the reflection of spiritual disharmony." Such idealized notions of "beauty" demanded eugenic controls to avoid the pollution of the body politic by the ugly and deformed. Thus, in addition to the legal bars against "racial" categories, such as those that kept the Irish, Jews, and African Americans, as well as the "contagious" (as Judith Walzer has shown in her study of Typhoid Mary), from appearing in specific social environments, there have been laws against the "ugly." These "ugly laws" were generally part of vagrancy laws, which imposed fines on "unsightly" people who were seen in public places. In my home city of Chicago, the infamous Chicago municipal code 36-34 (1966) (repealed in 1974) imposed fines on persons who appeared in public who were "diseased, maimed, mutilated, or in any way deformed so as to be an unsightly or disgusting object." Such laws are the equivalent of the "Jim Crow" laws in the South or the Nazi posting of signs ordering Jews not to enter parks. They heighten the sense of one's visibility. No wonder individuals desired to become "(in)visible" by looking like the group in power.
The discourse of "passing," which comes out of the racialization of nineteenth-century culture, is the very wellspring of aesthetic surgery. The boundary between reconstructive and aesthetic surgery was distinguished on the basis of the introduction of procedures that were seen as enabling individuals to "pass." "Aesthetic" procedures were and are those that enable individuals to pass into a category that they perceive as different from themselves. Given a general scientific acceptance in the nineteenth century of a permanent human constitution, which intimately connected the internal and external qualities of a human being, aesthetic surgery could not be seen as "real" medicine. A medical procedure that attempts to "correct" the "uncorrectable" simply masks the reality of the individual. The attempt to alter the unalterable, to change the psyche of the individual by changing his or her physiognomy meant creating a simulacrum of a human being rather than a "new person." But, of course, those wanting to "pass" had to believe that changing the exterior also changed the inner reality or at least that society would accept the external appearance as a true indication of the internal reality. Following the Enlightenment notion of human autonomy, "passing" not only was possible but also became an imperative for some members of certain race, class, and gender groups in the nineteenth century.
These groups placed what Lawrence Haworth has called "critical competence" at the center of their definition of the human being. Each individual must be autonomous, which Thomas Scanlon defines as seeing "himself as sovereign in deciding what to believe and in weighing competing reasons for action." You are the sum total of what you believe yourself able to become. This is the ideological underpinning of "passing." It is what Isaiah Berlin has called "positive liberty": "I wish to be somebody, not nobody ... self-directed and not acted upon by external nature or by other men as if I were a thing, or an animal ... incapable of playing a human role, that is, of conceiving goals and policies of my own and realizing them." The parallel between refusing the constraints of "external nature" (the ill or deformed body) and the desire to play a "human role" lies at the very heart of aesthetic surgery as a means of expressing autonomy and thus "passing." But if claiming the right to change one's body is a claim of autonomy, relying on a surgeon to execute the change is a surrender of autonomy. This tension marks the history of aesthetic surgery from its inception and continues to define it today.
Following the influential sociologist Max Weber's (1864-1920) argument about the construction of validity through group consensus, one can see "passing" as a type of silent validation. Belonging to a new group must evoke certain responses by third parties (such as erotic or economic acceptance), and the most important of these are silent. The person with a "too-small" nose who has had aesthetic surgery is accepted without comment into the world of the large-nosed people, and the small-breasted person after a surgical procedure silently enters into the cohort of the large-breasted. Silence is acquiescence. If there is any sign that one is unable to "pass," then the procedure must be considered a failure. If the cohort is able to detect the alteration, it will make some further distinction between "authentic" and "inauthentic" bodies, and "passing" becomes impossible. Each age recognizes the reconstruction of the body in its own time. Such rejection, however, is usually not because of the surgeon's limits but because of the psychological makeup of the patient or of the cohort. Belief is everything, and once one begins to recognize in others or in oneself the marks of transformation, no silent acceptance is possible.
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