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Sunday, 29 September 2013

Cosmetic Surgery - Culture or Couture?

Contrary to popular belief, plastic surgery predates Beverly Hills. In fact, the origins of reconstructive surgery predate modern America. The term “plastic surgery” stems from the Greek word πλαστικος (plasticos), meaning “to mould” or “give form”. However, the origins of the specialty even out date this archaic linguistic root. The early Egyptians are generally credited as the pioneers of the specialty, with the Edwin Smith Papyrus describing the surgical management of facial trauma some 3000 years ago. It was not until 1818, however, that this word was applied to reconstructive surgical procedures by Von Graefe in his work Rhinoplastik. Reconstructive surgery has therefore been around for a long time, absorbing various components of related specialties along its evolutionary course to become what it is today. Towards the end of the 19th century, Listerian principles and advances in anaesthetic technique allowed surgery to be a safe, predictable, and available undertaking. It was perhaps inevitable, therefore, that the concept would soon be entertained of performing surgery for reasons other than the reconstruction of damaged anatomy. The first documented cosmetic rhinoplasty was undertaken by John Roe (an American) in 1891. Since that time, advances in reconstructive surgery have gone hand-in-hand with similar applications to cosmetic procedures. The very fact that the Hippocratic Oath states “primum non nocere” (or “first do no harm”), has led physicians, surgeons and laymen alike to question the ethics of performing “unnecessary” surgery.
The difficulty arises when the surgeon and the patient population are faced with an ever-changing idea within a particular society as to what exactly constitutes “normality”. Body image and the concept of ideal beauty have undergone many changes in the last two centuries alone. In 18th century Georgian England, women attended court in false teeth, false bosoms, false calves and even, with the help of belladonna (deadly nightshade), falsely enlarged pupils to increase their sex appeal. Corsetry has enjoyed a prolonged period as a favourite among women over the years as an aid to attaining the slimmer, more attractive waist. Little, however, is mentioned of the discomfort involved in such attire and the two years of regular use required before the internal organs were repositioned to the extent that the waist was the desirable hand’s width across. Acceptable body shape also differs according to geography, with social norms varying with cultural diversity. For over a thousand years, until only last century, it was considered a desirable quality in Chinese women to have dainty feet. For this purpose, the feet were cut and bound at an early age in order to encourage an organically grown heel which would cause the woman to hobble upon walking. Indeed, the woman’s value as a love object was in direct proportion to her inability to walk. When faced with such extreme measures historically undertaken to achieve the desired “look”, cosmetic surgery seems humane and civilised by comparison. What is more grotesque, the woman from Chad who stretches her lips to absurd proportions by the use of metal rings, attached since early childhood, to achieve beauty or the woman from England who attends an outpatient clinic to have an injectable synthetic material implanted into her lips to achieve voluptuousness. Many would call the latter vanity, but happily condone the former under the facile umbrella of “culture”.
The chicken-and-the-egg conundrum can be aimed towards the evolution of cosmetic surgery. Was the exponential boom in the cosmetic surgery industry in the latter part of the last century due to a change in the public perception of the specialty, or was public interest spurred in a self-perpetuating cycle by the increasing availibility of the surgery? Certainly public perception has changed. In 1923, a vaudeville actress by the name of Fanny Brice had her nose “bobbed” to reduce the size and shape of what was considered to be a sign of her Jewish heritage. Many at the time wondered, aghast, as to why she had done it. By stark contrast, a mere 40 years later, there arrived on the entertainment scene an actress and singer by the name of Barbara Streisand (who, in an ironic twist, played the part of Fanny Brice in the movie Funny Girl). This time, many wondered, aghast, why on earth she had not done it. This is testament to the rapid change in the accessibility of cosmetic surgery, especially in the United States of America. There are several reasons to account for this increasing acceptance of cosmetic surgery, not least of which takes us back to the previous paragraph on the ever-changing nature of social norms. If one considers Marilyn Monroe as the quintessential beauty icon of the 1950’s, it is no great secret that her hourglass figure was achieved by a combination of large hips, a large bust, and a relatively small waist. With the help of a corset and shaped bra, and during an era where bare flesh was rarely displayed, it was relatively easy for the average women to emulate this fashion silhouette without resorting to the surgeon’s blade. As time marched on, fashions changed, and the arrival of the “Baywatch Babe” and the “Waif” coincided with an era where nakedness was accepted and less was considered more by the underwear and swimwear fashionistas. This social pressure meant that those women not genetically suited to the trend, and who could not, or would not, undertake the torturous crash diets required to achieve this shape, were increasingly turning to cosmetic surgery as a quick means to an end. Thus it was comparatively easy to conform to the fashion and advertising fads in the former part of the last century than those inflicted on us more recently.
Quite apart from the view of society is the view of the individual. The extent of deformity is not necessarily proportional to the degree of distress it causes. A child with severe facial asymmetry due to a congenital birth defect may have grown to accept his or her face depending on their own personality characteristics and their personal support networks, such as family and friends. Equally, a child from a similar background may be suicidally depressed due to a minor disparity visible only to the trained eye (and, of course, to the patient themselves). Every reconstructive surgeon has a similar tale among his caseload. It is easy to suggest that the features with which we are born are ours to keep, and as such we should learn to live with them as testament to our strong character. However, the proponents of this particular mindset tend to be either people who are fortunate enough not to be afflicted with the feature in question, or people who are blessed with the type of personality that can take a blow from nature’s battery on the chin. Unfortunately, there is a percentage of the population who are both unhappy with their appearance and who lack the supposed moral fibre to come to terms with their condition. For these people, cosmetic surgery has become a beacon of hope. It should be stressed at this stage that professional psychological support is an essential component in the cosmetic surgeon’s multidisciplinary team. Much surgery can be avoided by concentrating on the psychology behind the patient’s desire to change themselves.
Of course, regardless of this, there will always be a cohort of people who will never look at cosmetic surgery as a worthwhile practice. Reconstructive surgery is widely considered a noble and acceptable vocation, as it attempts to restore features damaged by trauma back to a semblance of normality. In this way it can be viewed as quality-of-life-saving surgery. But there is a thin line between what could be considered cosmetic, and what could be considered reconstructive. An abdominoplasty (or ‘tummy-tuck’) is generally considered to be a cosmetic procedure. However, when performed on a striated and pendulous abdomen, secondary to multiple pregnancies, or after massive weight loss, it tends to fall more under the mantle of  reconstruction. It might be considered a genetic ‘accident’ that our features are how they are. In this way it is as much out of our control as an assault in a dark alley. Thus a man born with a large nose (by comparison to social norms) should have as much recourse to surgery as a man left with a dorsal hump to his nose following damage by a blunt object. So regardless of aetiology, it is always vanity that drives the need for surgery from a cosmetic point of view. The Oxford dictionary defines ‘vanity’ as ‘excessive pride in or admiration of one’s own appearance or achievements’. It is also defined as ‘the quality of being worthless or futile’. Both meanings stem from the same Latin word vanus, meaning ‘empty, without substance’. The common perception is that cosmetic surgery involves vanity above and beyond that of reconstructive surgery, as it is the search for perfection over normality. Again, this is not necessarily the case. Following women’s emancipation, there came a gradual acceptance in society for women to both  follow the career path of men, and to follow career paths based on the vices of men. Thus in the 1940’s, women were undergoing breast reduction surgery not only to fit into the boyish fashions of the time, but also to hide their feminine charms in order to appear more professional alongside their male colleagues. On the other side of the coin, more recently, women were seeking breast augmentation in order to get better pay as exotic dancers, glamour models, or stars in the adult film industry. Thus ambition, rather than vanity, was a driving force for these women. In the same way, the acting profession pigeon-holes actors and actresses into age groups for casting purposes. Clearly, the choicest jobs are given to those in the younger adult age group, leading many with aspirations of stardom to undergo rejuvenation surgery. Again, this is not so much a question of vanity, but the dog-eat-dog reality of Hollywood.
In the United Kingdom, this debate takes on an extra dimension, as one has to consider the impact of different surgeries on the National Health Service. Reconstructive surgery has a place in the NHS, but cosmetic surgery obviously does not. The difficulty is in separating the two. When faced with an eight year old boy with prominent ears who is getting mercilessly teased at school, even the stoniest heart would suggest that otoplasty would be a worthwhile procedure to undertake on the young man in order to bring his ears back to a less noticeable position. Let us remember that his hearing is perfect, and although his ears are prominent, they are within the normal spectrum of ears for a child his age. Without surgery, he could lead a perfectly normal life. Compare this with an eighteen year old girl who has reached sexual maturity, but whose breasts have never grown beyond the buds of pubescence. She has reached an age where body image, and especially secondary sexual characteristics, is extremely important. She, too, is getting bullied by her peers, colleagues, and co-workers. Without surgery, she could still lead a perfectly normal life. She opts for surgical breast augmentation. Suddenly, to the supporters of the young boy, we have left the world of reconstruction and entered the shadowy world of cosmetic surgery. In fact, as I have shown, the two cases are both cosmetic in the strictest sense, although because of the distress caused to the patients by their respective conditions, they might equally be labelled reconstructive. Either way, neither one is morally justified over the other.
In conclusion, there is a grey area separating cosmetic and reconstructive surgery. Although the latter generally enjoys the better reputation and its practitioners are held in higher regard by the general public, it should not be assumed that the former is merely the frivolous exploitation of technology in order to feed our immortality complex and serve our shallow vanities. There are many psychosocial factors involved in both the initial choice, and the sequelae of cosmetic surgery procedures. The quality-of-life benefit, both socially and psychologically, seen by those who choose to undergo the knife in the name of improved cosmesis is often the only justification needed for the surgeons practising this dynamic and demanding specialty.


  1. Nice essay - Is there a line to be drawn at body dysmorphic issues? Where counselling / psychology / other non-surgical procedures are perhaps better than fixing the perceived 'fault'? I guess that there is a line but are practitioners mandated to not cross it?

  2. Good points. That is where counselling has a place in cosmetic surgery. However, many psychologists are now suggesting cosmetic surgery as a possible treatment for BDD... after psychotherapeutic avenues exhausted, of course