The Making of the Modern Face:

Cosmetic Surgery /BYELIZABETHHAIKEN

n November 11, 1960, Rod Serling invited CBS viewers to join him in The Twilight Zone. The episode that aired that night"The Eye of the Beholder"begins as Patient 307 (later identified as Miss Janet Tyler), her head swathed in gauze, waits in her hospital room. "I never really wanted to be beautiful," Tyler tells her doctor. "I just wanted people not to scream when they looked at me." Her doctor is sympathetic and confides his confusion to a nurse: "What is the dimensional difference between beauty and something repellent? Why shouldn't people be allowed to be different?" But with Tyler, he is regretfully stern. She has exhausted her state-rationed medical opportunities, he reminds her; should this effort prove unsuccessful she will be "allowed" to move into a special area where people of her type have been "congregated." Tyler protests: "The state hasn't the right to penalize someone for an accident of birth...hasn't the right to make ugliness a crime!" The doctor shrugs helplessly, lights a cigarette, and turns away. In true Serling style, the twist at the end is starding, if predictable. In an oddly ethereal sequence, the layers of gauze unwind to reveal the teen beauty queen face of Donna Douglas. The doctor and nurses gasp in horror, and the camera finally pulls back to reveal a society of aggressively identical pig-like beings, which has no room for someone like Janet Tyler. In 1960, this episode could have been interpreted in a number of ways: as a pointed comment on the McCarthy era (the pig faces being reminiscent of George Orwell's 1984); as a critique of conformity (the vision is as chilling as the one Kurt Vonnegut describes in Harrison Bergeron, in which piercing noises stymie

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intellectual creation and weights tie dancers to the ground); as a comment on the burgeoning civil rights movement (there is no mistaking the message about the kind of society created through practices like segregation); even as a sally in the American Medical Association's campaign against "socialized medicine" (the not-so-veiled reference to the rationing of medical care). But it was taken as none of these. The collective memory of those who saw this episode is that it was about beauty, and about the peculiarly unforgiving culture of modern America, which had set certain standards and rewarded those who met themand which had invented cosmetic surgery for those who did not. Cosmetic surgery is one branch of what we now call plastic surgery (from the Greek plastikos, to shape or mold). Precedents can be traced around the globeto India, hundreds of years B.C., where members of a brickmaker caste tried to reconstruct noses cut off as punishment for adultery; to sixteenth century Italy, where Gasparo Tagliocozzi pioneered techniques to repair the facial scars that resulted from frequent duels (Stark, 1975, 509510)but the history of plastic surgery is essentially a twentiethcentury story. At the turn of the twentieth century, cosmetic surgery appeared to contradict both the traditional American injunction against vanity and the Hippocratic injunction against doing harm and reputable surgeons, who derisively called it "beauty" surgery, generally refused to perform it. Now, at the turn of the twenty-first century, cosmetic surgery seems to embody the American dream, and physicians of all persuasions cannot hang out their shingles (or launch their websites) fast enough. And despite its international origins (and its apparendy increasingly international future), the story of the branch of plastic surgery we call cosmetic surgery is essentially, and peculiarly, American.^ In the early part of the 20th century, Jacques Joseph perfected noses in Berlin, Suzanne Noel smoothed wrinkled brows in Paris, and during the first World War, French, British, and American surgeons worked together in wartime surgical services as pioneers in what was then known as maxillofacial surgery (Barsky, 1978, 1019). Only in the

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United States, however, did this experience translate into a postwar boom in cosmetic surgery.^ The culture that produced cosmetic surgery is the increasingly visual, psychologized culture of the twentieth century United States. Early in the twentieth century, the intertwined processes of industrialization, urbanization, immigration and migration transformed the United States (Higham, 1973; Kraut, 1994). From a predominantly rural nation, in which identity was firmly grounded in family and region, and in which wrinkles and sagging breasts were simply facts of life, the United States became an increasingly urban nation, in which identity derived from self-presentation (Susman, 1984, 273-274)and in which wrinkles were no longer facts to be accepted but "problems" to be conquered. Proponents of aesthetic surgery, who began to discuss and emiphasize the social and economic importance of external appearance, were inspired by this new culture even as they themselves helped to shape it. In more recent years, the extension of a western (and by nature westernizing) visual culture around the globe has influenced both the desire for aesthetic surgery and its practice. Just as in the 1920s movies and fan magazines taught young American women that beauty looked a certain way, today young Asians and Africans cannot help but come in contact with American fashion magazines and American movies, which familiarize them with Western ideals of beauty.^ Cosmetic surgery is one of the fastest-growing medical practices in the world. The American Society for Aesthetic Plastic Surgery recendy reported that more than two million Americans elected to undergo cosmetic procedures, both surgical and non-surgical, in 1998an increase of four percent over the previous year. And since this organization's statistics cover only activities reported by three specialty boards (plastic surgery, dermatology, and otolaryngology), the number of procedures performed in North America alone is clearly higher. Worldwide, from China to Peru, the number of people who are convinced that anatomy does not equal destiny increases each year (Hoge, 1980; Stanley, 1995; Koop, 1998; Pomfret, 1999). And while much is made over body

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sculpting, the fact that, in 1998, liposuction continued to rank first in popularity and breast augmentation inched back up to second should not obscure the fact that the procedures ranked numbers three, four, and fiveeye surgery, face lifts, and chemical peelsall concern the face, which remains (even in these Baywatch days), the locus of individual identity.^ The words used to describe their work have changed over time, but for those who practice cosmetic surgery, thinking about the meaning of their workits historical precedents, its cultural connotations, its implications for the futurehas been as important (and at least as challenging) as learning to use a scalpel or a laser. That facial surgery is grounded in complex questions of gender, race, culture, and personal identit)' was clear to the pioneers of this specialty. During and immediately after the First World War, surgeons spoke and wrote in unselfconscious terms about the fact that their goal was to recreate a face that would enable its wearer to function in a society in which the male roleideally, a family breadwinner but at least self-supporting^was well defined. As one surgeon put it, "We know from a considerable experience the patient... will undergo untold hardships to be restored to the normal..." Attempting to amplify the meaning of normal for such a patient, the surgeon explained that the question, "What is the use of life if he is not in a condition to seek and earn a livelihood...," was paramount. The goal was a masculine identity and the means to it was an acceptably male face (The New York Times 14 June 1918; Ryan, 1918, 69; Vanderbilt, 1916). The question of facial configuration and social identity became even more important after the war; in fact, during the 1920s and 1930s it dominated plastic surgeons' world. Surgeons' preoccupation with the idea of an individual identity that was also an American identity is easier to understand if one considers the context. The second wave of immigration from Europe to the United States began around 1890; unlike those who rode the first wave, who hailed largely from the British Isles, these new immigrants came from the darker lands of southern and eastern

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Europe: Russia, Poland, Italy, Greece. Can it be a coincidence that one of the first references in the United States to a "Jewish nose" in the context of plastic surgery dates from a text written in 1892? (Roberts, 1892, 231-233). In 1921 and 1924, in a cultural climate permeated by "scientific" racism and eugenic thought, the U.S. passed restrictive immigration laws whose goal was to reconstruct the identity of the nation by changing its face. These laws virtually ended immigration from Asia and set strict quotas that privileged northern and western European immigrants over those from southern and eastern Europe. In retrospect (and to at least some contemporary observers) these new restrictions signaled an attempt to turn back the clock, to return to a time which, if not idyllic, was at least peopled by those perceived to be familiar, similar, easily assimilable. In 1923, when the beloved Jewish comedienne Fanny Brice explained that she got a nose job because she wanted to play the role of Nora in Henrik Ibsen's play A Doll's Home, The New York Times hailed her as "the intrepid Fannie, whose motto is 'all for art and a nose well lost'"but Dorothy Parker's quip that Brice had "cut off her nose to spite her race" was widely quoted (The New York Times 15 August 1923 and 16 August 1923; Katkov, 1953, 141). And, in fact, evidence from published studies and medical records suggests that the concept of "identity" was key for Jews (as it would become later for members of other racial and ethnic groups) in several ways. Those who sought surgery shared a belief that Americans "read" faces, ran them against familiar stereotypes, and from this made assumptions about identity and character. Moreover, they shared a conviction that altering the terms of this exchange would liberate them to create their own individual identities. As Arthur Steelman (nee Schulberger) told sociologist Frances Cooke Macgregor around mid-century, "I wanted a Jew to know I was a Jew...At the same time I didn't want others to know I was a Jew. At first I was horrified when I looked like an Irishman. I was a man without a country. Now I'm beginning to get used to it" (Macgregor, 1974, 103-105).

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The question of identity is also central to the history of the facelift. Physicians performed face-lifts as early as the 1920sperformed, in one case:, quite literally, when an aging actress had her face lifted in front of an audience of beauty shop operators and reporters. Not until the 1960s, however, when what fashion editors dubbed the "Youth Quake" rocked the nation, did surgeons begin to wresde en masse with the question of the effect of aging on female identity. In her 1956 Clamour Book, beauty advisor Lily Dache warned women, "Today, there is no excuse for a woman to grow old, unless she is ill...If you want to keep up with this modern, wonderful world, you must be young in thought, feeling, and appearance" (30-31). In the more down-to-earth McCalls, writer Eugenia Harris agreed: "Up to a point, being an old hand [ir\the fashion business] gives us an advantage. But then suddenly that point is passed. The very shm, very chic, but obviously mature women of last year suddenly remind you of the tall, gaunt, madwomen of Chaillot...It's not quite decent that they're still workingto say nothing of looking for jobs" (1961, 78-79). Today, when mass-market magazines and newspapers routinely run cleverly designed advertisements enticing readers to change their lives by changing their faces and bodies, mid-twentieth century marketing efforts look pretty tame. As these two stories suggest, however, even when they tried to be cautionary, surgeons often encouraged prospective patients to think in terms of sweeping transformation. The first of these stories ran in American Weekly, a widely distributed Sunday newspaper supplement, in 1946. The caption reads "To a homely girl, life may seem an endless succession of Embarrassments, Frustrations, and Anguish until she decides, one day, to ... have a plastic surgery operation. Then a remodeled nose, a rounded chin, may alter her personalityand her whole life." The accompanying illustration, which depicts, first, a disconsolate secretary sniffling and doodling caricatures of large noses as her boss ignores her, and second, the same secretary with a smaller nose basking in the welcome attentions of said boss, underscores the idea of unlimited possibility (Potter, 1946).

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The idea of transformation is equallyif perhaps unintentionallyreplicated in an Esquire article from 1965, in which a surgeon told his interviewer, "I had a woman patient recendy; a very smart, chic, well dressed woman...she wanted a facelift...she was married to a veiy responsible man in an upper income bracket, and she wanted to look better for her husband. It sounded okay...Later on I heard she absolutely ran amokdivorced her husband, ran ofif to Mexico, took a twenty-five year old boy as a loverthe whole route. It was dreadful." Dreadful, perhaps, for the surgeon; probably dreadful for the unsuspecting husband but for the middle-aged woman sidelined by the youth culture of the 1960s who stumbled across this article as she waited her turn in the beauty shop, dreadful is probably not the word that came to mind (Harris, 1965, 134-136). .....--throughout the 1960s, when surgeons meditated on the question of aging and its effects on identity, they were clearly concerned only with women. When they did mention men, it was only in the context of comparison: whereas aging was widely perceived to alter female idendty in a negadve way, it brought benefits to men, who were perceived to become more powerful, not less, as they aged (Davis and Davis, 1975). Surgeons were doubtless infiuenced as well by the homophobic culture of American masculinity, which held that "real men" did not care about their looks (ergo: men who did care were suspect) (Alvarez, 1957). As Los Angeles surgeon Michael Curtin put it, any man considering a facelift was "either an aging actor, a homosexual, or both" {San
Francisco Examiner 4 August 1972).

In 1961, Coronet broke new ground with a report of a study of 53 West Coast menmiddle class, heterosexual commission salesmen and sales managers in their 50s and 60s^who had found facelifts extremely beneficial (one year later, their incomes had increased, on the average, by $1,300). Foreshadowing the hundreds of ardcles that would follow in publications ranging from Eorbes to Gentleman's Quarterly, author Marilyn Mercer explained, "We put such a premium on youth today that a more youthful appearance may be necessary for survival" (1961)an observa-

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don that has an eerily prophetic ring to it more than thirty years later, when stories of down-sized, middle-aged men who resort to eye lifts, face lifts, liposuction, and hair transplants to reconstruct a more masculine, more youthful, more powerful identity are so common they seem like tropes (Kelly, 1977; Business Week, 1980;
Psychology Today, 1983).

For those who perform cosmetic surgery, the relationship between the physical face and the construction of individual identity has always been and continues to be central. It is also something of a catch-22.^ If cosmetic surgery is not about identityif, in other words, it's only about changing external appearancethen it's not deep and meaningful but superficial; it may not even be medicine. This is a stance that most practitioners have rejected. Just as the first generation of surgeons struggled to distance themselves from what they perceived as the less than honorable history of the "barber-surgeon," they fought long and hard to shed the pejorative label of "beauty doctor." The surgeons did this, in part, by organizing themselves into associations (and, a bit later, into specialty boards), by prescribing standards in education, training, and professional behavior, and by enforcing these standards (granted, with varying degrees of success) through examinations, licensing requirements, and self-policing (Davis, 1926, 203-210). Just as important, they formulated an ethical and philosophical foundation for the practice of altering appearance through surgery. Medicine, they said, has evolved from a preoccupation with curing disease to a concern with the wellness of the whole person. Individual well-being depends on mental as well as physical health, and a mentally healthy person is one who feels comfortable functioning in the society in which she or he lives. Medical practitioners have accepted, even embraced, the conviction that their mission is to repair the disjunction that can develop between the internal and the externalto facilitate "wellness" by facilitating the development of an identity that feels authentic. Thus, they argue, cosmetic surgery is properly about identity.^

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Granted, if they are to maintain their status and their self-image as responsible professionals, medical practitioners simply cannot say, "Let's face it, it's all about what sells in the market." But to acknowledge that cosmetic surgery is about identity is to raise some troubling questions. Within the context of the medical profession, accepting this connection naturally invites the question of whether cosmetic surgeons (not to mention ear, nose, and throat specialists, dermatologists, general surgeons, and others who routinely perform surgical procedures that we would define as cosmetic) are the appropriate professionals to deal with this issue. The first generation of plastic surgeons argued that a mark of "progress" in twentieth century medicine was the recognition that psychological functioning is just as important as physical functioning. They congratulated themselves for recognizing this as early as the 1920s and 1930s and for providing the services their patients needed (smaller noses, smoother brows) to function effectively in consumer society. But the relationship between those who practice "physical medicine" and those who practice "mental medicine" (psychiatrists, psychologists, psychotherapists) has not been smooth. Currently, it ranges from respectful (we can cooperate and learn from each other) to dismissive (make sure you send the prospective patient to a psychiatrist to find out if she's the litigious type) to competitive (we can fix this problem faster and better than you can). Perhaps more importantly, that surgeons prescribe cosmetic surgery as the solution for complex problems involving individual, social, and cultural identity reflects not only their grounding in medical culture, but the limitations of that culture. For much of the past century, medicine has encouraged practitioners to search for "magic bullets" (as well as to protect and when possible expand their specialty turf). A face lift may indeed be a "magic bullet"i.e., the quickest, even the most effective, solution for an individual patient who is convinced that her sagging chin line is making her life miserable but by giving and receiving the lift, the surgeon and the patient affirm the culture that created the disjunction in the first place.

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Naturally, the relationship between medicine and culture looks different depending upon where one stands. Medical practitioners tend to situate themselves within medical culture. From this point of view, cosmetic surgery comes out of plastic surgery, which comes out of general surgery, which is a branch of medicine, and the drive toward technical and technological advancement comes out of the recognition that functional defects are desirous of repair. Thus efforts to repair cleft palates and war injuries inspire surgeons to experiment and to take risks which lead to the development of other facial surgeries; efforts to reconstruct breasts post-mastectomy lead to breast augmentation; the two World Wars were major turning points, in facial reconstruction and in burn technique, respectively (Rank, 1968). There is, however, another way to view the history of this phenomenon. As a practice, cosmetic surgery is contemporaneous with reconstructive surgery, which means that plastic surgery emerges out of culture, as well as medicine. The drive toward technical and technological advancement is given impetus by consumer conviction that certain features are not advantageous and thus desirable of improvement, and by the whiff of money. Just as anti-Semitism and anti-immigrant sentiment inspired prospective patients to request, and surgeons to perform, nasal surgery beginning in the late nineteenth century, baby boomers^who grew up swearing not to trust anyone over thirty and now find themselves uneasily some twenty years past that will, as both surgeons and patients, transform the way we think about aging, as well as the way aging looks. From this point of view, the two World Wars were turning points in terms of technique and the supply of surgeons, but the real turning pointthe acceptance of and accommodation to a media-driven, urban, consumer cultureoccurs in times of relative peace and prosperity (Haiken, 1997). In a broader sense, to acknowledge that cosmetic surgery is about identity is to invite criticism and participation in the discussion about how identities are constructed in this culture. In modern twentieth century United States, our attitudes toward cos-

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metic surgery have been based on a series of assumptions: that inside every person who looks "other" is an "American" struggling to get out; diat inside every homely girl a confident girl is trying to emerge; that inside every middle-aged woman the "essential self (which, for whatever reason, in this culture, is assumed to be perpetually 25) remains intact; that inside every balding, middleaged ex-executive exists a virile power broker at the top of his game. These assumptions rest on a complex web of beliefs about what is good, desirable, and aesthetically pleasing. Methods for measuring and calculating objecdve standards of beauty have gone in and out of style (the science of anthropometry having replaced the "profilometer," an early twendeth century invendon: see Farkas and Kolar, 1987 and Straith, 1939) but the rhetoric in which many plastic surgeons indulge has not. Those who devote themselves to altering the human face and body are ardsts, sculptors whose medium is human fiesh; it was not by accident that mid-century surgeon Maxwell Maltz chose Dr. Pygmalion as the dde for his 1953 autobiography (and it is no coincidence that surgeons' web pages wax euphoric about the "artistic nature of their work"www.bodybybloch.com offers one striking example). The standards of beauty that shape plastic surgeons' work (and their patients' faces and bodies) are informed, they say, by objective measurement and educated, professional judgment of what is most aesthetically pleasing to the human eye. But if the phenomenon of plastic surgery is shaped by culture as well as by medicine, it seems logical that its practitioners would be as well. The vision of artisdc inspiration described above is problematic because it obscures, even denies, the extent to which plastic surgeons shape and are shaped by the specific culture they inhabitin this case, the visual culture (movies, magazines, models) of the United States in the twentieth century. Those surgeons who in the 1920s and 1930s described Semitic noses as "too large" were clearly operating within the realm of a culture that had defined certain looks as beautiful and certain others as less so an orientation suggested by their choice (in the 1930s) of the

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Venus di Milo as the central icon of their first official societal logo and today by their frequent use of the adjective "sleepy" to describe the way Asian eyelids look before they are westernized (Kaw, 1993). There is no question that our "ideal face" has changed somewhat since the 1950s; Donna Douglas is no longer our ideal and any fashion spread of significant length shades from cream to cocoa. Television commercials morph male and female faces of various ethnic persuasions so convincingly as to make the United Colors of Benetton look tame. Yet as the "Brown Out" threatened by actors and actresses of color in response to the snowy white Fall 1999 TV lineup suggests, what we see when we look at popular culture is both more inclusive than ever before and yet frustratingly narrow. And if this is not enough to convince, a quick tour around the globefrom China, where a mark of the new bourgeoisie is the "Big Nose" look to Lima, Peru, where to have a "Hispanic" nose (rather than Indian) is to move up a social class or more and cut-rate surgical clinics are springing up by the dozens to meet this new needtesdfies to the enduring power of whiteness (Koop, 1998; Pomfret, 1999). Surgeons are quick to cite the market as something that compels them. "If we don't, somebody else will," they argued in the 1920sand they did. They have been less inclined, however, to examine the effect they have had on the market. In the early twentieth century, when medicine was a cash business and family funds were carefully husbanded to cover the necessities of childbirth and contagious illness, the disdnctive economics of cosmetic surgery made it a luxury of the few. Over the course of the twentieth century, an increasing proportion of Americans were covered either by a proprietary medical plan or by the federal governmentbut with the exception of some Public Health Service hospitals and military medical centers, whose coverage was generous enough to spark a minor scandal in the early 1970s ("Facelifts on the Taxpayer!" the San Francisco C/ironkfe exclaimed on 20 July 1971), procedures defined as aesthetic or cosmetic were generally not covered. As a specialty defined by pre-paid

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elecdve medical procedures, cosmetic surgery remained disdncdve. Today, that disdncdveness remainsalthough the reasons for it have changed. Cosmetic surgery has begun to seem like a refuge for physicians abandoning the trenches of managed care in favor of the freedom and independence they once enjoyed (or hoped to enjoy) in medicine's free market. As a result, its economics are changing rapidly, as physicians, finance companies, and credit bureaus collaborate to extend their services to a wider sector of the populadon (www.celebritydoctor.com offers a fascinadng example of what happens when medicine meets the market). Similarly, while surgeons have long acknowledged the ways in which "culture" has shaped their specialty, they have been less forthright aboutor perhaps simply less aware ofthe extent to which they themselves shape culture. There can be no question that surgeons have played a reactive rolefiooded with requests for Sandra Dee noses in one decade, for Bette Davis eyes the next. Yet to think of surgeons merely as hapless carpenters buffeted by the capricious demands of generations of fashion-conscious women is to do them a grave disservice. That complex web of beliefs, desires, and dreams we call culture is no solid thing. It is created each day in each surgeon's office during the series of exchanges during which padents' requests fit, or not, with what a surgeon believes to be appropriate and desirable. Surgeons who over the course of the century have agreed with their padents that Jewish noses should be made smaller, that Asian eyes should be made to open wider, that lines and wrinkles are ugly and who have then acted on those convicdons have played a role commensurate with the fiood of perfect images that inspired the initial inquiries. Individual identity evolves through a complex social and cultural process of percepdon and refiection; as writer Lucy Grealy put it in her memoir. Autobiography of a Face, "It is no mistake that in movies and literature the dead sometimes know they are dead only after they can no longer see themselves in mirrors" (1994;

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222). At this point in time, as the number of Americans who perceive their identifies as being largely defined by their faces and bodies, and who thus choose surgery as the most effecdve way to alter or enhance their idenddes, increases each year, quesdons about the evolving relationship between identity and cosmetic surgery are significant. They may not, however, remain so. Imagine a (perhaps) not too distant future, in which babies are made to order, down to the size of their noses and the longevity of their hairlines, a future in which "post-birth alteradon" is remembered nostalgically as the primitive practice of well-meaning but technologically handicapped medical practidoners. If the market has its way with those accomplishments, cosmetic surgery as a way of altering the configuration of the face will become obsolete. But then, of course, we will face a new set of equally troubling quesdons about the complex reladonship between culture, appearance, and human idendty. Notes ^Much of this background is drawn from my book Venus Envy: A History of Cosmetic Surgery. Baltimore: Johns Hopkins University Press, 1997. Historians, of course, do not necessarily agree; for an alternative interpretation, see Sander Gilman, Making the Body Beautiful: A Cultural His-

tory of Aesthetic Surgery. Princeton: Princeton, NJ, 1999. ^This phenomenon is unique to the United States. British, French, and American surgeons participated equally in World War I, but at the onset of World War II Britain claimed only four plastic surgeons, and France, two. The United States, in contrast, had almost fifty. This pattern has continued in the intervening decades. ^By this I do not mean to say that non-Western peoples are simply "cultural dopes" (or dupes), unthinkingly adopting Western standards. But it is ingenuous, I believe, to accept that young Asian women who say they want to look "prettier" and cite westernized eyelids as a requisite step in that direction are saying what they mean and meaning what they say. Words like "attractive" and "pretty" accrete meaning through a complex process of cultural exchange and the result is that such words are not only multilayered but infused with the past history and present reality of differential powercultural, social, political, and economic.

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''Together the number of operations in these categories (approximately 275,000) top even liposuction (at 175,000) by quite a bit The most recent statistics are tracked and posted periodically by the American Association for Aesthetic Plastic Surgery at www.surgery.org and by the American Society of Plastic and Reconstructive Surgeons at www.pljisticsurgery.org. ^Anyone who thinks this discussion is no longer current should see Eileen Ringel's "The Morality of Cosmetic Surgery for Aging" in Archives of Dermatology 134 (1998): 427-431 and the responses to it in Archives of Dermatology 134 (1998): 1204-1206, 1293-1297. ^In this vein, the World Health Organization now defines health as "complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (Thomasma in Brock, ed., 1984, 51).

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