Plastic surgery, the practice of reshaping body tissues for reconstructive or aesthetic purposes dates back to antiquity. Derived from the Greek plastikos, meaning “to mold,” plastic surgery holds a critical place in cultures all over the world. For centuries, tribes would disc their lips, stretch their earlobes, bind their feet, file their teeth, and tattoo and scar their skin. If contemporary popular series such as Extreme Makeover and Nip/Tuck are any indication, plastic surgery has not lost any of its cultural power. While filed teeth may not appeal to everyone, men and women of today still have a wide range of surgical procedures from which to choose, including liposuction, nose jobs, eyelid surgery, tummy tucks, and breast augmentation and reduction. The term “plastic surgery” also includes nonsurgical options such as Botox, microdermabrasion, collagen injections, laser hair removal, and chemical peels. Plastic surgery, however, was not always so readily available or varied and was even shrouded in mystery, magic, and eroticism.

Ancient Egypt: Plastic Surgery to Recognize the Dead

While the Egyptians did not practice extreme forms of plastic surgery on the living, they would often prepare their dead using principles of plastic surgery. For example, Ramses II's mummy was surgically altered by having a small bone and a handful of seeds inserted into his nose to ensure that his most prominent feature would be recognizable in the afterlife. The mummy of Queen Nunjmet also had bandages stuffed in her cheeks and belly in the same sense that modern plastic surgeons implant silicone into a body. While the Edwin Smith Papyrus shows that the Egyptians had skills to perform similar surgical procedures on the living, there is no solid documentation that is was actually done. Scholars suggest this reluctance to perform plastic surgery on the living was due to the Egyptian belief that one’s face remained the same in the afterlife and, therefore, should remain recognizable even after death (DiBacco 1994).

Ancient India: The Birthplace of Plastic Surgery

An account of two successful operations for restoring a lost nose from the integuments of the forehead.

Ancient Rome: Plastic Surgery and Roman Baths

By the first century B.C., Romans were also practicing advanced plastic surgery procedures, perhaps prompted by the very public Roman baths. In a culture that praised the beauty of the naked body in both art and poetry, Romans viewed any abnormality, particularly the genitalia, with suspicion or even amusement. Consequently, one of the most popular plastic surgery procedures appeared to be circumcision removal, which is described in a rather detached way by Cornelius Celsus’s text De re medicina during the reign of Tiberius (A.D. 14-37). Celsus even describes a “breast reduction” surgery on an obese man whose breasts were “unsightly” and “shameful.”

Roman surgeons would also remove scars--particularly those on the back, which were marks of shame because they suggested that a man had turned his back in battle or, worse, he had been whipped like a slave. The poet Martial (A.D. 40-104) suggests that some slaves during his time had their brands removed by surgeons, but he gives no details of the procedures. Surgeons would often operate on gladiators who had noses and ears chopped off and on foreigners who would try to fit into Roman society.

Middle Ages: Decline of Plastic Surgery

During the time of Galen (A.D. 129-216), plastic surgery gained momentum and sophistication due to increased obsession with the human body. Galen attempted to cure eyes that squinted and drooped,and performed aesthetic rhinoplasty on both women and men of wealth who simply wanted a new nose. After the fall of Rome, however, many of Galen’s medical texts were lost; of his 600 books, only 20 survive. Though there were discussion of proper dental care during the Middle Ages, surgery in general was deemed to be pagan and sinful because the spilling of blood by a surgeon and the power he held over the body were akin to magic.

The Renaissance: A Brief Rise in Plastic Surgery

Translations of Galen re-entered Western culture during the late Middle Ages as crusaders encountered Arabic texts. For a brief time, plastic surgery experienced a rebirth of sorts, though mostly in barber shops. Two Sicilian barbers, a father and son team, would use skin flaps from the cheek or upper arm to rebuild a nose. The arm flap left less of a scar but demanded that the flap, still attached to the ear be joined to the nose for as long as twenty days. As in India, such surgery was a “trade secret passed on from father to son” (Gilman 1999).

Heinrich von Pfalzpaint, a knight from the Teutonic order, also held secret the procedure of a nose job that was taught to him by a foreigner and made him “very much money.” Many surgeons took skin grafts from donors, such as a neighbor’s pig, but were confused when the new nose would shrivel up and fall off. They concluded that the flesh was “sympathetic,” meaning that the graft died when its owner died.

Plate VIII from Gaspare Tagliacozzi, De curtorum chirurgia per insitionem (1597).

For Taglioacozzi, plastic surgery was one way humankind seeks improvement of self, both physically and emotionally. Still, his reconstructed nose was still a “virtual” nose that could fall off if the user blew too hard, and young women with reconstructed noses were hardly objects of desire (Gilman 1999). Young women who lost their noses could be disowned by their fiancés because it suggested either a venereal or moral disease. However, Tagliacozzi mused whether a reconstructed nose was still grounds for terminating a marriage arrangement. For a time in Renaissance Europe, Tagliacozzi’s surgical innovations promised at least partial restoration of the nose but, due to the religious zeal of the Counterreformation and the concomitant emphasis on the syphilitic nose as a justifiable punishment from God, Tagliacozzi’s work disappeared (Haiken 1997).

The Enlightened Nose

Plastic surgery would reappear in Europe in 1794 when British surgeons witnessed an Indian bricklayer repaired the nose of a British cattle driver who had had his nose and hand cut off while a prisoner of Tiu Sultan. British surgeons then imported the procedure to northern Europe, where interest rapidly grew. In 1818, Karl Ferdinand Graefe (1787-1840) coined the term “plastic surgery” and described connected grafts in his 1818 text titled Rhinoplastik. Graefe, like Tagliacozzi, believed that the world needed to see the nose-less patient in medical terms rather than as a morally branded sinner. Graefe further attempted to remove the moral stigma associated with nose reconstruction by giving the procedure a classical name (rhinoplasty) similar to other surgical procedures.

The move to a medical model for understanding the lost nose began to spread. However, the first notable plastic surgeon in the United States, John Peter Mettauer of Virginia (who primarily operated on cleft palates and hypospadias using tools he designed himself), still struggled with American surgeons who lived by Dryden’s admonition that “God did not make his Works for man to mend” (Gilman 1999). In addition, as the nineteenth century wore on and the European culture began its colonizing efforts in earnest, the nose became inextricably associated with race, an association that lasted until the current era, as seen in what is now called the “Michael Jackson Factor.”

Two World Wars and Innovations in Plastic Surgery

War has played a significant role in the history of plastic surgery. For example, WWI trench warfare meant heads and necks were more vulnerable, and pilots and passengers in the new and dangerous airplanes often suffered serious facial injuries that were unprecedented any time in history. Injuries such as shattered jaws, blown-off noses, and gaping skull wounds accelerated the techniques and experimentation of plastic surgery and prompted Harold Delf Gilles (1882-1860) to establish the first hospital devoted to reconstructive plastic surgery (Backstein and Hinek 2005). In addition, these drastic surgeries enabled surgeons to imagine that even transgender surgery could be performed.

Despite medical advances after WWI, there were still no standard criteria, and something of the Victorian opposition to vanity still prevailed. Because any untrained surgeon could claim to be a plastic surgeon, patients often experience severe complications, such as amputation or at the very least severe scarring. Plastic surgery became associated in many minds with the term “quack.” However, when surgeons who had served in WWI established the American Association of Plastic Surgeons, they effectively signaled the end of unregulated plastic surgery (Haiken 1999). This first association was joined by the American Society of Plastic and Reconstructive Surgeons in 1931 (renamed American Society of Plastic Surgeons in 1991 to show the conflation of historically politically charged terms “reconstructive” and “cosmetic”) and by the American Board of Plastic Surgery in 1937. Finally, plastic surgery was achieving recognition as an independent specialty.

WWII ushered in such plastic surgery techniques as rebuilding entire limbs, extensive skin grafts, microsurgery, antibodies, as well as increased knowledge about tissue health. Several factors contributed to the postwar plastic surgery boon and the breaking down of traditional reluctance to undergo plastic surgery. First, continued activity of professional organizations and publications helped further legitimize the industry. In addition, after there was no war to generate patients, surgeons consequently began a widespread trend toward marketing surgical techniques toward particularly groups--particularly middle-aged, middle-class women who were affluent and largely finished with raising families.

Furthermore, this demographic felt increasing pressure to remain young in a postwar culture often dubbed the “cult of the body beautiful” (Gilman 1999). Indeed, plastic surgeons would often use the vocabulary of postwar domesticity--such as sewing, housecleaning, and cooking--to refer to their procedures. Some critics even accused surgeons of inventing new names, such as “bat wing deformity” (the flabby skin on the upper arms) or “spare tire deformity” (protrusion of the lower abdomen) to create a need for plastic surgery that might not otherwise exist (ibid). By the 1960s, plastic surgery was fully integrated into the medical establishment.

Silicone breast implants also grew in popularity during the 1960s. Showgirls would inject their breasts with liquid silicon, a substance initially used in Japan in WWI to plump out legs withered by polio. Injecting liquid silicone, however, often had dangerous side effects, such as amputation of the breasts due to infection and guaranteed “pendulous” breasts by the time women were 40. Yet advances in silicone breast augmentation (which later was made available in sac), gave hope to women who had undergone a mastectomy (Haiken 1997).

1990s: Continued Popularity

Silicone gel-filled breast implants

The Future of Plastic Surgery

Throughout its history, plastic surgery has been shaped by cultural priorities and pressures that illuminate the complex interplay between the cosmetic and reconstructive. The fact that many Western societies today have become more comfortable with plastic surgery suggests that they view it as another method of self-improvement--not just for women, but men as well. Big Tent Books even published a new picture book that explains to kids why mom is getting a flatter tummy (Springen 2008).

While critics warn that plastic surgery is creating a world where beauty standards are brutally conformist, plastic surgeons today implement an exciting array of technological advances that continue to push the boundaries of their industry. For example, surgeons are researching new fillers that last longer and new lasers that inject “energy” into the skin. They are also exploring the potential of cloning technology as a method of body rejuvenation and are looking to the secrets of growth within the womb where scarless healing takes place. Without such imagination of plastic surgeons and their patients over the ages, plastic surgery would not be the phenomena it is today.

-- Posted August 31, 2008

References

American Society of Plastic Surgeons. “The History of Plastic Surgery, ASPS and PSEF.” Accessed: July 20, 2008.

Backstein R, and A. Hinkek. 2005. “War and Medicine: The Origins of Plastic Surgery.” University Toronto Medical Journal. 3:217-219.

DiBacco, Thomas. Dec 13, 1994. “Plastic Surgeries Earliest Cases Date to Ancient Egypt, India.” Washington Post. Accessed: July 20, 2008.

Haiken, Elizabeth. 1997. Venus Envy: A History of Cosmetic Surgery. Baltimore, MD: The John Hopkins University Press.

Gilman, Sander L. 1999. Making the Body Beautiful: A Cultural History of Aesthetic Surgery. Princeton, NJ: Princeton University Press.