Under the Knife: The Rise of Modern Plastic Surgery
A common misconception is that plastic surgery as we know it emerged as a direct and unexpected consequence of the First World War. To an extent this is true, however the practice can also trace a far deeper and, at times, more complicated history. This article studies the medical, social and ideological developments which have contributed to the evolution of plastic surgery, with a particular focus on the early twentieth century, when the practice can be said to have emerged in its modern form. Its intriguing history speaks to changing ideas about the nature of work, the self, and race, to name but a few. Primarily, the spotlight here will be on cosmetic plastic surgery (defined as elective procedures opted into for perceived aesthetic enhancement), as opposed to its reconstructive counterpart, which is considered medically necessary to correct facial injuries or defects and to restore function. Although attention will be paid to the ways in which the two disciplines have grown apart from one another, their twin development is so tightly interlinked that the history of one cannot be entirely understood without the other. With this in mind, we will first approach the origins of the practice as a whole, before looking at its role and remarkable development during the First World War. Next, the article will circle back to look at the ideologies which have underpinned the rise of cosmetic surgery in particular, before finally studying the racialised element of the practice, which came to the fore during the twentieth century.
Origins and Development
The earliest recorded instance of facial ‘plastic surgery’ comes from India in 600 BCE, performed by Sushruta, a Hindu surgeon. The Suśrutasaṃhitā, an ancient Sanskrit text on medicine and surgery, details how Sushruta carried out a type of reconstructive rhinoplasty by performing a skin graft from the cheek of his patient. It is not until considerably later that records once again show facial surgeries being undertaken. In fifteenth century Europe, surgeons sought to remedy the highly distinctive and morally charged facial disfigurements caused by syphilis, which was epidemic on the continent at this time. It is in this Renaissance literature that the emergence of separate concepts for reconstructive and cosmetic surgeries first become noticeable. However, the practice was still rudimentary at this point, largely due to the high risk of such procedures, and as such, this distinction was by no means categorical or widespread.
These loose definitions carried into the early nineteenth century, when facial surgeries reemerge in primary source records. Indeed, it is at this point that the term ‘plastic surgery’ – from the Greek plastikos, meaning “to shape or mould” – first emerged. Initially, it was used to refer to reconstructive procedures only, primarily rhinoplasties to correct functional deficits, but with the steady rise of so-called “beauty surgeries” from the 1840s onwards, it gradually expanded into the catch-all term we know today.
Scholars largely agree that modern cosmetic surgery started to take shape by the end of the nineteenth century. Medical advancements such as Joseph Lister’s development of the antiseptic technique in 1876 and the invention of local anaesthesia in the 1880s offered greater potential for clients (as opposed to ‘patients’) to opt into elective surgeries. Not only was the likelihood of infection significantly reduced, but with the application of local anaesthetic, it was no longer necessary to surrender oneself entirely to the surgeon. In this way, clients were able to retain a greater degree of agency for the first time, not only in electing to undergo the operation in the first place, but on the operating table itself.
The First World War
It was during the First World War that plastic surgery made significant advances and the distinction between reconstructive and cosmetic operations truly crystallised. The conflict resulted in a shocking increase in facial injuries, as trench warfare frequently left the upper body exposed. Additionally, steel helmets contributed heavily to shrapnel injuries to the face. In response to this crisis, new surgical techniques were rapidly developed by plastic surgeons, perhaps most notably by Major Harold Gillies who pioneered a number of experimental skin grafting techniques at the Queen Mary Hospital in Sidcup, Kent. Furthermore, the First World War also necessitated better communication and organisation between plastic surgeons, both nationally and internationally, which allowed the practice to begin establishing its professional credentials. Indeed, it is no surprise that the world’s oldest plastic surgery association, the American Association of Oral Surgeons (today the American Society of Plastic and Reconstructive Surgeons), was formed shortly after the war in 1921. By laying claim to greater medical legitimacy, reconstructive surgeons also began to define themselves in opposition to cosmetic practitioners, whose work they perceived as tangential to their own. Interestingly, however, by proving plastic surgery to be a legitimate medical discipline, the work of reconstructive surgeons actually benefited the reputation of cosmetic practitioners as well. By helping to shake off the associations with ‘quackery’ that had long plagued plastic surgery as a whole, both branches saw their reputations improve during this period.
The high incidence of disfigurement during the war, combined with its extreme visibility, constituted a problem in British civilian life, both socially and morally. Fears that physical disability would impede veterans’ ability to work challenged traditional gender norms in which masculinity was firmly rooted in the ability to perform productive labour, provide for one’s family and live self-sufficiently. This view was expressed in a 1916 article, in which plastic surgeon, John Staige Davis, explicitly cites what he believed to be the three main goals of the surgeon: to relieve “pain and deformity”; to restore function, and, most importantly, to ensure the ability of the patient to earn a living. It is thus clear that by the early twentieth century, plastic surgery was viewed as a significant means through which to maintain dignity, not only in relation to ideas of gender, but in terms of labour as well.
In the Pursuit of… Normality?
The ideologies of plastic surgery, particularly that of cosmetic surgeries, were tied to Enlightenment ideas about the self in the nineteenth century. For example, in a parallel to John Stuart Mill’s utilitarianism which placed ‘happiness’ within his vision of autonomy, the notion that each individual could remake themselves in the pursuit of happiness gained popularity throughout the industrial period. Gradually, people ceased to understand themselves as bound by their ‘God-given’ qualities and instead saw fit to remake themselves as they chose.
Later, these ideas found fertile ground in the changing landscape of the late nineteenth and early twentieth centuries. Historian Elizabeth Haiken, has described this period in the United States as a time of change from “Protestant Victorianism” to “secular consumerism,” in which the definition of ‘beauty’ shifted from being the sum of internal characteristics and good health to an external and, most importantly, attainable goal. In addition, urbanisation, a more mobile and sizeable population, and the expansion of mass media at this time broadened the horizons of millions of Americans, which had twofold consequences. Firstly, Haiken suggests that it produced an “ethos of acquisitive individualism,” in which culture became centred on individual self-representation as opposed to family and locale. Second, increased contact with strangers aided the construction of notions of difference, in particular racial difference constructed against a perceived white Anglo-Saxon Protestant ‘normal’.
Underlying this was an implicit assumption which equated ‘normal’ with ‘beautiful’, and ultimately ‘happy’ – all of which appeared to be within reach due to advances in plastic surgery. As older Enlightenment ideas about the malleability of the self met with developments in surgical science after the First World War, plastic surgery became increasingly seen as a potential route to happiness (or at least acceptance) for those othered by the changing world around them. A 1959 American Weekly article summed this up perfectly:
“Where plastic surgery is concerned, doctors are increasingly aware it is not a desire for beauty, but a healthy minded wish to ‘look as good as everyone else’ that this year will swell their waiting lists.”
Plastic Surgery and Race
Of course, ideas of ‘otherness,’ beauty, and race were interwoven long before the twentieth century and have been present within the very concept of ‘beauty surgery’ since its inception. One cannot overlook the influence of pseudosciences such as physiognomy and phrenology, which professed that undesirable traits (such as criminality, violence, alcoholism, and low intellect) were connected with specific facial and cranial features. Significantly, these tended to be features disproportionately associated with racial and ethno-religious groups outside of the perceived Anglo-Saxon Protestant ‘norm’. Racist assumptions such as these contributed to the development of stereotypes and stigmatisation of ethnic features. Of course, this was but one factor amongst many in the development of racist preconceptions about appearance, but nonetheless contributed heavily to the marginalisation of minority ethnic and ethno-religious groups which continue to have lasting consequences for Black, Jewish, Italian, and Irish communities in the United States and beyond.
It is also interesting to note the impact of photography on the connection between appearance and racist stereotypes. The development of the camera and the expansion of print media allowed facial features to be captured and categorised on a much larger scale than ever before. Images were circulated and classified in what photography theorist, Allan Sekula, has termed a “shadow archive” – a social and moral hierarchy in which a photograph, once released into the public domain, is ranked according to the appearance of its subject. Ultimately, this process served to further codify ‘beauty’ according to Anglo-Saxon standards.
It is therefore unsurprising, following the aforementioned developments in medical science and philosophy, that the twentieth century saw the emergence of a number of plastic surgeries marketed to “correct” perceived stereotypical features of minority ethnic groups. Such marketing strategies were at once products of pre-existing racist stigmas and actively contributed to racist beauty trends, exploiting the discrimination of which they encouraged. By acting as arbiters of beauty, they promoted intolerance towards minority ethnic groups in the public sphere whilst simultaneously offering a ‘solution’ to this discrimination. Indeed, extensive scholarship in this area by Elizabeth Haiken and Gilman Sander has pointed out that plastic surgeries primarily served as a form of defence for marginalised people who sought a level of “civil inattention” in the public sphere. This is visible from the 1930-1950 patient records of New York plastic surgeon, Jerome Webster, in which clients from marginalised groups frequently cited a desire for public acceptance when justifying their cosmetic surgeries. Interestingly, work and labour figured prominently in their consultations, showing that many hoped to achieve better job prospects or work in public-facing occupations, such as clerical roles or the performing arts. This harks back to the importance of labour that can be seen in plastic surgery during the First World War, and makes clear that the ability to work unhampered, either by physical disability or social prejudice, remained a key source of dignity for those undergoing surgery and was a central goal of the surgeon.
Conclusion
In conclusion, both cosmetic and reconstructive plastic surgery have a complex and often dark past. In looking at plastic surgery’s early development, role in war, underlying ideologies and racialised elements, this article has sought to unpack just a few key strands of its intricate history. Other significant elements of this story include the role of gender and the impact of consumerism, both of which have been somewhat overlooked here and would be certainly worthy of further investigation. With this in mind, it would be possible to dig even deeper into the fascinating story of plastic surgery, interrogating even further the factors which, for well over a century, have led people to go under the knife.
By Lizzy Stott
Bibliography
Primary
Davis, John Staige. “Plastic and Reconstructive Surgery.” JAMA 67, 5 (1916): 338.
McCoy, T.R. “Beauty Can Be Bought.” American Weekly. April 26, 1959.
Webster, Jerome Pierce. Patient Records. New York, Columbia University Irving Medical Centre: 1930-1950.
Secondary
Biernoff, Suzannah. Portraits of Violence: War and the Aesthetics of Disfigurement. Michigan: University of Michigan Press, 2017.
Doyle, Maggie. “Sidcup, Kent: Reconstructive Surgery.” BBC Sounds: World War One At Home. Podcast audio. July 30, 2014. Accessed Oct 25, 2023. https://www.bbc.co.uk/sounds/play/p022yl3g.
Haiken, Elizabeth. Venus Envy: A History of Cosmetic Surgery. London: Johns Hopkins University Press, 1997.
Mazzola, Riccardo F. “Commentary on: The 19th Century Origins of Facial Cosmetic Surgery and John H. Woodbury.” Aesthetic Surgery Journal 35, 7 (2015): 890-891.
Rogers, Blair O. “A Chronologic History of Cosmetic Surgery.” Bulletin of the New York Academy of Medicine. 47, 3 (1971): 265-302.
Sander, Gilman L. Making the Body Beautiful: A Cultural History of Aesthetic Surgery. Princeton: Princeton University Press, 1999.
Sekula, Allan. “The Body and the Archive.” October 39, 3 (1986): 3-64.Wallis, Brian. “Black Bodies, White Science: Louis Agassiz’s Slave Daguerreotypes.” American Art 9, 2 (1995): 38-61.