Before & After

PrintPrintEmailEmailIn A Moveable Feast, Ernest Hemingway’s celebration of the long cocktail party that was Paris in the twenties, he pays tribute to the war veterans who frequented the Café Lilas and describes “the quality of their artificial eyes and the degree of skill with which their faces had been reconstructed. There was always an almost iridescent shiny cast about the considerably reconstructed face, rather like that of a well packed ski run, and we respected these clients more than we did the savants or the professors.” But what Hemingway, a romantic about war and just about everything else except the English language, viewed as a badge of honor, the mutilated veterans felt as a curse.

Trench warfare inflicted a disproportionate number of injuries on the face, and four years of it had left scars all the more horrible for being impossible to hide. Clothing and gloves could camouflage some body wounds, a crutch or prosthesis mitigate others, but without a nose or jaw or the flesh that covers them, even the most courageous hero was loath to apply for a job, or court a girl, or walk down a street. As the British surgeon Sir Arbuthnot Lane put it, “the race is only human, and people who look as some of these creatures look haven’t much of a chance.”

In response to this unprecedented, heartbreaking, and potentially expensive social problem—if the maimed veterans could not support themselves, they would become wards of the state—the British, French, and Germans all set up special hospitals, and physicians, surgeons, and dentists began to develop innovative treatments for new kinds of injuries. America, though still officially neutral, soon joined the medical battle on the side of the Allied forces. On June 26, 1915, almost two years before Woodrow Wilson asked Congress to declare war, the Harvard Unit, consisting of 35 physicians and surgeons, 3 dentists, and 75 nurses from Harvard, Columbia, and Johns Hopkins, headed for France. Soon Americans were devising radical new methods to treat especially severe facial wounds, and The New York Times reported that “the skill of American dentistry holds undisputed first place, and is particularly highly esteemed in France.”

Though this first generation of modern plastic surgeons insisted function was their primary concern, they also worked for cosmetic ends. Patients were determined to get aesthetically pleasing results. They “will undergo untold hardships to be restored to the normal. This rule has no exceptions,” one surgeon said. The Great War not only gave birth to plastic surgery as a modern medical specialty but also marked a rare moment when the proponents of reconstructive or “serious” surgery and the defenders of cosmetic or “frivolous” surgery declared a truce in what would become a lone and morally charged battle.

No set of medical procedures save abortion has aroused so much controversy.

Perhaps no set of medical procedures save abortion has aroused so much controversy. Physicians have turned against physicians; surgeons have blamed the entire female sex for its vanity and individual males who sought treatment for their lack of masculinity; patients turned consumers have sued doctors turned marketers; dissatisfied customers have battled manufacturers and government regulatory agencies; and a critic recently faulted one television network for exploiting “America’s insatiable obsession with cosmetic surgery,” while simultaneously berating others for not screening “this vital message to today’s youth.” What is it about plastic surgery that raises so many moral hackles? The answer has something to do with human vanity, puritan values, and the line, always wavy and porous, between reconstructive and aesthetic surgery.

Though World War I made plastic surgery both crucial and more respectable, the specialty has a long, if frequently interrupted, history. As early as 600 B.C. a Hindu surgeon reconstructed a nose by using a piece of the cheek, and by A.D. 1000 rhinoplasty, nose surgery utilizing skin from the forehead, was known as an Indian technique. This was because of, according to the British Madras Government Consultation Book of 1679, a barbaric custom: “not to kill but to cut off the noses with upper lips of the enemies.”

Social conditions continued to give rise to medical advances. The sixteenth-century increase in dueling and street brawling may have inspired the Italian Gaspare Tagliacozzi, sometimes called the father of plastic surgery, to develop a method of reconstructing a nose by transferring flaps from the upper arm. But it is more likely that the appearance, at the close of the fifteenth century, of epidemic syphilis, of which a depressed or saddle nose is a telltale symptom, was a more urgent impetus. The syphilitic nose was an early battleground in the war between the morally fraught definitions of reconstructive and cosmetic surgery. A practitioner who introduced Indian techniques in England in 1815 drew a clear line. Maimed heroes of the Napoleonic Wars deserved his ministrations. Fornicators and their progeny did not.