Before & After

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In the years between the wars, plastic surgery had succeeded in professionalizing itself. Now it had to market itself. Cosmetic procedures became consumer products, and it did not take long to target the prospective buyers. If there were not enough men who needed to be reconstructed, there were plenty of women who ought to be improved. Doctors, women’s magazines, and women themselves agreed. Even the vocabulary took on a feminine domestic tinge, as professionals spoke of “neatening,” “tidying,” and “fixing up.” A surgeon told Good Housekeeping that the procedure was akin to fitting a garment. While the analogy was meant to be reassuring, it was not inapt. In 1919 Dr. Adalbert G. Bettman introduced the extensive face-lift incision that is still the basis of today’s procedures. The standard operation until after World War II entailed the seamstress-like act of removing a crescent of skin and pulling up the slack. Twenty-first-century surgeons employ various techniques, with incisions usually beginning above the hairline at the temples, extending in a natural line in front of the ear, and continuing behind the earlobe to the lower scalp. The doctor then removes fat, tightens underlying muscle and membrane, pulls the skin back, removes the excess, and securely stitches the layers of skin.

Whether the language was domestic or medical in the postwar years, the consensus was the same. Husband-hunting girls, divorce-aversive wives, and even career women had to look their best to succeed, and in the youth-oriented postwar culture, looking good meant looking young. America’s postwar prosperity produced the first generation in history of healthy, affluent fifty-year-olds, many of whom were willing to spend their hard-earned and carefully saved dollars to masquerade as the generation eager to shoulder them aside. The glut of plastic surgeons and the abundance of financially solvent patients altered the specialty’s dynamic. Doctors were no longer gods passing down diagnoses like divine judgments, or even gatekeepers determining who could or could not undergo surgery, roles other specialties still guarded closely. They were skilled practitioners selling their talents. Patients were no longer diseased bodies in search of cures. They were informed consumers shopping for the best product at the right price.

If a youthful appearance was essential for matrons of a certain age, large breasts were critical for younger women. Rosie the Riveter had swapped her slacks for Dior’s wasp-waisted New Look, respectable wives and mothers dreamed of walking the streets in their cone-shaped Maidenform bras, and the American Society of Plastic and Reconstructive Surgery classified as a deformity breasts which had once been merely small. The medicalization of nonmedical conditions was not new. Before the war one surgeon had described wrinkles as “more cruel than the loss of a leg.” But suddenly an entire professional organization was turning a normal body trait into a malformation that required treatment. Naturally, less marketing was necessary to sell restoration after a mastectomy or reduction, the earliest form of breast surgery and one often considered reconstructive because it addressed a physically uncomfortable and psychologically stressful condition.

While breast augmentation is currently the most popular feminine plastic procedure, it has a checkered past. Over the years, desperate women and resourceful doctors have inserted and injected into perfectly healthy bodies paraffin, sponges, the patient’s own body fat, and other natural and foreign substances. In the 1960s silicone, which had been used extensively in industry and the war effort, caught the popular imagination, and practitioners of dubious repute began injecting the substance into the breasts of women of questionable judgment, with spectacular but often disastrous results. Though silicone injections never became medically acceptable, in 1961 Dr. Thomas Cronin unveiled a silicone implant, and the plastic surgery establishment and women across the land took it to their breasts. But gradually reports of ruptures, “bleeding,” lumps, wanderings to lymph nodes, and deleterious effects on the autoimmune system began to trickle in, and in 1992 the FDA, under commissioner David A. Kessler, outlawed the sale of implants until further clinical trials and public hearings. A culture war ensued. Some women were terrified they had the implants, others that they could not get them. Some deplored past lack of information, others a patronizing stance that outlawed breast but not testicular, calf, or pectoral implants. The largest product liability settlement in the nation’s history settled a skirmish but did not end the war. In October 2003 an FDA advisory panel recommended that silicone breast implants be allowed back on the market after an 11-year hiatus. One woman’s advocate called the decision “a triumph of wishful thinking over science,” but a female bioethicist on the panel, who admitted to changing her mind only hours before the vote, observed that “to approve something which doesn’t have the data to support its safety seems to me to be irresponsible, but not to expand access seems mean.”