Cosmetic surgery/Introduction

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Bernadette Wegenstein

The listing of the three areas—medicine, culture, and beauty—in the subtitle of my Living Book on cosmetic surgery is not coincidental. The practice of cosmetic surgery—a surgical intervention into the body for merely aesthetic and not medical reasons—is a medical discipline, dating back to the times of the Hindu doctor Sushruta, who practiced rhinoplasty c. 500 BCE. The promise on which this medical discipline operates is, however, not only that of ‘health,’ but also that of ‘beauty,’ be it a restorative beauty that seeks to ‘repair’ what has been lost (due to age, accident, or illness)—hence reconstructive surgery—or a beauty that is yet to be born, or ‘carved out,’ with the help of an aesthetic surgeon's scalpel and with reference to the grounding pillars of beauty: symmetry and proportion. In both cases, the desire for such beauty can be defined as a cultural phenomenon: in the sense that it affects the way we humans look, what we want, and the way we define our appearance and correlate it to our inner qualities and characteristics.

To repeat after Meredith Jones, one of the authors included in this Living Book, cosmetic surgery is the quintessential expression of today's makeover discourse, a discourse whose primary dictum is bodily improvement—both moral and aesthetic. The concept of ‘makeover’ can be found in endless examples of today's western culture and its language: words and concepts such as rebirth, restart, new start, change, self realization, or new beauty are all indicators of what sociologist Anthony Elliott calls the ‘new individualism of instant change’. He holds the following factors responsible for this state of events: a) the importance of celebrity culture (on which we model our appearance), b) consumerism (the fact that we can buy makeover in different forms and fashions freely on the market), and c) the electronic economy of looking good (the fact that we can change appearances with computerized manipulation). This culture, which seeks improvement and progress on the macro- as well as on the micro-level of the individual experience, wants to achieve a state of being that another one of my Living Book authors, Carl Elliott, describes as ‘better than well.’ This is a state that the true authentic self had to work hard for, or at least search for (even on the internet), a self that was supposedly always meant to be, but had to be ‘discovered’ with the help of technologies such as liposuction or Prozac. Ultimately, these enhancement technologies give birth to a ‘new better self.’ As Jones points out, such a birth often takes place on the screen (see the format of the reality television makeover show)—where all of the above-mentioned sociological factors find themselves united: celebrity, consumerism, and electronic media.

The makeover principle is based on the Platonic notion of kalókagatheia1—which is derived from kalós (beautiful), kai (and), and agathós (good), and which assumes a correspondence between the beauty of bodily form and a beautiful disposition in the soul.2 Kalókagatheia is hence a union between the outside characteristic of beauty and an inner characteristic of wellbeing, which in a broader sense promises the state of happiness—or what Barbara Ehrenreich has labeled ‘America’s penchant for positive thinking,’ if we want to be critical of such a state. Cosmetic surgery's promise to restore the disjunction between these realms of an inner and outer self used to be derived from a perceived sense of ‘inferiority’ by a self (what Alfred Adler had described as an ‘inferiority complex’ at the beginning of the 20th century). However, in today's makeover discourse, as Cressida J. Heyes and Meredith Jones, two of the authors included in my Living Book point out, the language of inferiority complex has fallen away. Today, women and men, and at times children, choose cosmetic surgery as random consumers (and not patients), and they do so for a widely varying set of reasons. Indeed, cosmetic surgeons have to eliminate the possibility that their patients suffer from Body Dysmorphic Disorder.3 Instead, patients need to be seen as choosing surgery because they feel the obligation to improve, to better themselves, as is evident in the array of procedures suggested by the American Association of Plastic Surgeons. Statistics are quite revealing about recent developments in the consumption of cosmetic surgery in North America. According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2007—the last year that witnessed an overall increase in surgery cases—11.7 million (22% among them being minority patients) cosmetic surgical and nonsurgical procedures were performed in the United States for a total cost of $13.2 billion. Of these cosmetic surgical procedures, 91% were performed on women, which is why many of the articles in this Living Book are dedicated to the female experience.

This Living Book has served as an opportunity for me to put together scientific and cultural theoretical texts on the topic of cosmetic surgery. I consider it very important to include the perspective of all practitioners in the field: surgeons, psychologists, philosophers, ethicists, and finally from patients as well. I have added also some links (, that reveal the voice of today's so-called beauty addicts. Alex Kuczynski has agreed to contribute some of her well-known writings from the perspective of a ‘cosmetic surgery junky.’ In addition, the trailer for Made Over in America, my documentary on the culture of reality television makeover shows (together with Geoffrey Alan Rhodes, 2007), exhibits some cosmetic surgery patients who I have given a voice in that film. I want to make clear that the following short summaries of some of the entries are by no means conclusively representative of their respective fields. But my selection is not random either. All of these articles are seminal, influential, and important in the fields they represent. I want to thank all authors for their willingness to collaborate and to have their work linked to this Living Book project.

The 'Public Health' section includes some original socio-demographic data about who the cosmetic surgery patients are in today's North American market. For instance, in the United States, over 500,000 women undergo breast surgery procedures each year—for augmentation, reconstruction (mastectomy), or reduction. A study from Vancouver, Canada, ‘The Satisfaction and Quality of Life in Women Who Undergo Breast Surgery,’ revealed that women who had undergone reconstruction surgery for breast cancer often expressed how reconstruction was a way to get back ‘what was lost’ and to move on from the cancer experience. As one woman put it: ‘I think once I had this was just closure. It's really like that part of my life didn't happen. It's not denial. I mean I still have to be vigilant and everything it's just I got my life back, I really did.’ Finally, a breast augmentation patient summed up her experience as follows: ‘My confidence level, my self esteem, my self respect, my self worth, everything... it has affected everything. I am just so much more solid, grounded. I feel like I am a whole woman now.’ It becomes clear through such expressions that the breast is not just a sexual reproductive organ, but rather a vessel, often objectified, that stands in for femininity as such: a pars pro toto. In the study, ‘Prospective Demographic Study of Cosmetic Surgery Patients,’ the data reveals that the average private practice cosmetic surgery patient is a married (67.5%), educated at a college level or higher (66.9%), employed (74.3%), and a mother (74.5%). The authors point to the rather interesting fact of the preponderance of women seeking cosmetic surgery falling into two distinct groups: those who are older or those who are younger than their partner. Those who are the same age as their partner apparently seek cosmetic surgery less often. The article, ‘Socioeconomic Impact of Ethnic Cosmetic Surgery: Trends and Potential Financial Impact the African American, Asian American, Latin American, and Middle Eastern Communities Have on Cosmetic Surgery,’ reports that the plastic surgery patient profile is changing. While the majority of patients remain Caucasian women, over the last 10 years cosmetic plastic surgery procedures have been performed on almost as many Latin American patients as on male patients. The authors also address the issue of self-hatred or ethnic rejection in the case of cosmetic surgery by US minorities. The data reveals this tendency, as well as the cultural stereotype of big-busted Latina women, quite clearly: while rhinoplasty was the most common in African Americans and in Middle Eastern ethnic groups, breast augmentation scored highest for Latin Americans, and blepharoplasty for Asian Americans. I will return to these choices of ‘ethnic’ makeovers in the sections below. However, the authors stress that ‘ethnic beauty’ that enhances rather than hides ethnic traits is on the rise among the minorities. In order to test future cosmetic surgery patients for these disorders, some of the same authors from a research group in Melbourne have developed a screening test, made available via a link in the 'Public Health' section: 'The PreFACE— A Preoperative Psychosocial Screen for Elective Facial Cosmetic Surgery and Cosmetic Dentistry Patients.' This test is supposed to screen out the 10% to 20% of patients undergoing cosmetic interventions who report postoperative dissatisfaction.

The section 'Breast Reconstruction—Medical Discourse and Illustration' introduces the rise of the phenomenon of breast reconstruction after bilateral mastectomy due to an illness. The case of breast reconstruction is a unique case of cosmetic surgery because it includes aesthetic as well as reconstructive issues, not least due to the increasing number of breast cancer patients—which in 2011 alone amounted to 230,480 new cases of invasive breast cancer. This section aims to highlight is meant to highlight the immense technological advancements and the scale of communicational and translational needs between doctors and patients, as well as issues such as body image disorder as a result of breast reconstruction. The articles bring together seminal issues from the question of the necessity of mastectomy versus breast conserving surgeries to the psychosocial impact of bilateral prophylactic surgery. This rising trend of preventative mastectomies for patients with a higher risk (due to genetic testing, a family history, or previous breast cancer) of developing breast cancer is a particular case of elective cosmetic surgery. You can hear one such testimony by Jessica Queller on the uploaded YouTube video.

The 'Psychology and Sociology' section continues with a critical review of the rise of cosmetic procedures, which, in ‘Cosmetic Surgery and Psychological Issues,’ is estimated at 34% of all procedures (from 2005 to 2006). In this article the author points to two troubling psychiatric phenomena associated with cosmetic surgery patients: 1) the suicide risk among women who have undergone breast augmentation surgery, and 2) the above-mentioned Body Dysmorphic Disorder (BDD), which—according to this study—appears to be much more prevalent in patients seeking cosmetic surgery. In ‘A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery,’ the authors take a different perspective, in part contradicting the concerns outlined in ‘Cosmetic Surgery and Psychological Issues.’ The authors conclude that most people in their study appear satisfied with the outcome of cosmetic surgical procedures, except for those who fit the following categories: being young, being male, having unrealistic expectations of the procedure, previous unsatisfactory cosmetic surgery, minimal deformity, motivation based on relationship issues, and a history of depression, anxiety, or personality disorder. In ‘Diagnosing Culture: Body Dysmorphic Disorder and Cosmetic Surgery’ the author offers a critical reading of the very concept of mental disorder BDD. The author points to the paradox of the desire for cosmetic surgery as a ‘cure’ to BDD, when BDD may often be its very premise. The two remaining articles in this section, ‘Optimal Waist-to-Hip-Ratios,’ and ‘Facial Beauty and Mate Choice Decisions,' dive into the important question of why patients want to be beautiful and undertake all the above-mentioned psychological risks. The authors’ approach is derived from evolutionary psychology. For these attractivity researchers, physical beauty is a sexual trait; and physical attraction arises from an interaction between the perceiver’s brain and the perceived face or body figure—both of which have been modified, in a complementary manner, by the actions of steroid hormones. The first article finds that the observed activation patterns in the brain suggest that female body configuration represents a salient stimulus to men and that optimal female body configurations activate areas of men's brains that are associated with reward processing and appetitive behaviors. The second article examines these theories of beauty and the software program FacePrint that allows a user to ‘evolve’ an attractive face using a computer. According to this program and its developers, features indicative of higher levels of pubertal estrogens (full lips) and lower levels of androgen exposure (short narrow lower jaw and large eyes) produce an attractive female face. However, beauty expert Dr. Stephen Marquardt warns that women who undergo lip augmentation post reproductive age are ‘sending false signals.’

The 'Feminism and Cultural Studies' and 'Philosophy and Ethics' sections problematize the hard scientific data included in the 'Public Health', 'Psychology and Sociology,' and the 'Breast Reconstruction' sections, examining it in a historical and theoretical framework. I can only allude to some of the important considerations made in these contributions. ‘Beauty Normalized: Normalization and Optimization of the Human Body in Cosmetic Surgery and Psychological Attractiveness Research’ examines historical theories of physiognomy, particularly the practice of composite portraiture by Charles Darwin's cousin Francis Galton, who developed this technology in order to prove that psychological traits are as inheritable as morphological ones. The author connects this historical data with today's televised makeover shows. ‘Beauty, Desire, and Anxiety: The Economy of Sameness in ABC's Extreme Makeover thematizes the culture of reality television shows from the turn of the century (starting in the US in 2002 with ABC’s Extreme Makeover) and the ‘economy of sameness’ they promote and produce. ‘Surgical Passing: Or Why Michael Jackson's Nose Makes “Us” Uneasy’ is a feminist contribution that uses invaluable data from interviews with female cosmetic surgery users. It argues that we cannot simply treat cosmetic surgery as a ‘beauty intervention,’ but rather as an intervention into the identity of a person, with the extreme example of Michael Jackson's whitification. This argument is also central to ‘Eyes Wide Open: Surgery to Westernize the Eyes of an Asian Child,’ an article that raises stark questions about the limits of parental choice and the failure of the current model of medical decision-making to take into account the rights of the child. Here, the author makes a case for ethnicity being as important a marker of identity as gender and sexuality are. Blepharoplasty is described here as an insult to identity and compared to genital surgery and female genital cutting — both causing long-term psychological trauma. In ‘Architecture of the Body: Postmodern Space’ the author draws an interesting comparison between architecture, feminism, and postmodernism: the paper argues that bodies altered via cosmetic surgery aesthetically mirror postmodern architecture and simultaneously help to create subjects that belong inside quintessentially postmodern environments, such as cathedrals, shopping malls, or the Bonaventure Hotel.

The 'Philosophy and Ethics' section raises some concerns with regard to today's use of cosmetic surgery, connecting it with ethical issues. In ‘Is It Ethical to Use Enhancement Technologies to Make Us Better than Well?,’ one of the authors points to the questionable blur between enhancement and treatment in the promotional language of pharmaceutical products and warns us about their intentions. The co-author, on the other hand, does not see the pharma-industry as being solely at fault and also warns against the demonization of technology. Why shouldn't we sleep better and look better?, he asks. ‘Of Swans and Ugly Ducklings: Bioethics between Humans, Animals, and Machines’ critically assesses the ‘biopolitical regime’ of the makeover show The Swan, which had its debut in 2004 on FOX, and remains to this day one of the biggest reality television spectacles ever watched (the first-season finale was watched by more than 10 million Americans). ‘Cosmetic Surgery and the Televisual Makeover: A Foucauldian Feminist Reading,’ applies a feminist reading to the makeover show Extreme Makeover, which is understood as a contemporary manifestation of normalization (Foucault)—the discourse of conformity and (physiognomic) deviance from a norm are under examination. ‘Makeover Culture’s Dark Side: Breasts, Death and Lolo Ferarri’ reports—in the most drastic way—what the Cosmetic Surgery and Psychological Issues warns us against: the correlation between suicide and severe BDD. Finally, Sander Gilman, who developed the concept of ‘passing’ employed by some of our authors (according to which the physical makeover means the ultimate ‘passing’ into a visibly marked invisibility), talks about the history of cosmetic surgery as one of the earliest forms of plastic surgery, i.e., the procedure to reverse circumcision which is mentioned in the Bible.

The 'Selected Links' section provides additional sources for the reader to trace today's cosmetic surgery discourse as outlined by both scientific and tabloid material, as well as the trends in new research in the field.

'Reality Television Makeover Shows' provides clips from the shows which have been studied widely, and discussed by many of my Living Book authors. I have uploaded one glamorous example from Dr. 90210 for those very few among us who happen to have missed this show, as well as a trailer to my documentary (with Geoffrey Alan Rhodes), Made Over in America (2007).

'The Cosmetic Surgery Film Trailers' show a mini film history of cosmetic surgery as represented in four important films on the subject. In A Woman's Face (1941) we see a woman, who—as she says herself in the dramatic end sequence uploaded to the site—‘wants to belong’ (to the species of femininity and motherhood). Luckily, the disfigured criminal woman Ann Holm (Joan Crawford) had run into the cosmetic surgeon Dr. Gustav Segert, who had not only given her a new face and made her into a ‘good’ person, but is now even going to marry her! (Compare this clip with the one by Jessica Queller!) The 1962 thriller The Awful Doctor Orlof shows another side to the sex-appeal our culture attributes to the male figure of the cosmetic surgeon: the abuse of power. This evil doctor wants to restore the disfigured beauty of his daughter, Melissa, and thus abducts beautiful women to a castle with the help of his blind henchman, Morpho (another one of his creations), skin-grafting their beauty onto his daughter's face. In the Korean drama Time (2006) the doctors step into the background. They simply execute, in a professional manner, what the characters want for themselves: to relive a love story as if it was fresh, hence going back in time with the help of a renewed (and slightly westernized, one must admit) face. These characters are gathered from all the above-mentioned high risk groups: they are young, one is male, they have unrealistic expectations of the procedure, they have previous unsatisfactory cosmetic surgery experience, they suffer from no deformity (hence, they qualify for BDD), their motivation to alter their face is based entirely on relationship issues, and they definitely suffer from anxiety and a personality disorder. No wonder this makeover can only go wrong! The Skin I Live In by Almodóvar (2011) has been inspired by the legendary French horror film, Les yeux sans visage (1960), of which you can see a clip just above Almodóvar's trailer. I recommend letting both clips run at the same time.



1 The term was not invented by Plato. The notion of agathoi (the good) has been in circulation since Homer. In Athenian society, the agathoi were the most virtuous, best educated, and best equipped (by birth and through acquired skills) to rule next to the king and also as a group (aristoi) over the people (demos). This aristocracy was replaced in the sixth and seventh centuries by dictatorships, and the aristocracy became part of the demos. At the end of this development, the noble and 'best' start to be labeled good (agathoi) and beautiful (kaloi). According to Julius Jüthner, this conjunction was an expression of a new social class of nobility that was identified not only through birth but also through merit and money. This class included all types of deserving people, from chevaliers to regular civilians. J. Jüthner, ‘Kalogathia,’ in Charisteria. Alois Rzach zum achtzigsten Geburtstag dargebracht (Reichenberg: Verlag von Gebrüder Stiepel, 1930), 115–114.

2 I explore this concept throughout my book, forthcoming from the MIT Press (2012), The Cosmetic Gaze: Body Modification and the Construction of Beauty. It offers a cultural and technological exploration and critique of thw 21st century makeover culture and its historical anchoring in 18th century physiognomy, 19th century eugenics, and 20th century genocide.

3 Preoccupation with some imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. 2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 3. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). As quoted in K. A. Phillips, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (New York: Oxford University Press, 1996), 33.

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