Plastic surgery has become synonymous with the quest for youth and beauty, albeit with varying degrees of success. But the field has, for centuries, been driven by medical necessity — and it has nothing to do with plastic.
The discipline derives its name from the Greek word “plastikos” — to mold or give form. And while the idea of perfecting yourself surgically is a relatively recent phenomenon, there is evidence of reconstructive surgery going back to antiquity.
An illustration depicting 19th-century plastic surgery being performed on a woman with facial burns during. Credit: Universal History Archive/Universal Images Group Editorial/Getty Images
By the 6th century B.C., physicians in India were carrying out procedures not dissimilar to a modern-day cosmetic rhinoplasty. In a detailed compendium called “Sushruta Samhita,” the Indian physician Sushruta — who is sometimes called the father of plastic surgery — outlined a remarkably advanced technique for skin grafts.
As in Egypt, the procedure involved repairing noses. But according to Yousef, patients’ motives were, in a sense, cosmetic.
“In ancient India, there was a practice of having one’s nose removed as punishment for adulterous acts or (other acts that were) against the law at the time,” said Yousef, who is also a trainee surgeon at Sydney’s Royal Prince Alfred Hospital. “It was a public sign of shame — if you walked around with an absent nose, people knew that you’d done something.”
Sushruta’s technique involved constructing new noses using skin from elsewhere on patients’ faces. “There are two schools of thought,” Yousef said. “That the skin was either from the forehead or the cheek. But he basically raised the skin and the underlying fat, before transporting it to the area of the nose.”
“Celsus described what we today would call blepharoplasty, or eyelid rejuvenation,” Yousef said. “It was used when hairs (eyelashes) became inverted and started to affect the patient’s ability to see. They were trying to shorten the eyelid so the hairs wouldn’t reach the eye.”
In the ancient world, patients were usually “seeking to replace something rather than enhance their aesthetic appeal,” Yousef said. And given the pain and risks involved, going under the knife was reserved for those most in need. “Wine was the anesthetic,” Yousef added.
Progress in the field was slow over the ensuing centuries. Like much of medical science, it was the development of modern germ theory and the 19th-century invention of anesthesia that began shaping the practices seen today.
As with so many innovations, however, there was another factor that accelerated plastic surgery’s progress: war.
During World War I, the sheer volume of patients with facial injuries — coupled with advances in blood transfusions and infection control — allowed doctors to experiment with innovative new techniques, according to Andrew Bamji, author of “Faces from the Front,” a book tracing the origins of modern plastic surgery.
“If you’ve got 100 patients to learn from, that actually isn’t very many, given the various types of injuries you can have,” the writer and retired rheumatologist said in a phone interview. “But if you’ve got 5,000 patients, it’s a different game altogether.”
A doctor examines a patient at the maxillofacial Center of Marie Lannelongue Hospital in Paris. Headed by doctor Maurice Virenque, the hospital has been a pioneer of reconstructive surgery in the 20th century. Credit: AFP/Getty Images
The institution at the heart of Bamji’s book, Queen Mary’s Hospital in London, was the “first to concentrate all the patients in one place,” he added. Skin grafts, bone grafts, facial reconstructions and wound-stitching techniques all made dramatic leaps forward.
“You’ve got literally dozens of surgeons working there, and they can bounce ideas off each other. We have photographs of two operations happening in the same operating theater at once — which from a cross-infection point of view, nowadays, would be completely forbidden — but… you have this incredible interchange of ideas and the development of reconstructive techniques.”
At the time, the priority for military and civilian patients was improved functioning, such as chewing or breathing more easily. And the idea of using surgery to simply improve one’s appearance remained in its infancy. Doctors in Europe and America had experimented with rudimentary cosmetic procedures prior to World War I, though they were “hit and miss,” Bamji said, adding that “quite a lot of it went wrong.”
At the start of the 20th century in France, for instance, doctors sometimes attempted to re-contour patients’ faces using paraffin wax. Although solid at room temperature, when the wax warmed in the body “it started to melt, and so it sank into the lower regions,” Bamji said.
“Most plastic surgeons yearned to be recognized as ‘serious surgeons’ and avoided what were considered frivolous procedures,” he added.
The post-war period saw drastic changes for the field. Improved technology, diminished risk and increased disposable income all contributed to plastic surgery’s growing popularity — as did a surplus of doctors after the end of World War II, according to Bamji.
“You’ve got all these plastic surgeons that haven’t got anything else to do,” he said. “Once they were done with all the wartime causalities, of which there were vast numbers, then they can get on with all these other things.”
By the 1960s — in the US especially — many of today’s most common cosmetic procedures, such as breast augmentation, rhinoplasty and face re-shaping, were becoming more commonplace. Innovation was still driven by the needs of trauma patients or those suffering from cancer or disfigurements. But the technology could be used to vainer ends.
A patient recieves botox injections at a Philadelphia hospital in 2002. Credit: Don Murray/Getty Images
Tastes continue to change, too. And while the Covid-19 pandemic has impacted the entire industry, with ASPS reporting a 15% drop in cosmetic procedures carried out in the US in 2020 compared to the previous year, some procedures suffered far larger falls — the number of breast augmentations was down 33% and buttock lifts were down 27%, year over year.
Patients await a check-up after a plastic surgery procedure at a clinic in Tirana, Albania. Credit: Gent Shkullaku/AFP/Getty Images
“People started thinking about doing things that would make them feel good in the long-term.”
Top image: A physician and patient at Moscow’s Beauty Institute cosmetology clinic in 1968.
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