Creating beauty

Aesthetic Surgery

Creating Beauty to Cure the Soul by Sander Gilman

1998

Review by William C. Brender, MD

Aesthetic Surgery

Jacques Joseph

Nasenplastik und sonstige Gesichtplastik

1931

Aesthetic Surgery

“We restore, repair and make whole, those parts which nature has given but which fortune has taken away, not so much that they may delight the eye, but that they buoy up the spirit and help the mind of the afflicted.”

Jasper Tagliacozzi 1597Father of Plastic Surgery

Aesthetic Surgery

(Reconstructive Surgery is) “an attempt to return to normal,

Aesthetic surgery is an attempt to surpass the normal.”

Harold Delf Gillies 1882-1960

Aesthetic Surgery

Surgeons were concerned about aesthetic results:

• careful suturing of edges of facial wounds• nasal fractures reduced and splinted

Papyrus (3,000 BCE)

Aesthetic Surgery

Importance of “beautiful” suture stressed

Cornelius Celsius (25 BCE - 50 CE)

Aesthetic Surgery

“(Billroth performed) plastic operations with artistic ability to correct defects of beauty...one could see his joy when he was able to successfully improve the appearance of a damaged person, so that that person was no longer the object of pity or horror.”

Theodore Billroth (1829-1894)

Aesthetic Surgery

“Beauty is the outward and visible sign of health - perfection - virtue….”

Jules Hericourt (1850-?)

Aesthetic Surgery

Beauty Myth

“The accepted wisdom is that if you understand your body as “ugly”, you bound to be “unhappy””

Aesthetic Surgery

Mens Sana in corpore sanoThe mark of the healthy body is the happy soul

Mens non sana in copore insanoThe mark of the unhealthy body is the sick soul

Aesthetic Surgery

• Modern society - attempt to change our body - diet, cosmetics, fashion and surgeons

• Pursuit of “Body Beautiful”/“Happy Soul”.

Aesthetic Surgery

“Plastic surgery with the aesthetic as well as the reparative objective, will be commonplace in another five years, as neatness and cleanliness are today”

Henry Schireson (1881-1949)

Aesthetic Surgery

Widespread AcceptanceNo longer limited to “Rich”

Status symbol in South America

Aesthetic Surgery

Increased number of procedures performedliposuction - #1breast enlargement - #2eyelid correction - #3chemical peels - #4facelift - #6(breast reduction - reconstructive - #5)

Plastic Surgery

Male Cosmetic Surgery

1992 13%

1997 33%

Aesthetic Surgery

Benefit psychologically“self conscious”“social acceptance”“positive” change in appearance improve professional chances increased admiration

Aesthetic Surgery

This artistic branch of surgery has long been perceived as “frivolous”

and not “serious” medicine.

Aesthetic Surgery

Performed nose jobs on three members of same family in “vaudeville” manner

People in audience faintedReinforcing the tasteless aspect of

advertising

J. Howard Crum (1888-c.1970)?performed first facelift

Aesthetic Surgery

Core of the Psychological theory of Aesthetic Surgery:

Curing the Physically Anomalous is curing the

Psychologically Unhappy.

Aesthetic Surgery

“….did not claim only to cure the “pug nose”; he claimed also to be curing his patient’s unhappiness”

John Orlando Roe (1849-1915)Rochester, New York

Aesthetic Surgery

Beautiful is a sign of the healthy and in modernity the healthy becomes a sign of the happy.

Aesthetic Surgery

Prozac nicknamed Cosmetic surgery of the Brain

Decline in stigma associated with Aesthetic Surgery parallels the change in stigma of

mental illness.

Aesthetic Surgery

“People have the feeling they can’t control their own future; that working hard and being a good citizen won’t get you anywhere, That’s why beauty has become the main value in the market.”

Marcelo HernandezArgentinean psychiatrist

Aesthetic Surgery

“often…compared cathartic psychotherapy with surgical intervention.”

“convinced that the patients would benefit if we were more often to hand over the treatment of these affections to the rhinological surgeons.”

Sigmund Freud (1856-1939)

Studies of Hysteria (1895)

Aesthetic Surgery

Reversal of Traditional Medical Model

• Classic model - the patient comes to the physician who makes a diagnosis and then provides the treatment.

• New model - the patient tells the doctor the diagnosis and how they want it treated.

Aesthetic Surgery

Reversal of Traditional Model

Classic model - operation is performed on a deformed patient to make them look normal

New model - operation is performed on a healthy patient to enhance the way they look

Aesthetic Surgery

“…the idea that we get a permit to operate on someone who is totally

normal is an unbelievable privilege. In a way it’s the ultimate

surgery.”

Joseph M. Rosen MDDartmouth-Hitchcock Medical Center

Aesthetic Surgery

Definition of heath - “a state of complete physical, mental and social well-being.”

World Health Organization

Aesthetic Surgery

Cosmetics -adjunct of treatment (disguise) of illness

Origin of “cosmetic surgery” - late 19th century subspecialty of “medical cosmetics” - disguise of syphilitic’s symptoms (i.e. missing nose or ulcerated lesion )

Aesthetic Surgery

Medicamenti faciei

make up as a form of medication for the soul

Ovid (43 BCE - 17/18 CE)

Aesthetic Surgery

The study of the ugly is to the examination of beauty what the study of pathology is to illness.

Karl Rosenkranz (1805-1879)

Aesthetic Surgery

Caveat: One culture’s “normal” is another culture’s ugly.

Rod Sterling (1924-1975)The Twilight Zone 11/11/60

Eye of the Beholder

Aesthetic Surgery“Charum”

Men who are “flat-nosed” or snub-nosed are forbidden from becoming priests.

Aimed against those with leprosy who were seen as ritually unclean. The unclean is also the ugly, and the unhappy.

Leviticus 21:18

Aesthetic Surgery

“absence of the nose is a horrible thing to look at.”

Erik, the Phantom Phantom of the Opera (1911)

Gaston Leroux (1868-1927)

Aesthetic Surgery

All lost noses, in the age of syphilophobia, were signs of sin. Syphilis marked the face of the naïve and the innocent as well as the lecher and hypocrite.

Aesthetic Surgery

“Big noses” cannot mate with “little noses”

Edmond Rostand (1868-1918) Cyrano de Bergerac 1897

Aesthetic Surgery

The Jewish Visage

The “unmanly” “bodily infirmity”The tubercular Jewish woman

THE JEWISH NOSE

Aesthetic Surgery

NostrilityThe anatomy of the Jew in which the “hooked nose” represents the first visual representation

of the “Primitiveness of the Semitic race”

“Dr. Celticus”Anti-Semitic Pamphleteer

Aesthetic Surgery

The Nose was a Sign of the Jew’s Nature.A sign that does not vanish when the Jew is

acculturated. Being seen as a Jew meant being persecuted,

attacked, and harassed.Alteration of the body through surgery was seen

as the “cure”.

Aesthetic Surgery

Tradition of the Sweet Sixteen Nosejob

Aesthetic Surgery comes to be understood as “Somatopsychic Therapy”

Aesthetic Surgery

The Deformity affects the Conscious Mind through the Patient’s Reception in Society.

The Operation alters the Perception of the Body in others and thus alters the Patient’s Consciousness.

Aesthetic Surgery

The focus of the patient’s unhappiness is on their fixed (racial) physiognomy

Image of the African Face: low forehead, flat wide nose

Enrico Morselli (1852-1929)

Aesthetic Surgery

“We, belonging to the higher races, regard as ugly all noses which approach that of the ape…”

Paolo Mantegazza (1831-1910)

Aesthetic Surgery

PLUMPNESS - Double Edged Sword

Aesthetic Surgery

PLUMPNESS - Double Edged Sword

“Normal” women can be plump and are therefore “healthy”.

“Criminal” women, such as prostitutes are plump, a sign of their “natural” tendency to their craft.”

Cesare Lombroso (1835-1909)

Aesthetic Surgery

Micromastia

? Real Diagnosis? American Culture“Feel less of a Woman”Desire the fullness of pregnancy

Aesthetic Surgery

“Ideal patient is someone who, in the aesthetic sense, is less than optimal, but who otherwise is well adjusted.”

Jim Pietraszek, MD , La Jolla, CA

Aesthetic Surgery

Ability of the patient to tell a complete narrative is a predictor of positive outcome.

Inability to narrate is a sign of psychological instability.

Aesthetic Surgery

“Unhappiness” is a problem of your fictive life, rather than your ill organs.

“You are what you imagine yourself to be.”

Hans Vaihinger (1852-1933)

Aesthetic Surgery

“The anomaly of the unhappy patient….is explained as a too heightened sensitivity to beauty”

Jacques Joseph (1865-1934)

Aesthetic SurgeryJoseph’s Psychological Scale

Hypo-aesthetic - unfazed even by gross deformities

Ortho-aesthetic - normals who can “objectively” evaluate their deformities

Hyper-aesthetic - “extremely unhappy” with strongly developed sense of beauty such as painters, sculptors, and others with artistic nature

Para-aesthetic - pathologic aesthetic sensibility focus on “imagined deformities”. Have normal or even beautiful features that do not need change.

Aesthetic Surgery“Bad” Patient Qualities

male, unmarried, twenty to thirty-five. low self esteem,grandiose ambitions, hyposexual with no long termrelationships, extremely obsessive yet passive with surgeon, aggressive when not accommodated, anxious,vague about goals of surgery, dissatisfied followinginitial postop enthusiasm, minimized problem

Knorr, Edgerton, and HoopesJohn Hopkins University

Aesthetic Surgery

Dependent and Controlling Females who Hate the Aging Process

Any violation of the body engenders exacerbation of neurosis even with the normal patient.

Evidence of depressive symptoms preoperatively will be intensified in the immediate postoperative period

Erich Lindermann (1900-1974)

Aesthetic Surgery

Negative Result of Surgical Intervention

Exacerbation of unhappiness through the patient’s experience of trauma awaken existent psychic patterns.

Helene Deutsch (1884-1982)

Aesthetic Surgery

“Monomania”

Male patients requested multiple nasal procedures

The “normal” nose still made the patient unhappy

1892 paperRobert F. Weir (1838-1894)

Aesthetic Surgery

Polysurgery

The demand for repeated surgeryA sign of psychopathology

Aesthetic Surgery

Dysmorphophobia

Compulsive disorderAnxiety about having something “obvious or

comical” about one’s body(i.e. unusually formed nose, knock-knees,

disgusting odor)

Aesthetic Surgery

Dysmorphophobia

Preoccupation with some imagined defect in appearance in a “normal”-appearing persons or the exaggeration of a slight physical anomaly

(i.e. bald head, nose (male), ears, breast (women)

Aesthetic Surgery

Nasal Neurosismale obsessionthree qualities (big, ugly, asymmetrical)Phallic Nature of the Nose (Ex Naso Viris Hastam)Nose reveals the “Castrated”/Circumcised nature

of the man with the long nose, where you are a Jew or not

Aesthetic Surgery

Freud’s Little Hans

“if - says the child - I can be circumcised and made into a Jew, can I not also be castrated

and made into a woman?”

Aesthetic Surgery

Nasal interventionsOne cure for sexual dysfunction and hysteria was

to operate on the nose Shared relationship embryologically between the

tissue of the nose and that of the genitaliaMale menstruation - “occasional bloody nasal

secretion”

Wilhelm Fliess (1858-1928)

Aesthetic Surgery

“The “surgical quack” is the surgeon who does harm, (and) who almost kills the patient. “

Sigmund Freud Psychoanalysis and Quackery

Aesthetic SurgeryBreast Obsession

Female Equivalent of Nasal NeurosisLarge Pendulous Breasts - Mark of the PrimitiveCaucasian breast - hemispherical shapeAfrican breast - pointed breast shape

Aesthetic Surgery

Thersites- ComplexCompulsive sense of being seen as ugly because

of a specific quality of the bodynamed after ugliest man in Greek army at TroyHomer’s Iliad - most vicious warrior, not aware of

his ugliness

Hermann Stutte (1909-)

Aesthetic Surgery

Body Dysmorphia Syndrome

1980 - excessive concern with an “imaginary” defect

Patients believe themselves to be “quite ugly” and are convinced that they “could be very attractive if some changes were made surgically”

1994 - preoccupation with a defect in appearance which either “excessive” or “imagined”

Aesthetic Surgery

DMV IV - preoccupation with an imagined defect, causing clinically significant stress or impairment of social, occupational, or other important areas of functioning, not accounted for by another mental disorder.

Aesthetic Surgery

BDDObsessive compulsive disorderLate 20s or early 30sAffects both men and women Avoid describing their defects in detailTheir preoccupations are self-described as

“intensely painful” “tormenting” or “devastating”Requires psychopharmacological intervention

?Michael Jackson - 30 operations

Aesthetic Surgery

Dysmorphophobia is not necessarily an indicator to the surgeon not to operate - but you may put your own life at risk

M Tavis MD

Aesthetic Surgery

Polysurgical AddictionA compulsive need for surgical interventionsWhose search for perfection/(in)visibility, means

they will never be satisfied “Castration anxiety” center of male desire for

repetitive surgeryWomen undertake surgery to “fulfill an

ungratified infantile wish for a child”

Karl A. Menninger (1893-1990)

Aesthetic Surgery

“Surgeon’s intuitive response”

knowing a difficult or dangerous or unhappy patient when one sees one

Aesthetic Surgery

“Recommend a Simple Interview Question Method of Counseling designed to Identify Underlying Psychological Manifestations and to control the Problem Patient.”

MR Wright and WK Wright

Aesthetic Surgery

Psychological Testing

Minnesota Multiphasic Personality InventoryPatient Attitude ScaleExpectation for Plastic Surgery ScaleEsthetic Analysis Form (dentistry)

Aesthetic Surgery

The act of narration is one of the marks of a healthy psyche.

“The patient’s inability to state accurately and succinctly the thing that displeases him.”

“The more pronounced the deformity of loss, the more apt is a reasonably good result likely to be acceptable.”

Aesthetic Surgery

“Cosmetic surgery appeals to vain people. There many idle men and women who have nothing to do but study themselves….learn to avoid these psychopaths.”

Charles Conrad Miller (1880-1950)

Aesthetic Surgery

The problem patients are dangerous and difficult, they are never happy

with the results and they sue!

Aesthetic Surgery

“Anything that attracts notice to a child in an unpleasant way is, as a rule, bad for the child.”

Vilray Papin Blair (1871-1955)

Aesthetic Surgery

“..a nasal defect may produce such an inferiority complex as genuinely to hinder the patient’s happiness and progress.”

Harold Delf GilliesNew Zealand reconstructive surgeon

Aesthetic Surgery

“The surgeon seeks to ease the mind by remolding the…features to a conformity with the normal.”

Maxwell Maltz, MDChicago aesthetic surgeon

New Faces, New Futures (1936)

Aesthetic Surgery

“The result of aesthetic surgery can be “..an infusion of confidence, and a losing of sensitiveness which sometimes amounts to an inferiority complex.”

George Warren Pierce, MDSan Francisco surgeon

Aesthetic Surgery

“prejudice and discrimination - real or imagined - and the desire to “look American” played a substantial role in the motivation for surgery”

Francis Cooke Macgregor 1989

Aesthetic Surgery

“Passing” remains a major goal of aesthetic surgery

“Disfigurement becomes the last bastion of discrimination”

Angus McGroughter British Aesthetic Surgeon

Aesthetic Surgery

Body sculpture and Psychic Surgery may be closely related.

Passing is either acquiring “health” and “happiness” or being seen as “ill or

“psychopathological”. Both are attributed to the individual who wishes to “pass” unnoticed.

Aesthetic Surgery

Tagliacozzi Myth

Condemned after his death for his “attempt to improve upon the work of the Almighty”

Chastised for his practice of plastic surgery This was a religious problem not exclusively a

Jewish problem

Gaspare Tagliacozzi (1545-1599)Father of Plastic Surgery

Aesthetic Surgery

“Chavalah” (Wounding)

Traditional Judaism rejects surgical alteration of the body except for reconstructive surgery

Halachic tradition would permit alteration of the shape of the nose for men and women for psychological reasons

Aesthetic Surgery“Cosmetic Surgery” is justified if

the defect: 1/prevents a woman from finding a marriage partner 2/prevents a happy relationship with her husband 3/prevents a person from fulfilling a constructive function in society - this applies especially to men who without such improvement could not earn enough to support their families

Secular Reposa

Aesthetic Surgery

Aesthetic surgery can be sanctioned if it ameliorates “grave psychological effect…such as a sense of inferiority”.

At this point it is not “only permissible but also a necessity”

Father Charles G. O’LearyPrinciple of Totality

Aesthetic Surgery

“Aesthetic surgery is not in contradiction to the will of God, in that it restores the perfection of the greatest work of creation, man.”

Pope Pius XII

Aesthetic Surgery

Women and Plastic Surgery

Aesthetic surgery is seen as a means of placing the woman in a Position of Power concerning

her own body or is seen as making her complicit with Patriarchal Standards of Beauty.

Aesthetic Surgery

“The purpose of cosmetic surgery is to improve a person’s psychological functioning by modifying their body image.”

Gregory Borah, MD

Aesthetic Surgery

Aesthetic Surgery makes patients truly happy by restoring the ideal state that already exists in

the patient’s imagination.Aesthetic surgery does not remove psychological

symptoms because there are none.Aesthetic surgery does not manufacture patients

because there is no patient role and the individual retains a sense of autonomy.

Aesthetic Surgery

“The surgeon, however is not a psychologist or psychotherapist, who wants to create mental health but rather an artist, whose “artistic ability to create” along with “the patient’s willingness to be molded,” assures the happiness of both. Happiness is defined as the ability “to offer external changes which are more compatible with the vision of the inner self.”

Sander L. GilmanCreating Beauty to Cure the Soul

Aesthetic Surgery

Thank You