Aesthetic SurgeryCreating 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 1597 Father 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 SurgerySurgeons were concerned about aesthetic results: • careful suturing of edges of facial wounds • nasal fractures reduced and splinted Papyrus (3,000 BCE)
Aesthetic SurgeryImportance 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 sano The mark of the healthy body is the happy soulMens non sana in copore insano The 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 Acceptance No longer limited to “Rich”Status symbol in South America
Aesthetic SurgeryIncreased number of procedures performed liposuction - #1 breast enlargement - #2 eyelid correction - #3 chemical peels - #4 facelift - #6 (breast reduction - reconstructive - #5)
Plastic SurgeryMale Cosmetic Surgery 1992 13% 1997 33%
Aesthetic SurgeryBenefit psychologically “self conscious” “social acceptance” “positive” change in appearance improve professional chances increased admiration
Aesthetic SurgeryThis artistic branch of surgery has long been perceived as “frivolous” and not “serious” medicine.
Aesthetic SurgeryPerformed nose jobs on three members of same family in “vaudeville” mannerPeople in audience faintedReinforcing the tasteless aspect of advertising J. Howard Crum (1888-c.1970) ?performed first facelift
Aesthetic SurgeryCore 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 SurgeryBeautiful is a sign of the healthy and in modernity the healthy becomes a sign of the happy.
Aesthetic SurgeryProzac nicknamed Cosmetic surgery of the BrainDecline 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 Hernandez Argentinean 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 ModelClassic model - operation is performed on a deformed patient to make them look normalNew 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 totallynormal is an unbelievable privilege. In a way it’s the ultimate surgery.” Joseph M. Rosen MD Dartmouth-Hitchcock Medical Center
Aesthetic SurgeryDefinition of heath - “a state of complete physical, mental and social well-being.” World Health Organization
Aesthetic SurgeryCosmetics -adjunct of treatment (disguise) of illnessOrigin 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 facieimake up as a form of medication for the soul Ovid (43 BCE - 17/18 CE)
Aesthetic SurgeryThe study of the ugly is to the examination of beauty what the study of pathology is to illness. Karl Rosenkranz (1805-1879)
Aesthetic SurgeryCaveat: 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 SurgeryAll 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 SurgeryTradition of the Sweet Sixteen Nosejob Aesthetic Surgery comes to be understood as “Somatopsychic Therapy”
Aesthetic SurgeryThe 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 SurgeryThe focus of the patient’s unhappiness is on their fixed (racial) physiognomyImage 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“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 SurgeryAbility 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 Surgery Joseph’s Psychological ScaleHypo-aesthetic - unfazed even by gross deformitiesOrtho-aesthetic - normals who can “objectively” evaluate their deformitiesHyper-aesthetic - “extremely unhappy” with strongly developed sense of beauty such as painters, sculptors, and others with artistic naturePara-aesthetic - pathologic aesthetic sensibility focus on “imagined deformities”. Have normal or even beautiful features that do not need change.
Aesthetic Surgery “Bad” Patient Qualitiesmale, unmarried, twenty to thirty-five. low self esteem,grandiose ambitions, hyposexual with no long termrelationships, extremely obsessive yet passive withsurgeon, aggressive when not accommodated, anxious,vague about goals of surgery, dissatisfied followinginitial postop enthusiasm, minimized problem Knorr, Edgerton, and Hoopes John Hopkins University
Aesthetic SurgeryDependent and Controlling Females who Hate the Aging ProcessAny violation of the body engenders exacerbation of neurosis even with the normal patient.Evidence of depressive symptoms preoperatively willbe intensified in the immediate postoperative period Erich Lindermann (1900-1974)
Aesthetic SurgeryNegative Result of Surgical InterventionExacerbation 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 proceduresThe “normal” nose still made the patient unhappy 1892 paper Robert F. Weir (1838-1894)
Aesthetic Surgery PolysurgeryThe demand for repeated surgery A sign of psychopathology
Aesthetic Surgery DysmorphophobiaCompulsive disorderAnxiety about having something “obvious or comical” about one’s body(i.e. unusually formed nose, knock-knees, disgusting odor)
Aesthetic Surgery DysmorphophobiaPreoccupation 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 noseShared 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 Surgery Breast ObsessionFemale 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 Syndrome1980 - excessive concern with an “imaginary” defectPatients 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 SurgeryDMV 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 womenAvoid describing their defects in detailTheir preoccupations are self-described as “intensely painful” “tormenting” or “devastating”Requires psychopharmacological intervention?Michael Jackson - 30 operations
Aesthetic SurgeryDysmorphophobia 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 TestingMinnesota 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 SurgeryThe 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 Gillies New Zealand reconstructive surgeon
Aesthetic Surgery“Thesurgeon seeks to ease the mind by remolding the…features to a conformity with the normal.” Maxwell Maltz, MD Chicago 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, MD San 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 SurgeryBody 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 MythCondemned after his death for his “attempt to improve upon the work of the Almighty”Chastised for his practice of plastic surgeryThis 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 surgeryHalachic 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 partner2/prevents a happy relationship with her husband3/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 SurgeryAesthetic 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’Leary Principle 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 SurgeryAesthetic 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 SurgeryAesthetic 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. Gilman Creating Beauty to Cure the Soul