aroused so much controversy. Physicians have turned against physicians; surgeons have blamed the entire female sex for its vanity, and individual males who sought treatment for their lack of masculinity; patients-turned-consumers have sued doctors- turned-marketers; dissatisfied customers have battled manufacturers and government regulatory agencies; and a critic recently faulted one television network for exploiting “America’s insatiable obsession with cosmetic surgery,” while simultaneously berating others for not screening “this vital message to today’s youth.” What is it about plastic surgery that raises so many moral hackles? The answer has something to do with human vanity, Puritan values, and the line, always wavy and porous, between reconstructive and aesthetic surgery.

Though World War I made plastic surgery both crucial and more respectable, the specialty has a long, if frequently interrupted, history. As early as 600 B.C., a Hindu surgeon reconstructed a nose by using a piece of the cheek, and by A.D. 1000, rhinoplasty, nose surgery utilizing skin from the forehead, was known as an Indian technique. This was, according to the British Madras Government Consultation Book of 1679, a barbaric custom: “not to kill, but to cut off the noses with upper lips of the enemies.”

Social conditions continued to give rise to medical advances. The 16th-century increase in dueling and street brawling may have inspired the Italian Gaspare Tagliacozzi, sometimes called the father of plastic surgery, to develop a method of reconstructing a nose by transferring flaps from the upper arm. But it is more likely that the appearance, at the close of the 15th century, of epidemic syphilis, of which a depressed or saddle nose is a telltale symptom, was a more urgent impetus. The syphilitic nose was an early battleground in the war between the morally fraught definitions of reconstructive and cosmetic surgery. A practitioner who introduced Indian techniques in England in 1815 drew a clear line. Maimed heroes of the Napoleonic Wars deserved his ministrations. Fornicators and their progeny did not.

But, if plastic surgery was possible, it was not always advisable or even safe. Tagliocozzi’s method, for example, entailed a variety of separate procedures over a period of several months, as well as a sort of cast that kept the arm elevated and attached to the nose. Moreover, the pain was excruciating and the risk of infection great. There was one more insurmountable obstacle. The fearless patient who endured the agony and survived the operation was left with scars that might not be as unsightly as the original condition, but were far from attractive and, more to the point, dead giveaways to what he or she had been up to.

During the 19th century, developments in anti-sepsis and anesthesia made surgery both safer and less painful, but scarring, and the past it signified remained a problem. If the point of the operation was to pass—as physically and morally whole, as naturally beautiful, as a member of another group—secrecy was essential.

The act of

passing and its opposite, the state of authenticity, run like parallel fault lines through the plastic surgery terrain. Facial features frequently hinted at national and racial background. They also revealed character, or so it was believed. In the late 19th century, John Orlando Roe, a Rochester, New York surgeon, listed five kinds of noses—Roman, Greek, Jewish, Snub or Pug, and Celestial—and the character traits they signified. “The Roman indicates executiveness or strength; the Greek, refinement; the Jewish, commercialism or desire of gain; the Snub or Pug, weakness and lack of development; the Celestial, weakness, lack of development, and inquisitiveness.” Roe was not alone in having such theories, of course, but he was rare in that he did something about the assumed inequalities. In the 1880s, he developed a procedure that worked from within the nostrils and left no exterior scars. Now an Irish immigrant—Roe’s first operations were on pug noses, which were considered Celtic—could pass as a real Anglo-Saxon American, and no one would be the wiser.

Late-19th-century methods were primitive by post-World War I standards, but the intent was sweeping. Plastic surgery aimed at nothing less than fostering human happiness. “Few patients suffer more of mental discomfort than the unfortunate possessors of some unsightly disfigurement on the face which attracts constant notice; few are more solicitous for any operation which promises relief, and none are more grateful for the slightest improvement in their condition,” wrote one surgeon. The reference to “mental discomfort” is telling. Plastic surgery and psychology, two initially suspect and subsequently extremely popular specialties of modern medicine, were entering their long and volatile love-hate relationship.

World War I turned plastic surgery’s attention from the inequities of birth and the promise of happiness to the destruction of war and the battle for survival. As physicians and dentists rose to the occasion, headlines and articles proclaimed supernatural achievements. Varaztad Kazanjian, chief dental officer of the Harvard Unit, became known as “the miracle man of the Western Front” for his inventive wiring and splints of vulcanized rubber to keep wounded faces from contracting before they reached a hospital for bone grafting. “There is nothing impossible in dental surgery now,” a Red Cross nurse told reporters. Great expectations would continue to foster, and haunt, the specialty.

Returning from her third visit to Paris since the outbreak of the war, Mrs. William K. Vanderbilt told The New York Times of the extraordinary work that the American Ambulance Field Service was doing on “these torn, mutilated human beings, without any faces, who would otherwise be unbearably repulsive and almost certainly economically dependent.… I have seen a man brought into a hospital with his jaw bone shot away. The lower part of his face was just—gone. What remained of his chin was hanging against his chest, as if it were a beard. And I have seen that man leave the hospital, scarred of course, but normal again.”

Success in restoring these “unbearably

repulsive” veterans to a semblance of the sons and husbands and fathers who had gone off to war ennobled the entire specialty. Once vilified for frittering away their expertise on sexual degenerates, pushy immigrants, and vain women, plastic surgeons were suddenly heroes, honored along with the veterans they had mended.

But, just as Armistice Day heralded a “return to normalcy” for the rest of society, it sent plastic surgery back to its marginal position in the world of medicine. Some surgeons limited their practices to deformities caused by birth defects and automobile and industrial accidents, but others began applying the skill and techniques they had perfected on wounded veterans to dissatisfied civilians, chiefly women. In 1923, Fanny Brice underwent rhinoplasty to transform her nose from what she called “prominent” to “merely decorative,” but the aura surrounding the operation, which was performed in her apartment at the Ritz-Carlton in New York City, was more circus-like than antiseptic. A year later, the New York Daily Mirror ran a contest “to take the homeliest girl in the biggest city in the country and to make a beauty of her.” The paper’s Pygmalion was Dr. W. A. Pratt, owner of the Pratt Feature and Specialty Company of Brooklyn. In 1931, Dr. John Howard Crum performed the first public face-lift on record in the Grand Ballroom of the Pennsylvania Hotel in New York and followed it with several others, during which a pianist accompanied him with appropriate popular tunes; flashbulbs popped, and men and women fainted.

In 1921, the need to screen out quacks and beauty “doctors” and certify reputable surgeons, even if they did perform cosmetic procedures, gave birth to the American Association of Plastic Surgeons. A decade later, the American Society of Plastic and Reconstructive Surgeons (ASPRS) merged with it, and a few years after that, the American Board of Plastic Surgery joined the association.

Professionalizing the specialty, however, did not eliminate the tension between reconstructive stalwarts and aesthetic enthusiasts. Doctors continued to struggle to justify their positions. In 1926, Dr. John Staige Davis explained, “The abdominal operation is necessary to the health of the patient, but the operation for removal of wrinkles is unessential and is simply decorative surgery.” But, if a new nose enabled a war veteran to hold a job and marry, could it not also improve the employment opportunities of a civilian man, or sweeten the marital and therefore financial prospects of a woman? Many in the profession and among the public, unable to shed their puritanical assumptions, hedged their bets. If the aim was to look better, the surgery was unacceptable. If the goal was to be less conspicuous, the procedure was permissible. The problem was where the line should be drawn and who was to draw it. How big or misshapen did a nose have to be to qualify as a deformity? Should

the doctor or the patient make the determination? The questions were further complicated by America’s democratic ideals. Wasn’t it subversive to deny an individual the right to self-improvement?

The debate, noisy and often acrimonious, was one of the first casualties of World War II. Surgeons stopped squabbling among themselves and again turned their attention to restoring war-ravaged faces and bodies. As in the last war, the effort was international. A Kansas City physician invented a machine that sliced flesh thinner than tissue paper, and, at Queens Hospital in East Grinstead, England, British and American surgeons took bone from the hip to form entirely new noses; skin from the inside of the arm to fashion eyelids, the absence of which caused the men to shed tears continuously; and thick skin from the stomach to create half a missing hand. Advances in anesthesiology made longer operations possible; blood plasma facilitated transfusions, and if infection occurred, penicillin would combat it. Once again, the press spoke of miracles, but physicians warned the public not to expect too much. Skin taken from other parts of the body often differed in color, texture, and thickness, and even the most expertly rebuilt face might be incapable of expression. Still, in the first four years of its existence, Queens Hospital not only performed 7000 operations, but witnessed eight marriages between reconstructed veterans and the especially pretty nurses assigned to care for them.

Though World War II temporarily silenced the debate between reconstructive and cosmetic surgery, it only exacerbated the problem. Not only were the new techniques even more impressive; there were now more surgeons eager to use them. How was the record number of physicians who had trained in this challenging new specialty to make a living once the war was over? Aesthetic surgery held as much promise for practitioners as it did for patients.

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. 21st-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-averse 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 50-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 non-medical 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 because they had the implants, others that they could not get them. Some deplored the 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 women’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.”

While face-lifts and breast augmentations were on the rise in postwar America, rhinoplasty, the earliest plastic procedure, remained the most popular operation. From the end of World War I until our current era of medical tourism, which sends patients hurrying around the world in search of good treatment at the right price with the best views, cosmetic surgery was a particularly American specialty, and the “nose job” was the typical American procedure. Before we were a multicultural society, we were a melting pot. Successive generations of immigrants left their names at Ellis Island, shed their accents, and graduated from Ivy League schools; but a family nose still carried a whiff of the old country.

If face-lifts were the product of ageism, and breast surgery of sexism, then rhinoplasty was a response to racism. Fanny Brice told the press that she underwent surgery “in order that her nose may return to normalcy,” but Dorothy Parker quipped that the comedian had “cut off her nose to spite her race.” In fact, Brice never tried to hide her background, and made her reputation performing Jewish material, but her conflict is typical of several generations of women who followed in her surgical footsteps. One postwar study revealed that most Jewish girls who underwent rhinoplasty practiced their religion, hoped to marry Jewish men, and insisted they had no desire to pass as gentiles. The reason they gave for undergoing the surgery was that they wished to be judged as individuals, rather than part of a group, even a group to which they claimed they wanted to belong.

For other "ethnics," the motives were less tortuously reasoned. Italians, Greeks, and Armenians who had nose jobs admitted that they did not want to be mistaken for Jews. Perhaps the supreme irony of this postwar epidemic of rhinoplasty was that, in the mid-20th century, most Jewish girls opted for the tiny turned-up model that Irish immigrants had suffered to have lengthened and straightened at the end of the 19th. Although plastic surgeons, some of whom likened themselves to artists or sculptors, spoke of a single timeless standard of beauty, too often, the noses, breasts, and other features they turned out were merely

this year’s model.

In 1958, Pope Pius XII condemned this catering to “the caprice of fashion.” While admitting the legitimacy of much plastic surgery, he warned that operations for mere “vanity” or to enhance the “power of seduction, thus leading others more easily into sin,” or “to hide a criminal from justice” were not in keeping with the church’s teachings. As requests for guidance on the issue poured into churches of all denominations, a minister, a priest, and a rabbi came together to debate the issue under the auspices of the American Society of Facial Plastic Surgeons. All three agreed on the value of reconstructive surgery, but they took different theological positions on the virtue of aesthetic surgery. The minister addressed the problem of authenticity and cited the warning “that a man should be as he is created to be; that David should not parade in Saul’s armor.” The rabbi condoned cosmetic surgery only if it enhanced a man’s ability to support his family or a woman’s to find or hold a husband. The priest found no sin in cosmetic surgery, as long as it carried psychological benefits.

The priest had put his finger on one of aesthetic surgery’s major marketing tools. Since the early post-World War I days, plastic surgeons had been happy to join hands with their psychiatric colleagues. Both specialties were young, gaining a public following, and fighting for professional recognition and respect. They also shared the same goal: to make the patient happy. Some surgeons went so far as to describe their procedures as psychiatry with a scalpel. The assertion, in the 1930s, by J. W. Maliniak, a founder of the ASPRS, that deformities may cause insanity carries a touch of self-promotion, but studies by child psychiatrists during the same decade demonstrated that physical abnormalities led to feelings of inferiority, which could produce anti-social and even criminal behavior. In his best-selling 1930 book The Human Mind, Dr. Karl Menninger not only explained Freudian theory to the American public, but also recommended that, “when it is possible by means of medical, surgical, dental, or other devices to correct some of the actual inferiorities, such treatment is, of course, indispensable.” Three years earlier San Quentin Prison launched a plastic-surgery program for inmates “intended to give them a better chance to go straight.”

Attempts at social engineering may have been minor and sporadic, but the potential for individual self-improvement was enormous. Spurred by Alfred Adler’s formulation of the inferiority complex, a less sexually determined and more user-friendly theory than Freud”s, Americans set out not only to look inside themselves for feelings of inadequacy, as an ad for Adler’s Understanding Human Nature had promised the book would enable them to do, but also to correct the causes of these feelings. Plastic surgeons rushed to record changes in character resulting from the upgrading of features, and the question of who would draw the

line between mere imperfection and true deformity became moot. It no longer mattered if the nose looked straight to the physician, or if the body weight seemed appropriate. If the patient thought the nose was malformed or the body obese, surgery was the only hope for a good prognosis. The shift in responsibility, however, could spell trouble down the road. Knowledgeable surgeons lived in dread, and naive ones learned the peril of operating on individuals who suffered from delusional disorders, for whom the surgery was never a success, and litigation was a likely after-effect.

The surprise, however, is not that the fix frequently did not work, but that it sometimes did. In 1961, a study of 53 male salespeople and sales managers in their 50s and 60s found that their incomes had increased by an average of $1300 during the year following their face-lifts. Whether the gain was the result of the operation or the economy is not clear. Another survey found that all but two women who underwent Ivalon sponge implants in their breasts were “extremely pleased,” and many swore that the implants had “changed their entire life.” Moreover, the results held up over time, or at least until the implants began to cause physical problems.

As the century progressed and individuals’ quests for self-realization triumphed over society’s strictures against vanity and self-indulgence, procedures proliferated. Tummy tucks, liposuction, hair transplants, foreskin reconstitution, collagen and Botox injections, pectoral implants, and buttock lifts, to name only a few, joined the old standbys like rhinoplasty, face-lifts, and breast surgery. The market for these uninsured procedures was surprisingly egalitarian. By 1994, 65 percent of the patients undergoing them had annual incomes of less than $50,000.

The rate of breakthroughs continues to accelerate. Researching this article, I left a plastic surgeon’s office with a stack of brochures devoted to a variety of procedures, including endoscopic plastic surgery, which promises smaller scars and a “minimizing” of after-effects, and grafts that take tissue from human cadavers and implant it “at affordable prices” on scarred patients. Marketing methods have kept pace with medical advances. Hardly a week goes by when I do not get an e-mail hawking penile enlargement. (Strangely enough, I receive no electronic importunings for breast augmentation, though it is easy enough to find online.)

The gender issue in plastic surgery is confused and constantly changing. Since 1997, the number of procedures on males has tripled, though they still account for only 15 percent of operations. While men were once suspect as patients—in the 1920s, a team of Johns Hopkins specialists warned of “insatiable” male cosmetic surgery patients—many surgeons now prefer operating on men, whose expectations, they say, are more realistic, and satisfaction more likely. In the 1970s, feminists viewed plastic surgery as one more weapon in patriarchal society’s war against

women, but, by 1988, Ms. magazine was hailing Cher for reinventing herself surgically. And, while the battle over the safety of breast implants is medically grounded, it is also politically charged. During the 2003 hearings on whether to return silicone implants to the market, conservatives accused the National Organization of Women of defending women’s right to control their bodies, except their breasts.

Medical progress has altered our expectations. According to Dr. Michael Schwartz, a Pasadena, California surgeon, “Surgical advances, improved technology, and developments in anesthesiology, which make cosmetic surgery safer and more affordable to the general public, also make it more socially acceptable. Patients no longer have to go into post-operative hibernation for a month. Now, they return to work and resume their lives almost immediately - in some cases, as if nothing has happened, in others, eager to proselytize about what has.”

But the ease and acceptability of the procedures have an unexpected side effect. Today, the belief holds sway that, if something can be fixed, it should be fixed. Whereas once, a patient might have undergone a single procedure, now the tendency is two or three or an entire makeover. Michael Jackson’s grotesque metamorphosis is the most celebrated and egregious, but by no means the only example of this trend. But the ability to reinvent ourselves physically raises the old question of authenticity, which in turn redefines the relationship between psychology and surgery. While patients seeking transsexual operations speak of bringing their bodies into harmony with their psychological selves, most aesthetic procedures are designed to enable the patient to pass as something he or she does not feel, whether it be younger or sexier or more Anglo-Saxon than accidents of nature and birth have determined. But at what cost do we deny ourselves? If melon-perfect breasts mean decreased sensitivity, a common side effect of augmentation, does the new body signify heightened sexuality or diminished health? Does a fresh face engender a transformed consciousness or merely give the outwardly altered individual more to hide? Some women who have never told their husbands about their rhinoplasties live in fear that their secret will be exposed in the noses of their children.

Even if the psychological toll is bearable, the practical problems can be insurmountable. In Ash Wednesday, a cautionary 1973 film, an aged-by-makeup Elizabeth Taylor undergoes a series of graphic, for the time, procedures to restore her youthful appearance and rekindle the affections of her philandering husband, Henry Fonda. Though the surgery is successful and a movie star-perfect Taylor re-emerges, when a younger woman enters the frame and Fonda falls for her, the jilted Taylor realizes that there will always be an authentically younger model waiting in the wings.

Equally troubling is the problem of homogeneity. “The ability to alter appearances,” the dental surgeon Ronald P. Strauss believes, “has affected how we respond aesthetically to difference … a minor variant of normal becomes a deformity.” These days, doctors

say they no longer turn out assembly-line, cute, turned-up noses. But is the trend to longer, more assertive noses that, as one doctor put it, allow his female patients “to go toe to toe with those guys on the stock exchange” a move toward individuality, or merely adherence to a new stereotype? Are cookie-cutter breasts a sign of sexual viability or craven conformity? And, while the sight of a pretty face or well-shaped body is pleasing, an army of faces that are appealing in exactly the same way and bodies that are molded from the same model can become stultifying.

In Venus Envy: A History of Cosmetic Surgery, Elizabeth Haiken ascribes the current epidemic of plastic surgery, at least in part, to individuals’ feelings of helplessness in an ever-more-crowded and complex world. The number of people who have the money and clout to make a difference in society and nonetheless choose to go under the aesthetic knife would seem to undermine this argument, but I think she has a point about the contemporary tendency to apply quick superficial fixes to more profound problems. Like Henry Higgins, whose lament about women in My Fair Lady was that “straightening up their hair is all they ever do,” I can’t help wondering why cosmetic patients of both genders don’t “straighten up the mess that’s inside.” But then I remember those face-lifted salesmen who increased their incomes, and those breast-enhanced women who changed their lives, and I know the answer is not so simple.

Perhaps total cosmetic makeovers in an era of limited medical resources are socially irresponsible. Perhaps the men and women who undergo painful, non-essential procedures that may have life-threatening side effects would benefit more from psychiatric than surgical care. But perhaps those same men and women regard my insistence on walking around in an outmoded, imperfect physical plant as churlish. Certainly, they are willing to pay the price, in both money and pain, and risk tomorrow’s consequences for today’s pleasures. And if, to paraphrase Hippocrates, they first do no harm to anyone but themselves, who would choose to stand in their way?

America has always prized self-improvement, marveled at self-invention, and pledged allegiance to individual freedom. Is it any wonder that plastic surgery, born in foreign wars, flourished on our domestic soil?