From the Quest for Recognition to Surface Imagination Surgery

FROM THE QUEST FOR RECOGNITION TO SURFACE IMAGINATION SURGERY

The interviewees in this study underwent their surgeries in contemporary North America. What are the historical and cultural conditions within which the profession developed and flourished in Europe and North America, and what are the resulting social and cultural understandings of cosmetic surgery? In particular, how has this context forged the important link between the embodied psychical surface of the skin and the topography of the photograph?

This chapter begins with an overview of modern cosmetic surgery as a medical specialty and cultural phenomenon, focusing specifically on the profession’s quest for legitimacy and the gendered and racialized nuances within this commercialized field. In the section “The Quest for Recognition,” I argue that the profession strategically emphasized the psychological outcomes of cosmetic surgery over the beauty outcomes in order to legitimate surgical interventions. Indeed, cosmetic surgery and psychoanalysis emerged in the same moment in history, and they have been entwined ever since. Dynamic power relations between surgeons and patients are a mixture of capitalist exchange and the entrenchment of body ideals in a sexist and white supremacist society. Furthermore, the relationship between doctors and patients is ambiguous because, in this medical encounter, unlike the majority in the West, the patient selfdiagnoses. The relationship traverses into further murky waters as surgeons consciously and unconsciously develop their own signature styles, which are often justified by recourse to classical aesthetics and the history of Western art.1

Next, I turn to an analysis of contemporary cosmetic surgical cultures in the section “Pygmalions and Pragmatists.” Drawing on Virginia Blum’s important work on the pervasiveness of cosmetic surgery and surgical attitudes toward the body, I evaluate the cultural impact of understanding our bodies as the raw material of surgical alteration. I see three major shifts in contemporary cultural understandings of cosmetic surgery.² First, in the late nineteenth and early twentieth centuries, cosmetic surgery is understood as a secretive, deceptive, or suspicious pursuit, either because the desired outcomes are in the service of vanity or because they reflect a wish to camouflage or erase congenital, accidental, sexual, or racial difference. Second, from the mid-twentieth century until the 1980s, the move to project the desire to have cosmetic surgery onto larger-than-life celebrities propels the surgical act into the public realm. Celebrities exist as visual objects that give substance to new ways of thinking about the body’s surface as transformable. We can maintain our moral outrage but still enjoy the plasticity of the body because we have no relationship to these figures outside their images. This is an important and gradual shift toward thinking about embodiment in a way informed by surface imagination. And third, in the late twentieth and early twenty-first centuries, ordinary people become the celebrities of surgical stories, coming onto the media scene with a surgical journey that is transformed into a story for the viewer’s consumption and inspiration.

I address the makeover – a process in which an ordinary person becomes a celebrity, initially through glamorous hair, makeup, and clothing, and now through cosmetic surgery (called an “extreme makeover” on reality TV) – as a cultural moment that mobilizes surface imagination fantasies. The makeover is well positioned to incorporate cosmetic surgery into its fold because both use discourses of self-transformation and selfimprovement through appearance. The extreme makeover highlights the pursuit of beauty as legitimate specifically on the grounds that the makeover candidates experience positive psychological effects through changing the body’s surface, as I discuss in “Makeovers and Surfaces.”

The scenography of the makeover hinges on one key element: the before and after photograph. Without this backdrop, the makeover cannot be staged. The before and after photograph operates as a device to fix the star of the makeover in time and space. In the before photograph, spectators are encouraged to see the tragedy and desolation in the face of the protagonist, assisted by bad fluorescent lighting, lack of facial expression, and a spoken monologue of personal tragedy. This singular piece of detritus from the previous passive life suggests that the protagonist’s true life – which is, of course, an active life of happiness and acceptance – has not yet begun. In contrast, the after photograph depicts a happier, glossier, and improved protagonist, poised on the precipice of her new after life, complete with much better lighting. As cosmetic surgery stories become figured as makeover stories of overcoming and encountering loss,3 the photograph is an important piece of evidence.

In the case of cosmetic surgery, photography is the medium through which the patient can compare her history to her present and imagine her future, although the photograph is not any of these points in her history, but rather a temporal messenger. Photography offers encouragement, shows what surgery can achieve in a surface imagination culture, and endorses and provides confirmation of transformation through digitally altered and/or before and after photographs. For cosmetic surgery recipients, before and after photographs become an autobiographical text that is often accompanied by a testimony of struggle and triumph over a persecutory and cruel body. Photography is a foundational medium in the construction of a surgical culture, and in “Photography and Loss,” I explore the multifarious roles that photography inhabits in the psychical and social experiences of cosmetic surgery. It is important to think through the various functions of the photograph, since it is the idealized surface of cosmetic surgery to which the de-idealized surface of the skin is compared. Specifically, I consider the roles and implications of before and after photographs, including airbrushing and digital manipulation techniques, for cosmetic surgery.

The Quest for Recognition

The history of cosmetic surgery in North America exposes dominant cultural ideologies about the relationships between character and appearance and health and illness, as these connect with European ideas about science, race, and colonialism. Psychoanalysis has a parallel history to cosmetic surgery, since these two emerging professions explored common human problems and have buttressed each other’s claims since their inception. Popular perceptions of cosmetic surgery shifted radically from the nineteenth to the twentieth centuries as a result of this relationship, as well as the effects of the First World War and an increasingly professionalized cosmetic surgery industry. Shedding its image as a practice to deceive others, the early twentieth-century cosmetic surgery industry engaged in a decades-long public relations campaign that touted its legitimate applications. These applications acknowledged and accepted the relationship between psychological well-being and physical appearance, and the relationship between the individual and the society. Contemporary North America can, therefore, be accurately described as a surface imagination culture in which we can all imagine modifying our bodies and the bodies of others through surgical intervention.

European philosophical ideas about the relationship between truth, beauty, health, and goodness continue to contribute to the positive valuation of beauty and negative valuation of ugliness. These ideas were crystallized in the science of physiognomy, which flourished from the seventeenth to the nineteenth centuries. Physiognomy is the scientific study of facial features for the purposes of determining moral character. Johann Caspar Lavater, pastor and author of Essays on Physiognomy (1775–78), expanded and popularized physiognomy, which gained ready acceptance in Europe due to the historical philosophical conceptions about the relationship between beauty and morality.4

In 1798, Pierre Joseph Desault gave the name “plastic” to surgery that aimed to change the appearance of the body.⁵ These first modern operations restored function or appearance that had been lost due to circumstances of birth or accident, and relied largely on skin grafting.⁶ Plastic surgery had as its aim the reshaping of the body and face, an action that was contraindicated by common Western religious and moral ideals, which were reinforced by the science of physiognomy. The development of plastic surgery generated many moral questions because it promised a permanent change to the so-called natural body. Surgery came to be seen as a disreputable profession whose goal was to conceal deformity or disease that, according to physiognomy and some Christian beliefs of the nineteenth century, were God’s corporeal reprimand for sin.⁷ Later, bearing the weight of a physical deformity with cheerfulness and good humour became a sign of good character and acceptance of God’s will, as opposed to a divine punishment. By the nineteenth century, the development of the cosmetics and fashion industries in Europe and the United States heightened cultural anxieties about the potential for corrupt, criminal, or degenerate individuals, and particularly women, to conceal their inner selves from the world for personal and economic profit.

Modern nose surgery began to develop in the seventeenth century as a response to epidemic syphilis in Europe, but was not further pursued until the nineteenth century.8 With the publication of Carl Ferdinand von Graefe’s Rhinoplastik in 1818, this appearance-altering surgery became commonly known as plastic.⁹ One of the symptoms of acquired or congenital syphilis was an infection of the bone and cartilage that resulted in a sunken nose (also called the “saddle nose deformity”). Surgeons experimented with paraffin injections, animal bone implants, and a technique called the pedicle flap in order to reconstruct the missing syphilitic nose.¹⁰ Because of its complicity in concealing a divine indicator of depravity, public opinion roundly denounced plastic surgery as a disreputable profession.¹¹ Plastic surgeons, on the other hand, conceptualized their work as merciful because it assisted patients to pass as healthy by remedying their disgrace-tainted faces.¹² The association of the saddle nose defect with syphilis and immorality lasted well into the twentieth century in the United States.¹³

However, the nose is imbued not only with connotations of disease and sinful sexuality. The nose is also a site onto which racist European anxieties about racial and cultural difference are affixed, and the history of cosmetic surgery highlights this unease. Sander Gilman’s Making the Body Beautiful takes the nose as its central object of study in developing the claim that cosmetic surgery was founded on the desire for “passing.” Gilman argues that the recipients of aesthetic surgery are not pursuing invisibility – having one’s appearance go unnoticed by the people in one’s daily life. Rather, they are pursuing visibility, or passing as a member of the group within which one desires to be included (categories such as race, health, and youth).¹⁴ The positive valuation of passing as can be fully realized only in visually oriented, surface imagination cultures; in discourses of passing, interiority is subordinated to exteriority. As rhinoplastic techniques were elaborated and improved upon in the treatment of the syphilitic nose in the nineteenth century, new techniques were developed that addressed the racialized nose as its subject. Following physiognomic logic and Enlightenment racial science, the nose that is too small, too big, too flat, or too short serves as a marker of individual and collective racial character.15 Invoking the classical and medieval classification system of the Great Chain of Being, medicine and science created a biological hierarchy that justified scientific, economic, and social racism, as well as European colonization.¹⁶ Depending on current trends in immigration and colonization, European and North American cosmetic surgery in the nineteenth century focused on the surgical assimilation of the Jewish nose,¹⁷ the Irish nose,¹⁸ the Oriental nose,¹⁹ and the African nose²⁰ (in Gilman’s terms). These so-called racial characteristics – whether or not they represented one’s actual racial and ethnic heritage – were associated with being visible as within a specific racial category, and this legacy has permeated the history of cosmetic surgery.

In addition to significant developments in rhinoplasty and the coinage of the term “plastic surgery,” the nineteenth century heralded two of the most important medical innovations for plastic surgery: anaesthesia in 1846 and antisepsis in 1867.²¹ While these technologies are important to medicine and surgery in general, they are specifically vital to plastic surgery. In the pre-anaesthetic era, surgery was a last resort and highly traumatic for both patient and surgeon. The absence of anaesthesia made it difficult to think about surgery as a solution to even a life-threatening problem, and unthinkable as a solution to a problem with one’s appearance. Further, the development of local anaesthesia by the 1880s eliminated the danger of dying under general anaesthesia.²² With the patient’s body and/or consciousness numbed by anaesthetic, the (plastic) surgeon could become more experimental and daring in the expansion of techniques. The discovery of antisepsis also made surgery a more appealing option, since it drastically reduced the formerly elevated chance that one might die of infection post-surgery.²³ These conditions, in conjunction with the First World War, advanced North American and European plastic surgery techniques. They also opened up debates about the legitimacy of plastic surgery and the distinction between cosmetic surgery and reconstructive surgery.

At the same time, developments were taking place in the new field of psychoanalysis, being articulated by Sigmund Freud. As Freud continued to theorize his discovery in his early work with hysterics, he articulated important connections about the relationship between psyche and soma.24 Without the psychological motivation and explanation provided by psychoanalysis, cosmetic surgery could not have moved in the direction it did; it needed first to justify doing harm to bodies without a medical reason. The plastic surgeon needed to distance himself²⁵ from the negative label “beauty surgeon” which originated in the European renaissance and was put back into use in the 1840s.²⁶ The solution was found in the notion of happiness.

After the turn of the twentieth century, psychoanalysis was popularized in the United States as something glamorous, and its treatment of sexuality and the unknowability of the unconscious seemed almost magical.²⁷ Psychoanalysis and cosmetic surgery shared the common possibility and promise of complete transformation. Diverging from the majority of Western medical practices, these transformations are initiated at the insistence of the patient, who arrives at the clinic of the analyst or surgeon with a problem and therapeutic course that she has herself identified.²⁸ In Creating Beauty to Cure the Soul, Gilman argues that aesthetic surgery is psychotherapy,²⁹ since cosmetic surgeons cannot justify their practice without recourse to psychological explanations, particularly the pursuit of happiness. While it is a widespread misconception that the Hippocratic Oath instructs doctors to “do no harm,”³⁰ this phrase expresses a familiar understanding of the practice of medicine and surgery: that physicians and surgeons will act in the best interests of the patient and will not intentionally inflict injury or illness upon them. In order to circumvent the idea that cosmetic surgery is just a dilettantish wish for perfect beauty, surgeons used psychological explanations and concepts to justify their practice as a legitimate cure. The rise of surgical solutions to states of psychological distress happened at the turn of the twentieth century concurrently with a fashionable modification and spread of psychoanalytic ideas throughout the United States, a historical moment to which I return shortly.

Blum argues that psychoanalysis and cosmetic surgery share a parallel “cartography of the subject.”³¹ Cosmetic surgery borrows from psychoanalysis to justify its interventions into the body’s surface, and psychoanalysis claims that symptoms on the body’s surface are indicators of psychological processes. The logics of psychoanalysis and cosmetic surgery are consonant yet reversed in their speculations about the split between psyche and soma: psychoanalysis can cure the suffering caused by bodily symptoms through analysis, while cosmetic surgery can cure psychological suffering through surgery.32 To complicate things further, Freud himself frequently used surgery as a metaphor for psychoanalysis: to convey the analyst’s impartiality,³³ for the excavation of the unconscious,³⁴ as an intervention that must be brought to full completion,³⁵ and as a way to define the “analytic field,” which, much like the “surgical field,” can become contaminated (by the transference or the analysand’s resistances, for example).³⁶ This metaphor justified the emphasis on the seriousness of psychosomatic illness and the analysts’ profession. In turn, cosmetic surgeons reversed this logic into a psychosomatic explanation that positioned the beautiful body as a vessel of health and happiness.³⁷ Borrowing from Freud’s assertion that hysterics suffer from being unable to put their experiences and symptoms into words, present-day cosmetic surgery asserts that a reliable indicator of a prospective patient’s satisfaction is the ability to tell the story of her bodily suffering specifically and totally. If a patient is unable to be precise about this, she is more likely to return to the surgeon’s office, unsatisfied and longing for more cosmetic surgery.³⁸

Happiness becomes a goal of cosmetic surgery as surgeons appropriate psychological explanations and methods to justify surgery undertaken for purely aesthetic reasons. Beauty, happiness, and health are conceived as complementary: if one of these variables is removed, the others are likely to collapse. While those inside and outside the profession may critique cosmetic plastic surgery as trivial or bad surgery and view reconstructive plastic surgery as necessary and good surgery,³⁹ it is very difficult to delimit the boundary between reconstructive and cosmetic plastic surgery. One solution to this predicament is to reconceptualize disfigurement. The legitimate recipient of cosmetic surgery is seen as the victim of both accidental and natural disfigurement,⁴⁰ and a natural disfigurement is no longer understood as divine omen. Further, unhappiness is defined as a non-normative state, so cosmetic plastic surgery seeks to reconstruct the patient’s happiness, a move that further blurs the difference between the cosmetic and the reconstructive.

The point is not to argue that surgeries categorized as reconstructive are unnecessary; accessing such surgeries has economic and social benefits for the patient. However, whether a surgery is categorized as reconstructive or cosmetic also has economic and social ramifications, as demonstrated in the example of breast augmentation for trans and non-trans women discussed at the end of chapter 4. A reconstructive surgery is likely to be covered under public or private health insurance, and there is little to no onus on the patient to justify the surgery to cosmetic surgeons as gatekeepers; the necessity of the surgery is taken for granted. The history of cosmetic surgery shows that the question of necessity is malleable and historically specific; a surgery that is classified as cosmetic may theoretically be as psychologically necessary for a patient as a surgery classified as reconstructive, and a surgery now understood as reconstructive may once have been considered purely cosmetic.⁴¹ While the motivations for reconstructive surgeries are unquestioned and considered universally valid, surgeons and patients have long struggled to make an argument for surgeries considered to be purely cosmetic. Further, patients and surgeons continue to use psychological explanations to make a case for cosmetic surgeries since these explanations have proven effective.

During the first half of the twentieth century, cosmetic surgeons and the public turned to psychoanalysis and psychology to explain and validate the decision to undergo surgery for a purely aesthetic result. Here I examine four historical moments where psychoanalysis and (cosmetic) surgery come together to co-constitute one another: the Emma Eckstein incident, Karl Menninger’s exploration of polysurgical addiction, Paul Schilder’s concept of “body image,” and Alfred Adler’s “inferiority complex.”

From 1895 to 1896, Freud collaborated with his colleague and friend Wilhelm Fliess in the treatment of Freud’s hysterical patient Emma Eckstein. Fleiss operated on Freud and Eckstein in early 1895, and they received the same nose surgery on the turbinate bone as a part of their psychoanalytic treatment.⁴² After the operation, Eckstein told Freud that she was in pain. Freud interpreted this as the formation of a hysterical symptom provoked by the surgical intervention, and was horrified to discover soon thereafter that she had developed an infection after a metre of gauze had been left inside her body.⁴³ This incident lead Freud to abandon the idea that physical intervention, from surgery to touching, should be a part of psychoanalytic treatment. In 1896, he moved away from his trauma theory – that patients experienced actual trauma to their bodies, particularly in childhood – toward the theory of the fantasy as the source of his patients’ ailments.⁴⁴

Karl Menninger is the first psychoanalyst to examine the psychical motivations for multiple surgeries in his 1934 article “Polysurgery and Polysurgical Addiction.”45 Menninger theorizes that surgery repeats the trauma of castration for the patient in a way that can be an “erotic capitalization,” the fulfillment of the wish for a child, or the avoidance of something that the patient fears more intensely than surgery.⁴⁶ Menninger presents two case studies of cosmetic surgery patients (a labiaplasty and a rhinoplasty patient, to be specific) as examples of surgeries that do not fit into his theory because the recipients were made happy by their surgeries. What distinguishes these patients is that they obtain only one surgery and do not want more. For those who are obsessed with and objectify their malfunctioning bodies, psychoanalysis is a better treatment than surgery, according to Menninger.⁴⁷

At the same time, Paul Schilder coins the term “body image” in his 1935 Image and Appearance of the Human Body, observing that the body is not just a biological entity or a perception, but is structured through “mental pictures and representations.”⁴⁸ This means that bodies exist in the social and cultural contexts through which others interpret them, an idea that proved invaluable to feminist analyses of women’s relationships to their bodies in the latter half of the twentieth century. This has also been a profitable idea for the cosmetic surgery industry, because it provides an explanatory model for a patient’s desire to have cosmetic surgery: a patient wishes to make the image of the body that others see match the patient’s image of the body. Gilman notes that Schilder’s formulation of the body image places cosmetic surgery as an intervention that might alter the body image socially or physically. However, because the root problem is located in the mental image of the body, only psychoanalysis can fully address it.⁴⁹

The final piece of this psychoanalytic puzzle is Alfred Adler’s theory of an “inferiority complex.”⁵⁰ The theory was developed at the turn of the century and became an invaluable explanatory device for cosmetic surgery by the 1920s. By the mid-twentieth century, the inferiority complex had become the most widely accepted justification for cosmetic surgery in North America. Initially, Adler was interested in the theory of organ inferiority, the idea that a physical weakness could become a site of psychological overcompensation. For example, a person who suffers from respiratory problems becomes an actor or a singer because they are so over-invested in their physical weakness that they overcompensate for it.51 Cosmetic surgeons readily adopted this idea, claiming that an inferiority complex can originate in a physical feature and thus cosmetic surgery is a solution to the psychological problem of feeling inferior.⁵²

During these moments of the intersecting histories of psychoanalysis and cosmetic surgery, analysts maintain Freud’s conviction that working on the surface will not resolve the patient’s psychical distress. At the same time, new and powerful ideas about the significance of the body’s surface to psychical well-being emerge. The cosmetic surgery industry finds new ways to pathologize discontent with the body in order to present cosmetic surgery as a legitimate therapeutic cure. After the mid-twentieth century, psychoanalysis wanes in popularity in North America because its method, based on the presence of an unconscious, is not assimilable to surface imagination conceptualizations of subjectivity. Nevertheless, the histories of intersection provide insight into how cosmetic surgery became a therapeutic intervention structured by surface imagination promises that an operation on the body can resolve a patient’s psychical distress.

While psychoanalysis became increasingly wary of physical intervention as psychotherapy, and cosmetic surgery conceived of its practice as physical psychotherapy, the professionalization of cosmetic surgeons, the rise of the mass beauty industry, and the First World War helped cosmetic surgeons create a powerful public relations campaign in the early to mid-twentieth century.

The disfigured soldier returning from the First World War radically changed social attitudes about disfigurement as a punishment doled out by God.⁵³ Surgeons now had a large number of casualties to experiment on in order to develop new techniques, and these techniques became the foundation of modern cosmetic surgery practice. The wounded soldier also opened up a new narrative for justifying cosmetic surgery that employed material and economic explanations. Because disfigurement caused by participation in combat was presumed to result in unemployment and therefore economic dependence, it compromised the returning soldier’s masculine identity and dishonoured his contribution to nation.⁵⁴ As plastic surgery temporarily shifted its focus from operating on racialized facial features to reconstructing disfigurement inflicted by the ravages of warfare, the status of the plastic surgeon working at the level of appearance was elevated.

The 1921 founding of the American Association of Plastic Surgeons (AAPS), the first North American association of plastic surgeons, was a strategy to legitimize the practice by demarcating reasonable doctors from so-called quacks, although many of the reasonable, legitimate surgeons borrowed heavily from the techniques of quackery in the first quarter of the twentieth century.55 Once plastic surgeons had a professional association, they attempted to cleave their field into two: the beauty surgeons, who operated on a purely commercial basis and without any regulations, and the plastic surgeons, who were highly skilled doctors and were required to follow strict guidelines established by their association.⁵⁶ By the 1920s, war surgery was effectively used to normalize cosmetic surgery in the public eye.⁵⁷

During the Second World War, American women’s magazines frequently published positive and enthusiastic articles about war surgery. While these articles were realistic in substance, their titles heralded the miraculous achievements of intrepid surgeons who saved soldiers from certain ostracism and unemployment at home.⁵⁸ This media coverage was strengthened by American cosmetic surgeons’ willingness to use the media in their public relations campaigns.⁵⁹

Haiken argues that as the Americans embraced a psychological world view after the Second World War, they were more inclined to seek private solutions to public problems.⁶⁰ American surgeons focused on developing their individual practices rather than influencing the direction of cosmetic surgery, while American patients criticized current beauty standards, yet felt it was more straightforward and less daunting to change themselves rather than challenge their society.⁶¹ As the beauty industry amplified women’s concerns about aging, cosmetic surgeons found a novel, individualized, and pervasive problem as well as the new audience they sought after the war to revitalize their practice.⁶² Although surgery that focused on erasing race by operating on caricatured features had never vanished, post-Second World War cosmetic surgery in the United States saw an increase in Westernizing surgeries, particularly blepharoplasty (the creation of an eyelid fold performed specifically on people of Asian descent).⁶³ The popular media coverage of wartime cosmetic surgery established conditions for an enthusiastic, trusting, and optimistic reception of face-lifting, beginning in the 1950s and 1960s.64 As face-lifting became a hot topic for American women’s magazines, and increasingly affordable, surgery for beauty’s sake launched the profession and culture of cosmetic surgery into the contemporary era.

Pygmalions and Pragmatists

The increased American interest in facelift surgery in the 1950s and 1960s marked a break from earlier ideas and a second turning point for the practice of cosmetic surgery into the realm of surface imagination. Unlike personal accidents or so-called abnormal features, aging happens to everyone who lives long enough. Thus, aging requires strategies that differ from those used to justify surgical intervention for accidental or congenital deformities. Instead, the body comes to be seen as a malleable flesh canvas and the individual is responsible for creating, revising, and maintaining the surface she presents to the world. Contemporary popular media do not often represent cosmetic surgeons as valiant heroes, as they did after the two world wars, but as artists and scientists. The artist and the scientist are no longer tethered to the burden of justification; they are committed to the pursuit of surface transformation. The makeover is important for both these new figures because it shares the transformational narrative of the surgeon-scientist’s and surgeon-artist’s work. The makeover story democratizes beauty, promising transformation for anyone. It is a product of surface imagination fantasies. In combination with tabloid stories about celebrity surgical makeovers, the surgical makeovers of ordinary people in reality television shows are useful as a device to justify everyday decisions to undergo cosmetic surgery.⁶⁵

The conceptualization of aging as a pathological state after the Second World War opened up the field of cosmetic surgery in Canada and the United States. It moved from being a niche speciality serving only a few to one that can serve everyone and anyone. With the exception of the general practitioner, no other medical doctor can claim such a universal reach. The increase in face-lifting surgery in the 1950s was followed by what fashion magazines nicknamed the “Youthquake” in the 1960s,⁶⁶ a heightened interest in teenage culture and fashion that emphasized the beauty and freshness of youth. The 1960s also saw a slight rise in men’s requests for facelifts, although this was a rare phenomenon.⁶⁷ While the popularity of cosmetic surgery increased from the 1950s onward, it remained a procedure that was done in secrecy.

In the late 1970s, a new kind of cosmetic surgery narrative began to surface in women’s magazines: the story of the disastrous surgery performed by the incompetent or fraudulent surgeon preying on women’s vulnerability to vanity.68 These cautionary tales for women were about the high price paid for vanity, a precursor to the intense tabloid interest in the cosmetic surgery of the stars⁶⁹ and the rapid increase in demand for cosmetic surgery in the 1980s.⁷⁰ These warning narratives came full circle in the 1990s with the American scandal over the potential dangers of silicone breast implants. These more recent admonitory accounts emphasized that doctors and industrial manufacturers had been aware of the possibility of serious side effects such as silicone leakage and joint inflammation, and that patients received inadequate information prior to undergoing breast augmentation. The silicone implants scandal was further fuelled by a litigious American culture and great skepticism about the links between medicine and industry.⁷¹

In Canada and the United States, the majority of cosmetic surgeries now occur under what Davis calls the market model of medicine. In this model, the decision to undergo cosmetic surgery is framed by the “discourse of risk.” The surgeon’s responsibility is to offer the patient the most complete explanation possible of the risks and benefits of the surgery, so that the patient is able to give her full, informed consent to the procedure.⁷² In contrast, the welfare model of medicine is framed within the “discourse of need.”⁷³ What is important in this model is that the patient and surgeon completely articulate the reasons why the patient requires the surgery in order to justify the surgery to a state funding agency.⁷⁴ According to Davis, in the welfare model of medicine, cosmetic surgery is not a question of consumer choice but of exploring the motives and necessity for the surgery. Conversely, in the market model, the question of why the patient and surgeon deem the surgery to be necessary takes a back seat to offering the information that would allow the patient to make a good consumer choice in order to obtain the best value and result.

The majority of cosmetic surgery patients in Canada and the United States pay for their own treatment,⁷⁵ and the cost of surgery varies depending on surgeon and geographical location. As a result of competition between surgical specialties⁷⁶ and less demand and opportunity within the field of reconstructive plastic surgery, many highly skilled plastic surgeons turn to cosmetic surgery.77 It is an appealing option for many reasons: surgeons operate on healthy patients with a high rate of satisfaction; there is a high turnover of patients, leading to greater economic profit;⁷⁸ and there are plenty of opportunities and challenges to develop as a surgeon. Thus, cosmetic surgery offers new plastic surgeons better material, economic, and career advancement opportunities. Patients are provided with a number of payment and financing options (including high interest credit cards that cater specifically to potential cosmetic surgery recipients), and the decision to undergo cosmetic surgery is framed as a consumer decision that balances the quality of the product with its cost. In the context of neoliberal medicine, physicians often dispense a commercial product⁷⁹ and the human body is treated like a work in progress, subject to current styles and functions, and a test site for the latest technology.

Blum argues that there is a process of “becoming surgical,” in which the patient reconfigures her body according to the imagined gaze of the surgeon.⁸⁰ Envisioning the body’s surface as fragmented and manipulable, in the way that the cosmetic surgery industry does, is key to surface imagination fantasies that locate identity and psyche at the level of skin. If the patient cannot explain her desires to the surgeon in a way that coincides with the current surface imagination discourse of cosmetic surgery, she will not be able to access surgery. Thus, the patient needs to know the cultural stories that circulate about cosmetic surgery, and particularly about cosmetic surgeons, in order to convince the surgeon.⁸¹

To understand how surgeons are represented in popular news media and women’s magazines in Canada and the United States, I searched the Toronto Star and the Globe and Mail archival records from 1987 to 2007, as well as Chatelaine, Harper’s Bazaar, Vogue, and Cosmopolitan for the same date ranges. The first two are newspapers that focus on Canadian national news coverage, Chatelaine

Only gold members can continue reading. Log In or Register to continue