Plastic surgery

• 1. Introduction

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  Plastic surgery carries a name that has nothing to do with synthetic polymers. The word comes from the Greek plastike tekne, meaning the art of modelling malleable flesh. That meaning was already in use in English as early as 1598, and the surgical sense appeared in 1816, decades before modern plastics were ever manufactured. What we now call plastic surgery spans everything from repairing a child's cleft palate to rebuilding a face shattered by shrapnel on a battlefield. It covers reconstruction after cancer, treatment of severe burns, and yes, the voluntary reshaping of noses and eyelids. How did a craft first documented in ancient Egypt come to perform nearly sixteen million procedures in the United States alone in a single year? And what happens when surgery designed to heal becomes entangled with obsession?

• 2. Ancient Roots

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  Treatments for a broken nose appear in the Edwin Smith papyrus, an Egyptian medical text dating to around 1600 BCE. That document, named after the American Egyptologist who acquired it, represents one of the earliest known surgical texts focused on trauma care. By 800 BCE, reconstructive techniques were already being practiced in India, and the Sushruta Samhita describes methods for nasal reconstruction using skin flaps taken from a patient's own body. The physician Sushruta, working in the 6th century BCE, is regarded as a foundational figure in the field, with contributions to both reconstructive and cataract surgery.

  Roman physicians in the 1st century BCE performed surgeries to repair damaged ears, though their knowledge rested entirely on texts inherited from Greek predecessors. Religious prohibitions barred them from dissecting human or animal bodies. Despite this constraint, the physician Aulus Cornelius Celsus left anatomical descriptions detailed enough that portions of his work on the genitalia and skeleton remain of interest to plastic surgeons today.

  By the 10th century, the Spanish physician Al-Zahrawi, who lived from 936 to 1013, was documenting the use of silk thread sutures and describing what is believed to be the first attempt at reducing breast tissue in men with gynecomastia. His text on cosmetic procedures, the Kitab al-Tasrif, also recorded techniques for cautery and wound management. Those Arabic writings eventually reached European practitioners through a chain of translations and intermediaries.

• 3. The Renaissance Surgeons

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  Federico da Montefeltro, Duke of Urbino and a figure well known to students of Renaissance portraiture, sustained severe facial injuries during a jousting accident. His portraits, most of them profile views, may reflect a nose that was surgically modified to improve his field of vision after the injury. Born in 1422, Federico's case offers one of the earlier documented examples of surgical intervention with an aesthetic dimension in early modern Europe.

  The Branca family of Sicily and the Bolognese surgeon Gaspare Tagliacozzi, who lived from 1545 to 1599, both became familiar with the methods described in the Sushruta Samhita. Tagliacozzi developed a rhinoplasty procedure that used a skin flap taken from the patient's upper arm to rebuild the nose, and he described it in his book De curtorum chirurgia per insitionem, published in Venice around 1597. The title translates as On the Surgery of Mutilations Through Grafting.

  In 1465, the Ottoman surgeon Sabuncuoglu Serafeddin, born in 1385 and still practicing into his eighties, provided detailed descriptions and classifications of congenital conditions including hypospadias, a condition in which the urethral opening sits on the underside of the penis. His illustrated manual, Cerrahiyyet'ul Haniye, meaning Imperial Surgery, covered a range of medical and congenital conditions. Common surgeries of the Renaissance period also included labiaplasty procedures, depicted in writing and illustration as early as the 7th century in texts such as Paul of Aegina's Medical Compendium and Lanfranc da Milano's 13th-century Great Surgery. The rise of print culture following the invention of the Gutenberg press allowed these early medical texts to be widely republished and disseminated.

• 4. Into the Modern Era

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  British physicians travelled to India in the 18th century to observe rhinoplasty techniques being performed by a Kumhar, or potter, Vaidya. Reports on these procedures were published in the Gentleman's Magazine by 1794, bringing the methods to wider European attention. Joseph Constantine Carpue spent twenty years studying these local techniques in India before returning to England, where he performed one of the first major rhinoplasties in the Western world in 1815.

  In 1814, Carpue operated on a British military officer who had lost his nose to the toxic effects of mercury treatments. Four years later, in 1818, the German surgeon Carl Ferdinand von Graefe published his major work Rhinoplastik, in which he modified the Italian method by substituting a free skin graft from the arm for the delayed pedicle flap that had been the prior standard. The first American plastic surgeon, John Peter Mettauer, performed the first cleft palate operation in 1827, using instruments he had designed himself.

  Johann Friedrich Dieffenbach took the field further still, specializing in skin transplantation and establishing techniques in rhinoplastic and maxillofacial surgery that shaped modern reconstructive practice. In 1845 he published Operative Chirurgie and introduced the concept of reoperation to refine the appearance of a reconstructed nose. Dieffenbach has been called the father of plastic surgery. By the late 19th century, surgeons were experimenting with new materials: George Monks in 1889 and James Israel in 1896 each described successful use of heterogeneous free-bone grafts to reconstruct saddle nose defects, and in 1898 Jacques Joseph published the first account of reduction rhinoplasty.

• 5. War and Innovation

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  Machine guns and explosive shells introduced during World War I produced a scale of facial injury that surgeons had never before encountered. Better infection control meant that wounds which would previously have been fatal were now survivable, leaving alive soldiers who had lost noses, chins, cheekbones, and eyes. Battlefield surgeons working under time pressure often had no opportunity to consider aesthetic outcomes, and the number of severely disfigured survivors grew rapidly.

  Harold Gillies, a New Zealand otolaryngologist working in London, recognised both the physical and the psychological dimensions of facial disfigurement and dedicated an entire hospital to studying and addressing it. He worked first with the French oral and maxillofacial surgeon Hippolyte Morestin on skin grafts, then persuaded the army's chief surgeon, Arbuthnot-Lane, to open a facial injury ward at the Cambridge Military Hospital in Aldershot. In 1917 this was upgraded to a purpose-built facility at Sidcup. There, Gillies and his colleagues performed more than 11,000 operations on more than 5,000 men, most of them soldiers with facial injuries from gunshot wounds.

  Among the most significant techniques developed at Sidcup was the pedicle flap: a section of skin cut from a donor site but left attached at one end, then swung across to cover the wound. Maintaining that physical connection preserved blood supply and reduced the risk of tissue rejection. After the war, Gillies established a private practice with Rainsford Mowlem and travelled widely to promote these techniques. In 1930, his cousin Archibald McIndoe joined the practice.

• 6. McIndoe and the Guinea Pig Club

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  When World War II began, the plastic surgery resources that Gillies had built were divided among the different branches of the armed forces. Gillies himself was posted to Rooksdown House near Basingstoke, which became the principal army plastic surgery unit. Tommy Kilner, who had worked with Gillies during the First World War, went to Queen Mary's Hospital in Roehampton; his name now attaches to a surgical instrument, the kilner cheek retractor. Rainsford Mowlem was sent to St Albans. Archibald McIndoe, serving as consultant to the RAF, moved to the newly rebuilt Queen Victoria Hospital in East Grinstead, Sussex, where he founded a Centre for Plastic and Jaw Surgery.

  McIndoe's patients were primarily aircrew who had suffered deep burns and serious facial disfigurement from burning fuel, including loss of eyelids. He developed new techniques for treating badly burned faces and hands, including the walking-stalk skin graft, and made a serendipitous discovery that immersion in saline promoted healing and improved survival rates in patients with extensive burns. The observation came from comparing the differential healing rates of pilots who had come down on land against those who had come down in the sea.

  Beyond surgical technique, McIndoe recognised that recovery required social reintegration. He discarded the convalescent uniforms worn by patients and allowed them to wear their service uniforms instead. With the help of Neville and Elaine Blond, he persuaded local residents to invite patients into their homes. His patients called him The Boss or The Maestro, and he referred to them as his boys. This community of patients, bound together by shared experience of experimental treatment, became the Guinea Pig Club at Queen Victoria Hospital. Among the better-known members were Richard Hillary, Bill Foxley, and Jimmy Edwards.

• 7. Cosmetic Surgery's Rise

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  In 1949, around 15,000 Americans underwent cosmetic surgery procedures. By 1969, that number had climbed to nearly half a million. The growth has not slowed: plastic surgery procedures in the United States rose 115% between 2000 and 2015. In 2014 alone, nearly 16 million cosmetic procedures were performed in the country. Of those, 92% were performed on women, a share that had risen from 88% in 2001.

  Rhinoplasty accounted for 15.2% of all cosmetic surgical procedures in the United States in 2020, making it the most common surgical procedure that year according to the American Society of Plastic Surgeons' annual report. Blepharoplasty, or eyelid surgery, came second at 14%, followed by rhytidectomy at 10% and liposuction at 9.1%. Breast augmentation has ranked in the top five cosmetic surgical procedures every year since 2006; in 2020, silicone implants were used in 84% of breast augmentations and saline implants in the remaining 16%.

  Younger patients represent a growing share of procedures. The American Society of Plastic Surgeons estimated more than 333,000 cosmetic procedures on patients aged 18 or younger in 2005, compared with roughly 14,000 in 1996. By 2018, more than 226,994 patients between the ages of 13 and 19 underwent plastic surgery. A 2021 study found that requests for cosmetic procedures rose significantly after the start of the COVID-19 pandemic, with cited estimates including a 10% increase in the United States and a 20% increase in France, a trend linked to the rise in videoconferencing.

• 8. Psychology and Risk

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  Body dysmorphic disorder, known as BDD, affects roughly 2% of people in the United States, but 15% of patients visiting dermatologists and cosmetic surgeons carry the diagnosis. The disorder leads individuals to become preoccupied with perceived defects in their bodies or faces; where a slight physical anomaly exists, the concern is markedly out of proportion to it. Half of BDD patients who undergo cosmetic surgery are not satisfied with the aesthetic outcome, and the procedures do not treat the underlying disorder. In some cases BDD can lead to suicide.

  Researchers have identified the increased use of body and facial reshaping applications as a potential trigger of BDD. A phenomenon described as Snapchat dysmorphia has been named to capture cases in which people request surgery to match the filtered version of themselves as they appear in Snapchat. In response, Instagram banned augmented reality filters that depict or promote cosmetic surgery. Some individuals whose physicians have declined to perform further surgery have turned to self-administered injections, taking on serious safety risks.

  Breast implants carry their own documented complication profile. The FDA stated in 2011 that one in five patients who received implants for breast augmentation would need them removed within ten years of implantation. In a study of 4,761 augmentation mammaplasty patients, surgeon Eisenberg found that overfilling saline breast implants by 10-13% reduced the rupture-deflation rate to 1.83% at eight years post-implantation. Prison populations were also subjected to plastic surgery across much of the 20th century, in programs intended to affect recidivism rates, a practice that continued from the early 20th century until the mid-1990s.