WORKING in the fashion business for the past twenty-some years, I have frequently had cause to contemplate beauty in its most conspicuous forms and also the apparent lack of it. We are raised on stories in which some ravishing heroine, the soul of goodness, is menaced by a wicked witch recognizable by her ugliness, and there is a kind of justice in this that we are loath to relinquish. I myself subscribe to the notion that by the time you're fifty, you have the face you deserve, which might seem no more than a cynical, grown-up attempt to keep alive that fairy-tale law of nature except that there is indeed some truth to it: after five decades of repetitive scowling or laughter or worry, one's attitude toward life is etched on one's face. And here is where the issue gets complicated -- because in the end it is not the geometry of one's nose or the shape of one's eyes or mouth that makes a face attractive. Rather, it is that "raw material" as manipulated by our expressions over time. The older we get, the more expression takes over, until the faces of the elderly are so full of personality -- so dominated by it -- that the actual contour of their features seems immaterial. If some of us find the prospect of plastic surgery unsettling, that is, I think, largely owing to some deep-seated suspicion, borne out by observation, that appearances aren't purely arbitrary -- that they contain important information, and by altering those appearances we falsify that information.

And yet who hasn't felt misrepresented by the face in the mirror, or registered the discrepancy between the people we know ourselves to be and the way others perceive us? We identify with Cyrano's suffering -- that of an exquisite soul eclipsed by a single unfortunate feature. Today, of course, a plastic surgeon could intervene, rendering Cyrano every bit as handsome as Christian, his rival for Roxanne's affection, and the story would have a happy ending. Or would Cyrano, an outcast and a laughingstock all his life, so readily accept the privileges that good looks confer? His is the soul of a poet, and his experience, however excruciating, has taught him tenderness, irony, reflection, and compassion. Similarly, in Little Women, Amy learns to live with her anomalous nose, and is the better for it.


A friend recently remarked that in some circles in New York (and I would imagine it's true in Hollywood as well) no one knows anymore what a fifty-five-year-old woman really looks like. The face that has been lifted has become the norm. Certain women I know, now in their forties, have already undergone what one surgeon refers to as "preventive" face-lifts. At the risk of sounding a puritanical note, I confess that there is still for me a certain Dorian Gray-like creepiness about this business of attempting to reset the hands of time, a sense that one doesn't get away without paying a penalty of some kind -- in some cases an enormous price, when something goes awry. Take, for instance, the fate of Consuelo, the Duchess of Marlborough, a legendary beauty who underwent a series of paraffin injections to fend off the effects of aging and, disfigured by the results, became a recluse for the rest of her life. And yet, despite this and any number of other, more recent cautionary tales, denial springs eternal.

AMONG the before-and-after pictures, the diagrams depicting physiognomic ideals, the occasionally ghoulish close-ups of faces disfigured by war or disease, that illustrate Sander Gilman's Making the Body Beautiful: A Cultural History of Aesthetic Surgery are two photographs reproduced from an early textbook on rhinoplasty and identified as "images of happy patients." In one a woman is smiling broadly, her face tilted to the sun, her arms spread as if she were about to fly; in the other a man and a woman dance in the street. They are still sporting bandages, so it is too soon to tell what changes their surgery will bring about in their lives -- how different a stranger's response to them will be, or which of the doors previously closed to them will now swing open. Rather, the patients' glee is in proportion to their conviction that they have been transformed, that what was wrong with their lives has at last been righted.


Gilman calls happiness "the central goal of aesthetic surgery" ("aesthetic" with an ae because, he explains, that's the way it is most often spelled by the surgeons themselves, who confer on their work "a classical lineage" by harking back to ancient Greece). Face-lifts, nose jobs, liposuction, decircumcision, buttocks implants, breast augmentation, and breast reduction, among other procedures, present themselves, Gilman drily notes, as surgical cures for what is often essentially a psychological problem -- a persistent sense of discontent. That more and more Americans are resorting to these remedies is borne out by statistics: in 1981 there were 296,000 such operations in the United States; in 1995 there were 825,000 on the face alone. Strikingly, the numbers indicate that altering one's appearance is no longer the exclusive prerogative of Michael Jackson, movie stars, and New York socialites: in 1994, Gilman tells us, 65 percent of plastic-surgery patients had household incomes of less than $50,000.

The discretion and shame once associated with "cosmetic" (or "plastic," as it is more colloquially, if less elegantly, known) surgery seem quaint hallmarks of a bygone era -- albeit the day before yesterday -- when people still had secrets, when women might sneak off for an extended "vacation" and come back looking "rested." Celebrities now publicly acknowledge the work they have had done: Gilman cites Roseanne's example -- an overhaul that included new eyelids, cheek implants, liposuction, a face-lift, a nose job, a chin implant, and breast reduction. An article in the August issue of Vogue, written by a woman who treated her fifty-five-year-old mother to a face-lift, describes it as a bonding experience. Evidence of just how commonplace these procedures have become now crops up everywhere, not only in mainstream magazines but in the far corners of the culture. The French artist Orlan, born in 1947, has made a career out of a series of operations that have turned her into a human compendium of art-historical "quotations," incorporating the chin of Botticelli's Venus, the lips of Moreau's Europa, the eyes of Gérôme's Psyche, the brow of Leonardo's Mona Lisa.

With its bizarre amalgam of new developments in medicine and prevailing trends in fashion, "aesthetic surgery" is a phenomenon that begs for examination, and Gilman, as both historian and critic, proves equal to the task. The medical history will come as a surprise to anyone who assumes, as I did, that cosmetic procedures were a luxury that surgeons got around to developing only after they had perfected life-saving techniques such as appendectomies and tracheotomies. Gilman traces the field's origins to a sixteenth-century epidemic of syphilis, which corrodes the noses of its victims and, in its hereditary form, the noses of their children. The most popular (and, presumably, effective) solution entailed grafting a flap of skin taken from the forehead, the cheek, or the upper arm; the scarring, however, was a giveaway. Finally, in the 1880s, a surgeon by the name of John Orlando Roe, in Rochester, New York, devised an operation that, by entering through the nostrils, would leave no trace, and modern rhinoplasty was born. That so much of the history Gilman recounts pre-dates anesthesia and antisepsis is testimony to the astounding determination of early patients to undergo surgery. That determination was -- and still is -- fueled by a certain fetishism, the tendency to fixate on a single aberrant feature and to blame it for one's social, professional, or personal misfortunes. Gilman demonstrates that this may be simply a more obsessive form of the fetishism with which we routinely size one another up (the better part of his first 200 pages is devoted almost exclusively to the nose, that badge of ethnic identity).

Reconstructive techniques developed in the aftermath of war -- the First World War in particular -- eventually proved useful for other, cosmetic purposes. With the onset of the twentieth century, aesthetic surgery began to address the effects of aging. The first face-lift, Gilman tells us, was performed on a Polish aristocrat in 1901. New procedures have been introduced as a perceived need for them has arisen. Whereas corpulence was admired in previous eras for its connotations of prosperity, thinness is idolized in ours. Hence liposuction, first performed in 1977.

However, what is beautiful or erotic can be defined only within the context of a given culture at a given moment; the definition varies not only from one era to the next but also from one society to the next. Gilman marshals any number of examples to demonstrate how remarkably capricious the trends in physical features can be -- among them, what he calls the "dialectic of the breast." During the twenties the flat-chested flapper epitomized the modern woman, free to lead a life of her own choosing, unencumbered by the duties of reproduction. As that ideal gradually became démodé, breast reduction gave way to augmentation, until, Gilman says, "beginning in the United States in the 1950s, there was a concerted effort to search for cures for this new disease of 'too-small breasts.'" Ample breasts went out of style again in the anorexic sixties, presided over by Twiggy and Penelope Tree, and made a comeback in the eighties, which were dominated by a new generation of shapely models, many of them with silicone implants. Cross-cultural differences prove to be equally dramatic. Gilman quotes one plastic surgeon in Brazil, where small breasts are the ideal, who speculates that many of the same women now undergoing breast reduction there would most likely want breast augmentation in America. Nor are these whims limited to women's bodies. In a chapter on procedures for men Gilman weighs the appeal of decircumcision: in gay circles in Germany, he tells us, it is in to be "cut," whereas in gay circles in New York it is in to be uncut.

INCORPORATED in this guided tour of aesthetic surgery's history are the ethical questions that arise along the way. From the outset this upstart branch of medicine provoked vehement opposition. Gilman quotes John Dryden's dictum: "God did not make his Works for man to mend." And, indeed, in an era when thieves, army deserters, and adulterers had their noses cut off as punishment, the physician who undertook the reconstruction of their noses found few supporters. It was, it seems, only in the wake of the Napoleonic Wars that plastic surgery acquired widespread legitimacy, as it came to the rescue of heroes mangled on the battlefield. But the potential to transform never ceased to be controversial, and at the end of the Second World War plastic surgery became associated with ex-Nazis attempting to change their identities.

Gilman is at his best chronicling the myriad ways in which plastic surgery has put itself in the service of minorities (among the pioneering surgeons in Germany, several were Jews), speeding their acculturation and helping them to approximate the ideals established by whatever tribe is in power at the time. In Saigon (only one of his many examples) plastic surgery thrived during wartime, as Vietnamese women transformed their bodies and faces to look more "Western," presumably in the hope of attracting the occupying soldiers. By 1975, when the withdrawal of American troops was complete, the industry had collapsed.

Roe's rhinoplasty, Gilman tells us, was conceived as a remedy for the pug nose, which branded so many recent immigrants as Irish. The Irish physiognomy was regarded as "servile," inspiring analogies to dogs (hence the name "pug"). Measured against the standard of the English nose in Britain or the German nose in America, the Irish nose was too short. The Irish nose and the Jewish nose and the African nose were all alike, Gilman writes, in that they represented difference. (The irony, of course, is that by the middle of the twentieth century the pug nose had become the ideal, as we are reminded by the face of every woman who underwent rhinoplasty in the 1960s.)

Jacques Joseph, a surgeon trained in Leipzig and Berlin at the end of the nineteenth century, and the author of the textbook on rhinoplasty mentioned above, was dismissed in 1896 by his (Jewish) supervisor for performing an operation that was purely cosmetic; vanity, he was told, was not sufficient grounds for surgery. In Joseph's eyes, however, such surgery was an act of mercy. For patients of limited means who "suffered from a 'Jewish nose'" he is said to have provided his services pro bono. These services, he claimed, were sought not only by Jews but also by gentiles with noses that looked Jewish. In many if not most instances the desire for assimilation seems to have been largely pragmatic; if society's discrimination on the basis of appearance was deemed unfair, then any endeavor to circumvent that discrimination was justifiable. A hundred years later the motives, it seems, remain unchanged. Gilman summarizes a 1960 Johns Hopkins survey of Jewish teenage girls who wanted rhinoplasty. The study found that the girls' desire to change their noses was no indication of an intention to marry or to have friends outside their religion, or even to deviate from their families' religious practices. Not to be seen as Jewish, even while retaining a Jewish identity -- this was the goal. To the extent that a new nose constituted a "betrayal" of origins, it was entirely superficial -- which is presumably a minor offense, if it is an offense at all.

Among the many misguided attempts to arrive at some universal organizing principle on the basis of anatomy was Hermann Heinrich Ploss's ethnographic study of female anatomy, first published in 1885 in two illustrated volumes. Owing to increasing and continuing demand, it was extended and expanded even after his death, and its popularity culminated in a four-volume eleventh edition in 1927. The shape of the breast, according to Ploss, was a reliable index for ethnic classification. His contemporary Ernst Brücke equated smaller breasts with "Germanness." Gilman summarizes Ploss's "findings": "the farther south one goes from Germany, the more pendulous the breasts and the larger the areolas seem to get." Alas, Ploss's distinctions so succeeded in infiltrating a certain widespread bourgeois sensibility that, I can report from experience, they persisted -- far from the source and unattributed -- in certain sectors of middle America throughout the fifties and early sixties (and for all I know they survive to this day). Growing up at that time in Pittsburgh, I often heard large breasts, full lips, brown eyes, and "olive" complexions condemned as "ethnic" -- a synonym for "other." The closer one got to the Mediterranean (a danger zone characterized by rampant sensuality and wanton behavior), the more exaggerated these traits became; the people to whom they belonged were also likely to be Roman Catholic.

Supermodels with silicone breasts and lips plumped up with collagen may not signify the repeal of those narrow criteria, but they surely represent the overthrow of the old hierarchy, in which everybody aspired to WASPdom. With the rise of multiculturalism, ethnic groups began to assert their differences. Barbra Streisand made history by not fixing her nose. What had been a stigma could under some circumstances prove to be an asset -- as in the case of a professor of comparative literature at Stanford who, Gilman tells us, was offered a nose job by his uncle and declined it because in his field Jews are presumed to be bright.

For those whose scruples stand in the way of surgical repairs, Gilman does not mention that the high moral ground has grown quite slippery lately, owing to a battery of new procedures that blur the distinction between dermatology and plastic surgery. Twenty years ago the choice between a face-lift and a facial was clear-cut; today, however, doctors have built a bridge between surgery and grooming, complicating the issue. If, for instance, a woman has the brown spots on her hands removed, or "frozen," what's the moral difference between that and a chemical peel to strip away layers of dead skin on her face? (Both are office procedures.) If she has a chemical peel, why not Botox injections to paralyze the muscles that knit her brow? If Botox, why not a face-lift? "I draw the line at general anesthesia," a friend says.

THE seven years I have lived abroad (in France and now in Italy) have irrevocably changed my perspective on all these matters. Although plastic surgery is by no means a solely American phenomenon, it seems to be rarer in Paris or Milan than it is in New York -- apparently, one is forced to conclude, because fewer people perceive the need for it. In France, for example, women seem to grow old with dignity, with their sexuality intact, whereas in the United States I'm continually struck by how many women over forty are trying to look thirty. This is generally attributed to our native insecurity, if only because it's easier to blame us than it is to blame the culture that has made us feel as we do -- an assignment of responsibility that would call into question some of our most cherished ideals. We have romanticized adolescence as a time of unlimited possibility -- an optimal condition in a country that regards life as a lottery -- to such an extent that we are tyrannized by youth. Plastic surgery appeals directly to our epidemic perfectionism and comes packaged in the trappings of self-improvement, our national pastime. Why let a large nose or a spare tire or a double chin get in the way of our pursuit of happiness?

If Making the Body Beautiful has a flaw, it is Gilman's evident reluctance to wrestle with the sexual politics that underlies plastic surgery's history and changing demographics. For a brief moment back in the seventies it looked as if feminism might put an end to the shame of aging and a woman's need to do something drastic about it. Women would be appreciated not -- or not only -- for how they look but for who they are. Men, having discovered the joys of equal partnership, would no longer regard beautiful, younger women as prizes. Men and women would grow old together.

So much for that plan. Instead we have a recent unabashed guidebook that would have been inconceivable twenty years ago. In those days the author, Helen Bransford, would have been run out of town for her cheerful admission that, as a woman in her mid-forties, she underwent surgery in the hope of holding her younger husband's attention. To the extent that equal rights have come to pass where plastic surgery is concerned, they seem to mean that men are now compelled to get face-lifts too. Rather than women's feeling better about their bodies, men feel worse about theirs (though the number of men getting pectoral implants is still nowhere near the number of women getting breast implants). Girls have deplored their failure to measure up to Barbie for years; now, according to a joint study by researchers at Harvard University, the University of Massachusetts at Boston, and McLean Hospital, in Belmont, Massachusetts, boys may grow up to reproach themselves for falling short of the standard set by G.I. Joe, whose muscles have grown progressively larger over the past thirty years. His latest incarnation features biceps with a circumference that is the adult equivalent of twenty-six inches -- larger than any bodybuilder's.

The images that bombard us daily, in magazines, advertising, television, and movies, are insidious, encroaching on the way we see ourselves; the premium we place on visual information, which bypasses words and telegraphs an instant message ideally suited to the velocity of our lives, is at an all-time high. Meanwhile, the Internet has spawned a new phenomenon -- the notion of the disembodied self as the true self, a lone wanderer in cyberspace. Those who meet in chat rooms, unencumbered by the superficial signals sent by clothes, hairstyles, and physiques, connect on a level presumed to be direct and pure, transcending physical limitations. Online we cultivate new versions of ourselves, suspended in the ether. Is it any wonder, then, that so many people today fail to identify with their bodies? Obese or short or gray-haired or bald, we insist that we are not who we appear to be. Our faces grow older, our waistlines expand, our thighs spread, and instead of inhabiting them, we renounce them. Our bodies have betrayed us, we think, not recognizing that it is we who have betrayed them, by moving out. Gradually our so-called inner reality grows so estranged from our outward appearance that only a surgeon -- an "aesthetic" surgeon, no less -- can reconcile the two, carving our flesh to make it conform to the images in our minds.


Holly Brubach received a National Magazine Award in 1982 for her dance criticism in The Atlantic.


The Atlantic Monthly; February 2000; Beauty Under the Knife - 00.02 (Part Two); Volume 285, No. 2; page 98-102.