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(The online version of this article appears in two parts. Click here to go to part one.)

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 Welcome to Your Facelift, 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.

(The online version of this article appears in two parts. Click here to go to part one.)

Holly Brubach received a National Magazine Award in 1982 for her dance criticism in The Atlantic. Her most recent book is A Dedicated Follower of Fashion (1999).

Illustration by Phillipe Lardy.

Copyright © 2000 by The Atlantic Monthly Company. All rights reserved.
The Atlantic Monthly; February 2000; Beauty Under the Knife - 00.02 (Part Two); Volume 285, No. 2; page 98-102.