Nip, Tuck, Pump, Scrape: Surgical Paths to Happiness?

Making the Body Beautiful: A Cultural History of Esthetic Surgery , by Sander L. Gilman. Princeton University Press, 396 pages, $29.95.

The difference between reconstructive and cosmetic surgery is as plain as the nose on your face.

Unless, of course, you don’t like your nose.

Or your chin. Or your eyes, ears, breasts or penis. Or any other number of body parts you deem undesirable and which make you miserable under your skin. Then the line between the medical necessity of reconstructive procedures (the rebuilding, say, of a soldier’s face blown off by war) and the elective quality of cosmetic or “beauty” surgery (a tummy tuck here, a lip pump there) starts to blur. Both reconstructive and cosmetic procedures, after all, have the same aim: to make someone happy.

Happiness, writes University of Chicago professor Sander L. Gilman in Making the Body Beautiful , is the main goal of plastic surgery, whether it is rebuilding a harelip (a procedure now considered reconstructive but which in the 19th century was labeled as esthetic) or building up (or paring down) that nose on your face. Happiness is, in fact, the only way to measure the success of plastic surgery.

According to E. Bingo Wyer in The Unofficial Guide to Cosmetic Surgery , “In New York City, high-powered baby boomers, including both men and women, represent nearly 70 percent of all cosmetic surgery patients–about 137,000 patients annually.” These are not people in pain, at least not physical pain. Most often their surgery is not covered by health insurance. They are not really sick. “Indeed, many of them keep their treatment a secret and thus forfeit all of the sympathy one gains from being ill,” Mr. Gilman observes. The only way they can determine if their surgery has been a success is if they deem themselves happier than before they went under the knife. “It is the patient, not the physician, who is supposed to judge the success of the procedure,” Mr. Gilman writes.

But how is that judgment made?

That is the uncomfortable question at the heart of Making the Body Beautiful . Mr. Gilman wades into the murky waters of racial identity, pop culture fantasies and the politics of acculturation. He calls his heavily footnoted study “a cyber-jigsaw puzzle,” into which he throws a number of interlocking sets of stories. He considers Amy’s obsession with her flat nose in Little Women and reports on Barbra Streisand’s decision to keep her own “too Jewish” nose. He describes the man who is transformed into a female breast in Philip Roth’s novella The Breast and ponders Mark Rees’ transformation, thanks to a bilateral mastectomy, from a masculine-looking woman into a scarred but happier male transsexual. And from this hodgepodge of case studies and cultural references, he comes up with a disturbing answer to the question of how esthetic surgery patients decide on the success or failure of their procedures.

According to Mr. Gilman, the ones who are “happy” after their operations are those who see themselves as able to “pass” from the undesirable group to which they belonged before the surgery into the group about which they had been fantasizing.

In other words, the pursuit of happiness through plastic surgery presupposes that there are desirable and undesirable categories. In-groups and out-groups. Hairy, bald. Fat, thin. Large-breasted, small-breasted. Large nose, small nose. Male, female. White, nonwhite. Never mind that our perceptions of these categories are constantly in flux, that even the categories themselves are not fixed. The patient (or more accurately, the client) and the surgeon pretend otherwise.

“Happiness in this instance exists in crossing the boundary separating one category from another,” Mr. Gilman writes. “It is rooted in the necessary creation of arbitrary demarcations between the perceived reality of the self and the ideal category into which one desires to move.”

Take that nose on your face, for example, and our society’s wildly fluctuating views of just how protruding a protuberance it should be. For centuries, people wanted to rid themselves of their too-small noses. With the syphilis epidemic of the 16th century that ravaged people’s olfactory organs, a small, flat nose had come to be seen as a sign of immorality. By the end of the 18th century and throughout the 19th, that negative connotation was given a racial twist: Jews’ and blacks’ small, flat noses were declared signs of their “primitive” natures. The Irish pug nose was also pronounced undesirable. “The Irish nose is the African nose is the Jewish nose,” Mr. Gilman concludes, underscoring in Gertrude Stein mode the absurdity of such universal racial markings. No matter: They all represented difference and danger.

In response to these racial prejudices, esthetic surgery developed procedures to “correct” such “ugliness.” In the 1880’s John Orlando Roe, a Rochester, N.Y., surgeon, perfected a procedure that would “cure” the “pug nose,” transforming his patients from “Irish” into “Americans.” “Whether black, Irish, or Asian, the nose that is too small or too flat has been altered by the esthetic surgeon because of its ‘otherness’ in relation to Western ideals,” Mr. Gilman writes. “These ideals are not just concerned with beauty and attractiveness, but with markers of who is and is not acceptably human, who can and cannot be trusted.”

But again–those markers are maddeningly arbitrary. How else to explain that the same groups that are characterized as having small, flat noses are also racially marked as having big schnozzes? And add this irony to the racial confusion: In the house of mirrors that is the world of esthetic surgery, the perfect proboscis now turns out to be the “upturned” one, the very Irish “pug nose” that Roe and others sought to correct a century ago. Mr. Gilman quotes a 1989 New York magazine article: “By the mid-60’s, an upturned nose had practically become a middle-class status symbol, and hundreds of teenage girls in New York (read: Jewish girls) seemed to be wearing the same design. The bone was narrowed, the tip pinched into a triangle, and there were two distinct bumps above the nostril.” Jewish girls, convinced their noses are “too Jewish,” that is too big, want to look like typical American. That is, Irish.

Mr. Gilman’s previous books include Jewish Self-Hatred and The Jew’s Body , but in this case he’s an equal-opportunity debunker. Bravely navigating the ethnic maze with admirable aplomb, he considers nearly every hyphenated group’s American dream of “becoming something else.” He gets away with such brazenness, and also rescues his dense and rambling prose style, by constantly offering entertaining literary and pop culture references upon which we can all hang our hats.

The novels cited by Mr. Gilman seem to reinforce a pessimistic view of esthetic surgery. “Literature remains surprisingly ‘moral’ when it sees individuals believing they can cross boundaries from the unerotic to the erotic, from the unhappy to the happy,” he reports. From Fay Weldon’s The Life and Loves of a She-Devil to Mary Higgins Clark’s Let Me Call You Sweetheart , from Carl Hiaasen’s Skin Tight to Philip Roth’s American Pastoral , the world of esthetic surgery in fiction is a dark dystopia that leads at best to unhappiness, at worst to madness and death.

And yet for the professional descendants of John Orlando Roe, business is booming: In 1996, the total number of all esthetic surgical procedures in the United States exceeded 1.9 million, or about one procedure for every 150 people per year. The fantasy that a nose job or a tummy tuck can change your life is tenacious. The professor isn’t opposed to such fantasies. They can (and do) make people happy, he points out. But only for a while. “The symbolic body, our fantasy of fitting into the world, of being unseen, unrecognized, unstereotyped, needs constant reinforcement,” he warns.

It’s as plain as the noses on your face.