A brief history of plastic surgery

Plastic surgery has become synonymous with the quest for youth and beauty, albeit with varying degrees of success. But the field has, for centuries, been driven by medical necessity -- and it has nothing to do with plastic.

The discipline derives its name from the Greek word “plastikos” -- to mold or give form. And while the idea of perfecting yourself surgically is a relatively recent phenomenon, there is evidence of reconstructive surgery going back to antiquity. The oldest-known procedures appear in an ancient Egyptian medical text called the “Edwin Smith Papyrus.” Thought to be an early trauma surgery textbook (and named after the American Egyptologist who purchased it in 1862), the treatise contains detailed case studies for a variety of injuries and diagnoses. As well as showing how the Egyptians treated wounds and bone fractures, the papyrus revealed a suggested fix for nasal injuries: manipulating the nose into the desired position before using wooden splints, lint, swabs and linen plugs to hold it in place. The Egyptians occasionally used prosthetics, too: In 2000, an ancient mummy was found to have a prosthetic toe that may have aided the woman's walking, according to researchers who tested replicas of the toe on modern-day volunteers. Whether these procedures can be considered types of plastic surgery is a matter of historical debate, according to Justin Yousef, whose research on the topic was recently published in the European Journal of Plastic Surgery. It is in India, in fact, that historians have found “the first description of reconstruction proper,” he said in a phone interview.

By the 6th century B.C., physicians in India were carrying out procedures not dissimilar to a modern-day cosmetic rhinoplasty. In a detailed compendium called “Sushruta Samhita,” the Indian physician Sushruta -- who is sometimes called the father of plastic surgery -- outlined a remarkably advanced technique for skin grafts. As in Egypt, the procedure involved repairing noses. But according to Yousef, patients' motives were, in a sense, cosmetic. “In ancient India, there was a practice of having one's nose removed as punishment for adulterous acts or (other acts that were) against the law at the time,” said Yousef, who is also a trainee surgeon at Sydney's Royal Prince Alfred Hospital. “It was a public sign of shame -- if you walked around with an absent nose, people knew that you'd done something.” Sushruta's technique involved constructing new noses using skin from elsewhere on patients' faces. “There are two schools of thought,” Yousef said. “That the skin was either from the forehead or the cheek. But he basically raised the skin and the underlying fat, before transporting it to the area of the nose.” Elsewhere in antiquity, the first known cleft lip repair is believed to have been successfully carried out by 4th-century Chinese doctors. And in ancient Rome, the encyclopedist Aulus Cornelius Celsus documented a procedure whereby excess skin around patients' eyes was surgically removed.

“Celsus described what we today would call blepharoplasty, or eyelid rejuvenation,” Yousef said. “It was used when hairs (eyelashes) became inverted and started to affect the patient's ability to see. They were trying to shorten the eyelid so the hairs wouldn't reach the eye.” In the ancient world, patients were usually “seeking to replace something rather than enhance their aesthetic appeal,” Yousef said. And given the pain and risks involved, going under the knife was reserved for those most in need. “Wine was the anesthetic,” Yousef added. Progress in the field was slow over the ensuing centuries. Like much of medical science, it was the development of modern germ theory and the 19th-century invention of anesthesia that began shaping the practices seen today. As with so many innovations, however, there was another factor that accelerated plastic surgery's progress: war. During World War I, the sheer volume of patients with facial injuries -- coupled with advances in blood transfusions and infection control -- allowed doctors to experiment with innovative new techniques, according to Andrew Bamji, author of “Faces from the Front,” a book tracing the origins of modern plastic surgery. “If you've got 100 patients to learn from, that actually isn't very many, given the various types of injuries you can have,” the writer and retired rheumatologist said in a phone interview. “But if you've got 5,000 patients, it's a different game altogether.” The institution at the heart of Bamji's book, Queen Mary's Hospital in London, was the “first to concentrate all the patients in one place,” he added. Skin grafts, bone grafts, facial reconstructions and wound-stitching techniques all made dramatic leaps forward. “You've got literally dozens of surgeons working there, and they can bounce ideas off each other. We have photographs of two operations happening in the same operating theater at once -- which from a cross-infection point of view, nowadays, would be completely forbidden -- but... you have this incredible interchange of ideas and the development of reconstructive techniques.” At the time, the priority for military and civilian patients was improved functioning, such as chewing or breathing more easily. And the idea of using surgery to simply improve one's appearance remained in its infancy. Doctors in Europe and America had experimented with rudimentary cosmetic procedures prior to World War I, though they were “hit and miss,” Bamji said, adding that “quite a lot of it went wrong.”

At the start of the 20th century in France, for instance, doctors sometimes attempted to re-contour patients' faces using paraffin wax. Although solid at room temperature, when the wax warmed in the body “it started to melt, and so it sank into the lower regions,” Bamji said. Standards improved in the inter-war period, which also saw the first attempts at sex reassignment surgery. But cosmetic procedures were frowned upon by parts of the medical establishment. In the 1930s, some surgeons “bobbed noses and performed some breast operations,” Dr. Richard L. Dolsky wrote in the American Journal of Cosmetic Surgery in 1999, although “such work occurred quietly, without fanfare.” “Most plastic surgeons yearned to be recognized as 'serious surgeons' and avoided what were considered frivolous procedures,” he added. It took a plastic surgery explosion boom of the 1990s, which saw the volume of procedures in America grow tenfold, for cosmetic procedures to begin outnumber reconstructive ones. By 2005, the number of cosmetic surgery procedures performed in the US was almost double that of reconstructive procedures, according to data from the American Society of Plastic Surgeons, or ASPS. Fueled by celebrity endorsements and economies of scale, cosmetic surgery also tapped into a new aesthetic of desirability, said Ruth Holliday, a professor of gender and culture at Leeds University's School of Sociology and Social Policy. “Post-feminist thinking, which first emerged in the 1980s, was all about showing how empowered you were,” she recently told CNN. “It was about women reclaiming their sexuality, both from the patriarchy and the feminist movement itself. Within the realm of plastic surgery, that translated into emphasizing all the parts of their bodies that were already widely eroticized by society -- thighs, curves, breasts -- to own and show off their femininity.” According ASPS data, 15.6 million cosmetic procedures were carried out in the US last year. New technology continues to drive the sector's growth, with some 85% of these procedures (of which Botox and fillers were by far the most popular) considered “minimally invasive.” Tastes continue to change, too. And while the Covid-19 pandemic has impacted the entire industry, with ASPS reporting a 15% drop in cosmetic procedures carried out in the US in 2020 compared to the previous year, some procedures suffered far larger falls -- the number of breast augmentations was down 33% and buttock lifts were down 27%, year over year.