does it heal the mind?
PLASTIC SURGERY: A NECESSARY VANITY

by
ALEXANDER EDMONDS

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Alexander Edmonds is an assistant professor of anthropology and director of the master's program in Medical Anthropology and Sociology at the University of Amsterdam, and author of Pretty Modern: Beauty, Sex and Plastic Surgery in Brazil (2010). This article originally appeared in The New York Times.

While living in Rio de Janeiro in 1999, I saw something that caught my attention: A television broadcast of a Carnival parade that paid homage to a plastic surgeon, Dr. Ivo Pitanguy. The doctor led the procession surrounded by samba dancers in feathers and bikinis. Over a thundering drum section and anarchic screech of a cuica, the singer praised Pitanguy for “awakening the self-esteem in each ego” with a “scalpel guided by heaven.”

‘The psychoanalyst knows everything but changes nothing. The plastic surgeon knows nothing but changes everything.’

It was the height of Rio’s sticky summer and the city had almost slowed to a standstill, as had progress on my anthropology doctorate research on Afro-Brazilian syncretism. After seeing the parade, I began to notice that Rio’s plastic surgery clinics were almost as numerous as beauty parlours (and there are a lot of those). Newsstands sold magazines with titles like Plástica & Beauty, next to Marie Claire. I assumed that the popularity of cosmetic surgery in a developing nation was one more example of Brazil’s gaping inequalities. But Pitanguy had long maintained that plastic surgery was not only for the rich: “The poor have the right to be beautiful, too,” he has said.

The beauty of the human body has raised distinct ethical issues for different epochs. The literary scholar Elaine Scarry pointed out that in the classical world a glimpse of a beautiful person could imperil an observer. In his Phaedrus Plato describes a man who after beholding a beautiful youth begins to spin, shudder, shiver and sweat. With the rise of mass consumption, ethical discussions have focused on images of female beauty. Beauty ideals are blamed for eating disorders and body alienation. But Pitanguy’s remark raises yet another issue: Is beauty a right, which, like education or health care, should be realized with the help of public institutions and expertise?

The question might seem absurd. Pitanguy’s talk of rights echoes the slogans of make-up marketing (L’Oreal’s “Because you’re worth it.”). Yet his vision of plastic surgery reflects a clinical reality that he helped create. For years he has performed charity surgeries for the poor. More radically, some of his students offer free cosmetic operations in the nation’s public health system.

In 1988 a newly democratic Brazil ratified an ambitious constitutional right to health care. Public hospitals, though, are poorly funded and often beset by long lines, crumbling infrastructure and rude service. (My middle class Brazilian friends, who pay enviably low premiums for private health insurance, generally would not set foot in one). A right to beauty thus seems to value a rather frivolous concern in a country with more pressing problems -- from tropical diseases like dengue, to the diseases of civilization like diabetes. Yet to an outsider trying to understand a new society, such a view had a whiff of condescension. I remembered the remark of a Carnival designer: “Only intellectuals like misery, the poor want luxury.” I wanted to try to understand what this medical practice meant to the people who practiced it and claimed they benefited from it.

After a long wait, I began new fieldwork among a tribe of Cariocas (residents of Rio) less familiar to me: socialites and their maids, divorced housewives, unemployed secretaries, aspiring celebrities, transvestite prostitutes and other patients who were making Brazil, as a national news magazine bragged, the “empire of the scalpel.”

I first met Ester through her former employer, a successful plastic surgeon, for whom she’d worked as his personal cook. Ester lived not far from the surgeon in Vidigal, a favela flanking the brilliant white sand beach of Leblon. One day after she’d prepared dinner for his family she shyly told him in private, “Doutor, I want to put in silicone.”

After reading up on prosthetic materials in an Internet café, she’d settled on a midcost model of breast implant (1,500 real, or about $900), size (175 cm) and shape (natural), and convinced the doctor in a minute that she was a good candidate. Hesitant to perform the surgery on his domestic employee, he referred her to a young resident in Pitanguy’s clinic.

Ester left school at 14 to work beside her mother as a maid and now has two young kids. While taking night classes to get her high school diploma, she dreamed of “working with numbers.” Job prospects were grim though, and she said she’d take anything, even “working for a family” (a euphemism for domestic service). I asked her why she wanted to have the surgery. “I didn’t put in an implant to exhibit myself, but to feel better. It wasn’t a simple vanity, but a . . . necessary vanity. Surgery improves a woman’s auto-estima.”

Ester mentioned a key concept in Pitanguy’s vision of plastic surgery’s healing potential: self-esteem. A prolific writer, Pitanguy says he takes a ‘humanistic’ approach to medicine. Most of his 800-plus publications are technical but some cite thinkers, such as Michel Foucault and Claude Lévi-Strauss, rarely found in medical works (hence Pitanguy’s sobriquet, given by a colleague: the “philosopher of plástica”). With its wide-ranging reflections, this oeuvre has earned Pitanguy a place in Brazil’s prestigious academy of letters. It also outlines a radical therapeutic justification for cosmetic surgery. He argues that the real object of healing is not the body, but the mind. A plastic surgeon is a “psychologist with a scalpel in his hand.” This idea led Pitanguy to argue for the “union” of cosmetic and reconstructive procedures. In both types of surgery beauty and mental healing subtly mingle, he claims, and both benefit health.

But does cosmetic surgery deliver the benefits it claims to? Residents in surgery profit from remarkable opportunities for training in cosmetic procedures. Many go on to open lucrative private practices. Patients though often say (after their wounds have healed) they are happy with results. Yet repeat surgeries are common: either to correct botched operations or in pursuit of more ‘health.’ We might ask: If you’re psychologically suffering, why not have psychological treatment? One doctor had this response: “What is the difference between a plastic surgeon and a psychoanalyst? The psychoanalyst knows everything but changes nothing. The plastic surgeon knows nothing but changes everything.”

He was joking, but he hit on a change in Brazil’s therapeutic landscape.

Psychoanalysis and plastic surgery, both once maverick medical specialties, overlapped closely in their historical development. While the ‘talking cure’ treated bodily complaints via the mind, plastic surgery healed mental suffering via the body. Historian Sander Gilman called plastic surgery “psychoanalysis in reverse.” In Brazil, as in Argentina, psychoanalysis enjoys extraordinary popularity among wealthier Brazilians. But many veterans of Freudian or Lacananian therapy have supplemented or supplanted it with plástica. For the patients at public hospitals, psychoanalysis had never been an option, a psychologist who worked in Pitanguy’s clinic told me. Echoing the words of the mischievous Carnival designer, she explained, “The poor prefer surgery.”

Pitanguy’s ideas would have had little influence if it were not for his reputation as a skilled surgeon. Starting in the 1940s Pitanguy trained with leading plastic surgeons in Europe and the United States. One of his mentors in Britain was Sir Harold Gillies, who pioneered techniques in modern plastic surgery while operating on mutilated World War I veterans. His long career thus spans the 20th-century transformation of the specialty from primarily reconstructive techniques to primarily cosmetic improvements. Over the last five decades, Pitanguy has trained over 500 surgeons. His students have in turn trained new generations of surgeons, spreading their mentor’s techniques and philosophy as they open up practices around the country and abroad.

Pitanguy’s views of plastic surgery are in some ways no different than those of the wider specialty. Plastic surgery gained legitimacy in the early 20th century by limiting itself to reconstructive operations. The ‘beauty doctor’ was a term of derision. But as techniques improved they were used for cosmetic improvements. Missing, however, was a valid diagnosis. Concepts like psychoanalyst Alfred Adler’s inferiority complex — and later low self-esteem — provided a missing link.

Victorians saw a cleft palate as a defect that built character. For us it hinders self-realization and merits corrective surgery. This shift reflects a new attitude towards appearance and mental health; the notion that at least some defects cause unfair suffering and social stigma is now widely accepted. But Brazilian surgeons take this reasoning a step further. Cosmetic surgery is a consumer service in most of the world. In Brazil it is becoming, as Ester put it, a “necessary vanity.” Or as one surgeon said, “Faced with an aesthetic defect, the poor suffer as much as the rich.”

Oddly enough for a plastic surgeon, Pitanguy is an aesthetic relativist. Some plastic surgeons cite Greek mathematicians to argue there is a universal beauty ideal based on classical notions of proportion. But Pitanguy, whose patients often have mixed African, indigenous and European ancestry, stresses that aesthetic ideals vary by epoch and ethnicity. What matters are not objective notions of beauty, but how the patient 'feels.' As his colleague says, the job of the plastic surgeon is to simply “follow desires.”

Yet, such desires are not simply a matter of psychology. Brazil’s pop music and TV shows are filled with talk of a new kind of celebrity -- the siliconada. These actresses and models pose in medical magazines, the mainstream women’s press, and Brazilian versions of Playboy, which are read (or viewed) by female consumers. Patients are on average younger than they were 20 years ago. They often request minor changes to become, as one surgeon said, “more perfect.”

The growth of plastic surgery thus reflects a new way of working not only on the suffering mind, but also on the erotic body. Unlike fashion’s embrace of playful dissimulation and seduction, this beauty practice instead insists on correcting precisely measured flaws. Plastic surgery may contribute to a biologized view of sex where pleasure and fantasy matter less than the anatomical ‘truth’ of the bare body.

 

 

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