In or about June 1887, the human nose changed. In an unobtrusive little article in the Medical Record entitled "The deformity termed 'pug nose' and its correction, by a simple operation," John Orlando Roe, an otolaryngologist centered in Rochester, New York, reported on a new technique for reshaping the nose without scarring. Opening by declaring the importance of the nose--"The nose is the central and most prominent feature of the face; and on its shape, size, and appearance, to a great degree, depends the relative facial beauty of the person"--Roe goes on to describe a simple innovation that was to have widespread clinical and cultural effects. Before Roe, rhinoplasty had always been something of a tradeoff. As Roe himself wrote in 1897,

all attempts that had been made to correct [nasal] deformities . . . . involv[ed] the laying open of the skin, in order to reach the deformed part, and usually resulted in exchanging a deformity for an unsightly blemish. The unsightly scars left behind, therefore, had the effect of discouraging such operations, and, unless the deformity was excessively hideous, the person generally preferred to bear the ill he then had, rather than to flee to others he knew not of.

An unsightly scar for an improved shape: the price of a better profile had been the more or less visible mark of a nose whose lines had been surgically altered. Roe's innovation was to render the signs of surgery invisible by operating inside the nose. By turning back the tip of the numbed nose and using special retractors and scalpels, he was able to shave away excess tissue to bring the tip into line with the bridge. Some noses were then finished, others needed to be splinted and molded more gradually into shape. Either way, the result was dramatic: a new face emerging, as if by magic, from within the rough lineaments of the old (see fig. 1). The cost: around $1000, depending on the size of the job and the circumstances of the patient.

Roe's seamless nose job made an ancient operation remarkably new. By the late nineteenth century, Indian surgeons had been reconstructing noses for thousands of years, and Western surgeons had been doing reconstructions ever since the Indian technique was reported in the Gentleman's Magazine in 1794. Centered on replacing lost noses, the operation revolutionized treatment of injury and congenital malformations--even the ravages of syphilis and lupus, known for their tendency to eat away the soft palate and the entire outer nose, could be ameliorated by the complex art of rhinoplasty. The technique was elaborate for an era without anesthesia or antisepsis: surgeons carved the flesh they needed for a new nose off the forehead, swung the flap of borrowed tissue down to cover the defect, and stitched it in place until the operation "took." Then the remains of the flap were sewn back on to the forehead, and the new nose refined--given nostrils and shape--over a series of successive operations. The whole process took more than a month to complete. Needless to say, such surgeries were debilitating, terrifically painful and always already compromised: what the patient gained in the way of nasal flesh was paid for in extensive scarring and a high risk of infection. By the end of the nineteenth century, however, sterile procedure and local anesthetics such as cocaine enabled surgeons to experiment with more delicate techniques. Roe's operation--ironically far simpler than its flappy ancestor--was one result.

It was of course easier to shrink a nose than to build one. Within limits, though, Roe and others could build up noses, too. While flap operations remained the best way to reconstruct the most severe cases (those in which the entire external nose was simply gone, leaving only a hole in its stead), surgeons did find ways to enlarge the depressed saddle noses that so often resulted from accident or disease. In 1891, Roe described how he reshaped the nose of a man whose "fine Grecian nose" had been smashed by a kicking horse: by dissecting away deformed and protruding bone from inside the nose, Roe was able to restore the contour, if not the original size, of his patient's organ. And in 1892, the New York surgeon Robert F. Weir did for rebuilding the nose what Roe had done for reducing it. Drawing on Roe's intranasal technique, Weir's "On restoring sunken noses without scarring the face" showed how noses flattened by trauma or disease could be refashioned through a combination of scarless surgery (to reshape bones) and prosthetic support (to do what the bridge of a healthy nose does). Where Roe pared away excess tissue and bone to form straight noses with small tips, Weir carved depressed nasal bones to prepare them for structural implants (these ranged from a section of a duck's sternum [unsuccessful] to a platinum bridge specially designed for the purpose [successful]).

The age-old prerogative of healing and the new-fangled technology of seamless surgery thus came together in the invisibly altered nose, which marked the spot where, in ministering to human defect, surgeons began to reshape--from the inside out--the very idea of what a defect was, and what it meant to have one. With the ability to efface defects came, first off, an expansion of the definition of defect itself. If broken, overgrown, twisted and collapsed noses could be repaired surgically, so could noses with comparatively slight malformations; the advent of invisible surgery encouraged people to obsess about minor and even nonexistent defects. Weir makes this point, noting that after he adopted Roe's intranasal operating technique, he began to be plagued by a patient who had become so "much perturbed in mind concerning the unsightliness of his nose" that surgery "became more than an operation for the relief of a cosmetic annoyance. It seemed to his physicians and relatives essential to the balance of his mind that some attempt should be made to relieve him of what he persistently dwelt upon as a distressing deformity" (88). Acknowledging that the original "goodly sized organ" was "considered with some justice . . . to be unduly large" (88), Weir goes on to describe how, at the patient's insistence, he operated on this ever-diminishing nose four separate times in the space of two years, making the tip smaller, then decreasing the breadth of the nostrils, then shortening the whole, and finally correcting the slight hump that arose when the cartilage began to slide down and away from the fragile bridge (this last operation was done to repair the damage done by too many previous surgeries). This obsession with whittling away at one's looks was, to Weir's mind, a form of "monomania," a personality flaw that surgery did more to exacerbate than correct. The expansion of the definition of defect enabled by the new nose jobs thus extended beyond a person's profile to include the very contours of character.

Small wonder that this should be the case: for the personality disorder Weir diagnoses in his rhinomaniac is symptomatic of plastic surgery's own disordered notion of character. Consider Roe's completely nonsensical rationale for reshaping ugly noses. This rationale begins with the then-popular picture of the nose as an index of character. In his 1887 article, Roe builds his case for rebuilding the nose by citing a series of authorities:

Says Wells, 'A skillful dissembler may disguise, in a degree, the expression of the mouth; the hat may be slouched over the eyes; the chin may be hidden in an impenetrable thicket of beard; but the nose will stand out 'and make its sign' in spite of all precautions. It utterly refuses to be ignored, and we are, as it were, compelled to give it our attention.' (72)

"Mr. Warwick says: 'A snub nose is to us a subject of most melancholy interest. We behold in it a proof of degeneracy of the human race'" (72). "Mr. Ribot says, 'that of all the features, the nose is the one which heredity preserves the best'" (73). Even Tristram Shandy's father gets trotted out (as if two-dimensional characters were specially qualified to declaim on flat features): "No family, however high, could stand against a succession of short noses" (72). The mouthpieces of human physiognomy, noses are not to be snubbed. They provide an accurate profile of a person's family history, as well as outstanding information on individual character, so much so that personality types can be classified by type of nose: "The Roman indicates executiveness or strength; the Greek, refinement; the Jewish, commercialism or desire for gain; the Snub or Pug, weakness or lack of development; the Celestial, weakness, lack of development, and inquisitiveness" (72). The nose is the arbiter of human character: to know a person one must know that person's nose. This sense of the impeccable honesty of the nose (even that of the weak and underdeveloped one) provides, paradoxically, the rationale for invisibly reshaping substandard noses. Noses never lie. And yet they can be made to--"compel[led] to conform to the exact shape we desire" (74). The result of the surgery is thus to conceal the truth that the nose, if left to its own devices, cannot help but tell. The characterological implications of Roe's handiwork were as clear as the nose on your face: as of 1887, a skillful dissembler could disguise an unattractive nose as well as any other part of his physiognomy, and so disguise an imperfect--or ethnic--personality.

But the seamless nose job was not so much a question of deception--of concealing personality flaws behind a flawless profile--as of transformation. Seamless rhinoplasty took the index of character and turned it into the malleable feature--the part of the face that could be invisibly altered at will--even as it retained the deterministic language of physiognomy. The result was an idea of character as not only fixed by the nose, but fixable by it. This sort of physiognomy was indeed the very rationale of plastic surgery, which ratified its aesthetic ministrations (themselves therapeutically suspect) by arguing for their psychiatric benefits. Roe (and every other notable plastic surgeon to come after him) was clear that refining the shape of the nose invariably refined the patient's nature, making him or her happier, more outgoing, and so more successful as a person. Roe, Weir, and others described patients recovering pleasure in life, advancing their careers, finding community, and even finding true love as a result of nasal reconstruction. As the German surgeon Jacques Joseph put it in 1904, "The operative nasal reduction . . . will also in the future restore the joy of living to many a wretched creature and, if his deformity has been hindering him in his career, it will allow him the full exercise of his aptitudes" (quoted in Rogers, 83).

The key to this transformation lay in rhinoplasty's ability to repair the psychic distortions produced by the ill-formed feature. Roe was adamant that a single, local deformity could deform the entire person, inside and out. If the defective nose reflected a moral deficiency, it also did considerable damage to the morale, the effects of which were visibly rendered as further disfiguration of the face: "The effect upon the mind of such physical defects is readily seen reflected in the face, which invariably conforms to the mental attitude, and leads after a time to a permanent distortion of the countenance" (quoted in Rogers, 74). The resulting expression expressed the inner anguish caused by a defective expression that was itself an expression of an original personal shortcoming. And the result of such negative reinforcement was in turn a life practically lost to an endless and unnecessary cycle of mental and physical deterioration: "It will be a surprise to any physician, who will take the trouble to investigate the subject, to find how many brilliant lives, how many noble personalities, and how much valuable talent have been, so to speak, buried from human eyes, lost to the world and Society, by reason of the embarrassment and mortification caused by the conscious or in some cases the unconscious influence of some physical infirmity or deformity or unsightly blemish" (quoted in Rogers, 74). Plastic surgery could reverse the damage done by this affective domino effect simply by removing all trace of the precipitating symptom (as if it were itself the outstanding cause): "We are able to relieve patients of a condition which would remain a lifelong mark of disfigurement, constantly observed, forming a never ceasing source of embarrassment and mental distress to themselves, amounting, in many cases, to a positive torture, as well as often causing them to be objects of greater or less aversion to others" (quoted in Rogers 74). Unmaking the laws of physiognomy in the name of upholding them, Roe described an operation that ended the degenerative cycle of "positive torture" by replacing it with a positive feedback loop. Prettier noses made for happier people; happier people not only had prettier faces, but were better able to function in the world.

Plastic surgery was mind-altering, a quick fix that could permanently cure that otherwise inoperable condition, unhappiness. And as such, plastic surgery placed itself in direct competition with the emerging science of psychotherapy--a field that was, ironically, carving out its own professional niche as a form of metaphoric surgery. Hence Freud, in Studies in Hysteria (1895):

I have often in my own mind compared cathartic psychotherapy with surgical intervention. I have described my treatments as psychotherapeutic operations; and I have brought out their analogy with the opening up of a cavity filled with pus, the scraping out of a carious region, etc.

For Freud, surgery provides an apt analogy for psychotherapy precisely because of its palpable difference from psychotherapy: what makes the comparison work is its capacity to throw the invisible processes of analysis into bold, bloodless relief. Psychotherapy may be compared to an operation, but only because it is not really like one at all. There is no blood or pus in a talking cure; the analyst does not touch his patient, let alone scrape out his rotten parts; and the analysand is healed by an altogether more sterile technique. Freud himself acknowledged this: "An analogy of this kind finds its justification not so much in the removal of what is pathological" (i.e., in its capacity to image analysis accurately), "as in the establishment of conditions that are more likely to lead the course of the process in the direction of recovery" ( i.e., in its capacity to image analysis inaccurately, in its ability to send psychoanalysis in directions that are as essential to its success as they are antithetical to its nature) (quoted in Jacobus, 231). As Freud himself put it in his 1912 essay, "Recommendations to Physicians Practising Psycho-Analysis":

I cannot advise my colleagues too urgently to model themselves during psycho-analytic treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible. . . . The justification for requiring this emotional coldness in the analyst is that it creates the most advantageous conditions for both parties: for the doctor a desirable protection for his emotional life and for the patient the largest amount of help that we can give him to-day. (quoted in Jacobus, 232)

The surgical analogy encourages a coldness in the analyst that would otherwise be inconceivable, and as such it aids in creating a picture of the analyst as a detached, objective observer of his patient's feelings, rather than as an interlocutor whose willingness to discuss those feelings implicates him in their tenor, type, and expression. Plastic surgery evaded the circuitous routes of both psychoanalysis and its strategically imprecise language by focussing on the palpable reality of its own symbolic operations. Where psychoanalysis used surgical imagery to describe itself as an incisive practice, plastic surgery claimed that the most incisive approach to the mind was the practiced incision--the New Zealand surgeon Harold Delf Gillies was even known as the "plastic surgeon of the psyche" (quoted in Gilman, Creating, 113). In so doing, plastic surgery represented itself as an antidote to a psychiatry whose cutting edge was purely metaphorical.

From the first, then, there was a clear understanding that what plastic surgery ultimately operated on was a person's make-up. Rhinoplasty was above all a quite literal means of personal expression: if it occasionally encouraged unhealthy obsessions, it more frequently did the opposite, freeing people to change by releasing them from both the debilitating personal fixations and derogatory social classifications associated with imperfect, injured, and diseased noses. The seamless nose job thus brought down the entire edifice of physiognomy in the very name of upholding it. No matter that it was impossible to know the truth about a person's nose--wherever a nose came from, it was always a telling organ, a true (if carefully contrived) image of one's inner being. And in this way, what ought to have been an argument against cosmetic surgery--that it made a person inscrutable--thus became an argument for it: in giving an old nose new shape, the seamless nose job contained the makings of an entirely new individual. As such, it pointed to plastic surgery's power to reshape reality itself.

There will be time, there will be time
Time to prepare a face to meet the faces that you meet

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