Not painting, then, but sculpture; and not just written references to sculpture, but elaborate photographic comparisons between patients and statues. Consider the following series, which appeared in a 1907 article by the St. Louis oral surgeon Vilray Blair entitled "Operations on the Jaw-Bone and Face" (see fig. 3). These pictorial sequences illustrate an article whose most basic purpose is to report on a new technique for surgically correcting deformed jaws (what Blair defines as "excessive asymmetry of the dental arches" consisting in "either a disproportionate growth in the length of the body of the lower jaw, in a lack of development of the upper jaw, in a lack of development of the lower jaw, in a bending downward of the lower jaw at or in front of the angle, or possibly a forward displacement of the upper jaw, or in a combination of these conditions"). Blair's method of treatment was elegant in its minimalism. Stressing that the best cure for such conditions is simple mechanical "prevention" (during childhood, "the bone of the jaw will admit of considerable molding by means of appliances"), Blair described two basic techniques for surgically treating pathological malocclusion in adults. In the case of severe overbite, the operation involved sawing through the mandible at a point well back toward the neck (Blair notes that with the proper saw this takes about forty seconds per side), manually drawing the lower jaw forward until the bite is as well aligned as possible, wiring the jaw shut, and allowing it to heal in this locked position for eight weeks. Moving the lower jaw forward in this way effectively forced bone growth to take place between the two severed pieces--as with flesh, keeping some fragments of cut bone in contact allows "granulations" to fill in the intervening space and so form a "bone-scar" (74). Over time, the gap in the lower jaw fills in with bone, effectively lengthening it and so repairing aesthetic defects along with mechanical ones (opening, closing, chewing, and so on). In the case of severe underbite, the operation is simply reversed: the lower jaw is sawn through at the point where it has overgrown, and a section is removed. The severed surfaces are then brought together, the teeth are wired to hold the jaw in place, and eight weeks later the bone has healed into a shorter, healthier shape.

Blair was the first to describe these operations, and he was also the first to articulate the substantial ethical issues they raised. Such truly plastic surgery, he noted, could easily confuse aesthetics and therapeutics:

Granting that our skill and the condition in a particular case are such that we could shift the chin and jaw to any desired position, it still remains for us to exercise considerable judgment to determine . . . which position will give the most effective facial outline. Ideal occlusion would certainly be a simple guide. It is definite and easily defined, while facial contour is quite the opposite. Most of us who study faces can say what makes or mars them. We also have ideas as to what pleases us, but this is often a matter of taste, and all conclusions are modified by the temperament of the individual observer. (68)

The dangers of allowing personal taste to cloud one's medical judgment are great in such work, as is the temptation to counter such tendencies by relying too heavily on an impossible ideal of perfect occlusion. Even though "occlusion conserves unvarying mechanical principles; while facial contour adapts itself to and portrays the intelligence, the actions, the passions, and the sufferings of the individual and the race," it can be just as distracting as "temperament" when it comes to crafting a functional jaw: "occlusion must be an end, not a guide, while good mechanical and not ideal occlusion should be the object." The surgeon's job is thus to strike a balance between two impossible ideals, the ideal of perfect occlusion, and that of perfect facial symmetry: "our endeavor should be to set the bones in the position that will ultimately give a useful occlusion and the most symmetrical facial outline." While neither mechanics nor looks are reliable guides in themselves, the prerogatives of utility and symmetry line up perfectly--unlike the jaws they correct--every time. So it is that even as mechanical laws temper a surgeon's tendency to impose his aesthetic preferences on his patients, aesthetic principles help him preserve his clinical detachment in the face of a distracting desire to perfect unperfectible bites: "In none of these cases will it be possible to establish immediately the best occlusion, and approximately ideal occlusion would rarely be accompanied with the best facial result. On the other hand, the establishment of the best facial outline will never preclude a good useful occlusion." If concentrating on occlusion prevents the surgeon from becoming distracted by personal preference, then, an awareness of aesthetics prevents the surgeon from concentrating on occlusion to the exclusion of everything else.

Blair's argument depends on an understanding of beauty as a known quantity, something whose contours can be defined with absolute precision and whose existence is, as a consequence, subject to scientific verification. Devoting prime space to the history of beauty--one he traces as a gradual devolution from a long lost ideal--Blair situates the "Greek" as the original point of reference against which all faces must be measured. The Greek is an objective standard; it is simply "the most beautiful type ever recorded" (69). The tautology of Blair's logic, which sees the beauty of an image of beauty as proof of Beauty's essential, constant truth, is enabled by his use of pictures as passive assertions of both the beauty of the Greek type (which is simply allowed to speak for itself) and the place of that type as the mother of all modern faces, the face that is more or less present in every face, and whose look continues to dictate the relative beauties of both individual faces and entire races. Balancing mechanics (which are constant from one jaw to the next) against the visible laws of "beauty" (which, according to Blair, have remained constant since the ancient Greeks first carved them in the figures of marble gods) thus allows the surgeon to reconcile the inevitable gap between the ideal face and the limits of individual faces. Just as he ought to follow established aesthetic criteria when creating new looks ("Artists have formulated laws of correct facial outline that will further guide us in this work" [70]), so must he respect the reality of the face he is recreating: surgeons "must not attempt surgical impossibilities nor be misled by false issues . . . [they] are not called upon to attempt to raise the profile to a position in the scale to which evolution has not carried it" (70). It is thus that the work of improving facial appearance is made as objective as possible.

Blair's surgical innovation was as ontologically significant as it was technically important. He could do things with jaws that no one else could do; and he represented his surgical techniques like no one else had done, framing them as part of an elaborate visual conceit that linked sculpture to surgery by placing pictures of statues and patients side by side. Insisting that he be called a "general surgeon," he sought, like others before him, to promote his particular qualifications as a specialist not by describing them as what they were--hard-won skills in plastic and reconstructive surgery--but by aligning them with an entirely different tradition, that of high art. But unlike Roe, Weir, and Joseph, Blair made no written reference to the sculptural qualities of his work. Instead, he simply printed pictures of classical statuary alongside photographs of his patients before and after surgery. This move from word to image enabled Blair to specify and complicate surgery1s interest in the sculptural analogy, to expand medicine1s artistic claims by locating them in time, in space, and in a particular image of a particular face.

Beginning with the "classic Greek type" (characterized by "high forehead continuous with a long, straight nose, a short upper lip, somewhat retreating and full curved chin, short cranial index, with chin, lower lip, and root of nose all on a line" [68]), Blair's series of pictures traces the gradual devolution of the Greek face as "the increase of license" adds weight to the lower part of the face (69). Moving through its "Russian and Roman derivatives" and on to more modern, "lower" types, Blair's interest is in showing both how far we have come from the ideal, and how "atavistic" faces (by which he means faces with prominent lower jaws) can themselves display a very pretty maxillary prognathism that "is both mixed and modern" (69). In this way, Blair's essay situates the classical statue as an ideal to be studied, emulated within reason, but never actually realized. Modern faces have simply grown too far from it for the situation to be otherwise. The hybrid modern face is thus both a corruption of the ideal and, as the nearest anyone is likely to come to that ideal in the present day, an ideal in itself, the imperfect standard against which to measure the distance between a person1s profile and an ancient model whose timeless beauty is as fresh as ever.

Blair's pictorial sequencing thus situates the contemporary patient as the direct descendant of the classical statue. On one end of his iconography sits the ideal: the head of a Greek statue, a representative of a timeless, universal standard of beauty. On the other end sits the actual: the head of a plastics patient, depicted as "an extreme case" (73) whose exceptional character operates in a similarly representative manner. Just as the "classic type" stands as the impossibly perfect image against which all beauty becomes visible (through its failure to measure up), so the "extreme case" conjures up the extraordinary possibilities of mandibular deformity, evoking, in its singular exaggeration, a host of comparatively minor defects of contour, angle, and alignment. In this respect, the visual trajectory of Blair's illustrations charts what looks to be an irreversible move away from an ideal that has not only been lost, but was probably never embodied in the first place (the Greek type is after all a marble image, and not the skull of an actual Greek).

But what is perhaps most noteworthy about the series is how it seems to shape gross deformity as the beginning of a beautiful reformation. For Blair's "extreme case" has swung so far from the ideal that it actually begins to swing back toward it: there is, after all, a peculiar affinity between the gross underbite of Blair's patient, and the structure of the ideal Greek head, one of whose most prominent features is its receding, distinctly not prominent chin. The visuals thus trace a history of devolution that is also--thanks to plastic surgery--a history of revolution. If the modern face is a far cry from the classical ideal, the pictures suggest, modern surgery can work to close the gap between the two. Moreover, in some ways people with deformed faces make the best candidates for this type of mechanical-historical reconstruction. While it is not medically sound to shorten a healthy jaw for the sake of aesthetics, it is medically inevitable that patients with severe underbite will always have some degree of underbite, even after the most successful treatment. The classic Greek type (or at least its jawline), seemingly lost to a history of degeneracy and racial mixing, thus emerges as a very real possibility at the beginning of the twentieth century. And the seriously deformed faces of those with pathological malocclusion are the ideal materials for making that possibility into a reality.

Or so it would seem in theory. The implications of Blair's pictorial essay are clear enough, but so is the gap between the implied potential of plastic surgery to convert an ugly face into a typically gorgeous one and the reality of Blair's efforts, which do not show a deformed girl becoming a goddess as much as they show her simply regaining some lost function, and recovering some--but far from all--of her looks. Before surgery, severe backward and lateral displacement of the jaw resulting from an early injury had left the patient grossly misshapen and unable to open her mouth more than a crack. During surgery, Blair was able to center her jaw and move it forward three-eighths of an inch, enough to allow her to open her mouth seven-eighths of an inch and to improve, but by no means erase, the problem with her profile. The results were dramatic, but they were modest compared to the visual claims Blair was asking them to satisfy. Shown with neck and bare shoulders draped in folds of white cloth, Blair's patient is a bust as a bust: though the "after" picture shows how well Blair moved her severely underslung jaw forward, the end effect is more to show how far from the ideal she still is--and will ever be--than to show how close to it she has come. Plastic surgery may be a type of sculpture, the pictures assert, but it is an art bent on making the best of very indifferent materials.

Although Blair's essay described a major breakthrough in plastic and reconstructive surgery, it was met with yawns and disappeared into obscurity almost as soon as it was published (McDowell, 260-61). But all of this changed two years later, when Blair revisited both this case and his mode of presenting cases in his "Underdeveloped lower jaw, with limited excursion." Where the 1907 article had made no real impression, this one took the medical community by storm when it appeared in JAMA in 1909. The article centers on the detailed presentation of two cases of severe underbite, supplemented by striking photographs taken before and after Blair lengthened their jaws (see fig. 4). Dropping the lengthy digressions on beauty, degeneration, and surgical philosophy, Blair simply tells the stories of two cases, describing the extent of their original deformity, detailing the simple technique he used to lengthen and realign their jaws, and then enumerating the extraordinary physical and psychological results he achieved in each case. When first seen, Case One (the same patient who was shown up by a statue in 1907), was "delicate, and very thin," able only to open her mouth an eighth of an inch. After the operation, she had not only a "symmetrical chin and an improved profile" but "good health and mental relief," so much so that her "own brother did not recognize her when she returned home and within a few months she gained twenty-eight pounds over her previous weight which she has retained. She has been in good health ever since, which was not the case before, and she seems very happy." The story is not simply that of a young woman's face brought into line with healthy norms, but of a young woman whose facial realignment restores her to life, making her so happy and healthy that she is a new person inside and out. Case Two repeats this logic. Disfigured by scarlet fever so that she cannot open her mouth, Two's lower incisors have been removed to allow her to pass food into her locked jaw. Mildly diabetic, suffering from laryngeal diptheria and given to chronic, suppurating infections, she is even worse off than Case One. But with surgery to bring the jaw forward and implant a new chin, she is entirely rejuvenated.

In contrast to his first essay, Blair's style here is spare, personal, and to the point. His language is plain; he sticks to the facts; his intention is not to theorize but simply to narrate his cases from start to finish. Indeed, he focuses so closely on his two cases that the article is almost wholly unframed. Blair's introduction is of the briefest sort: "My reasons for reporting the two following cases are, first, that one of them is, as far as I know, unique in pathology, and the other presented a degree of deformity that is extremely rare; and, second, that the procedures resorted to for their relief have, as far as I know, never before been employed or suggested except by myself" (257). He never even approaches synthesis, instead stacking the second report on top of the first without attempting to relate them to one another. And there is no conclusion at all. The descriptions of the two cases are simply meant to speak for themselves. The operations are treated as straightforwardly as possible, as logical solutions to a clearly defined, if hitherto baffling, medical problem. The results are their own justification.

The overall effect of this pared-down prose is to turn the scientific report into a kind of latter-day medical fairy tale. Consider how Blair's direct, detailed approach gives the cases a palpably magical quality: two young women suffer years of physical pain, psychological distress, and social isolation because of facial disfigurements; they are resigned to their fates; and then one day, they meet Vilray Blair (their fairy godsurgeon), who puts them under his spell (general anesthesia) and grants their dearest wish while they sleep the deep oblivious sleep of patients etherised upon a table. These are clinical Cinderella stories, grim uplifting tales of how two homely, unhealthy girls awoke one day, like reconstituted sleeping beauties, to a happy ending only plastic surgery could provide. More to the point: they are true Cinderella stories, examples of a modern-day miracle that Blair can apparently work at will.

Blair's use of photography intensified the fantastic effect he created with his prose. Four sets of pictures supplement the text: a set of before and after portraits of Case One, two of which duplicate those that appeared in 1907, a set of before and after X-rays and plaster casts of Case One, a set of before and after portraits of Case Two, and a front view of Case Two demonstrating her newly acquired ability to open her mouth. This time, Blair's patients are not positioned alongside portraits of ideal marble heads. There is no explicit comparing and contrasting to be done; the patients do not appear to fall short of an impossible ideal; there is indeed nothing to be seen here but the plain success of Blair's methods, which evidently return each patient to a very passable, even pretty, profile. But even though Blair dropped the explicit comparisons to classical statuary, he maintained the essential form of that comparison. The cases still appear as draped busts, and as such their transformations take shape, even in the absence of classical models, as classical allusions. Indeed, it is the absence of the classical referent that gives these portraits their particular power. By suppressing actual pictures of statues while posing his patients as statues, Blair effectively eliminated the glaring gap between actual and ideal that marred his first attempt to craft a visual comparison between a sculptor's work in marble and his own work in bone and flesh. Instead, the reconstructed patient becomes the ideal. This effect is particularly strong in Case Two, the perfection of whose final profile is such that, in coming back to life, she seems to come to life as the image of classical statuary. With her high forehead, long straight nose, short upper lip, and--still--somewhat retreating and full curved chin, she is the postoperative analogue of Blair's classical model, a statuesque girl whose recovery seems to be set in stone.

It is tempting--and strangely fitting--to think that the reason Blair's first essay fell on its face was its appearance (or, to be more precise, it is tempting to think the essay fell flat because the unflattering face it holds up as a medical triumph is an aesthetic failure). Certainly Blair's first effort at pictorial work did more to emphasize the distance between his "extreme case" and the ideal Greek type than it did to dramatize the difference his operation made in the health and looks of his patient. He does not even include a formal case history of his reconstructed patient; she simply appears as Figure 8, the last in his series of classically posed busts, and the least successful, even after surgery, of them all. By contrast, Blair's 1909 effort--itself largely a rewrite of his 1907 flop--brought him immediate and lasting fame. Less openly ambitious, it ultimately achieved a great deal more. Blair made no great claims for plastic surgery as he had in 1907, but his understated prose and his carefully composed illustrations effectively classified his work as classical art work. Where others had written about the technical similarities between plastic surgery and sculpture, Blair used photography to frame his work as the logical culmination of the Western sculptural tradition. By converting a technical analogy (the procedures of plastic surgery--chipping, chiseling, shaping, molding--are like those of sculpture) to a more topical one (the plastics patient can be made to resemble a Greek statue), Blair made classical statuary into the reference point for understanding the technical promise and historical place of plastic surgery. In so doing he depicted a revolution in the history of medicine as a revolution in the history of art. Casting plastic surgery as the direct descendant of classical statuary, a hard-earned high art that both embodied sculpture's most basic impulses and perfected its technique, Blair ushered in the modern era of facial reconstruction as an art form whose figurative effects had immediate practical benefits.

Moving from devolution to revolution, failed comparison to striking allusion, Blair hit on the iconography that would sustain the discourse of plastic surgery throughout the first half of the twentieth century. His symbolic constructions were just as influential as his methods for surgical reconstruction, so that by the 1920s, surgical sculpture--originally a passing conceit--was fast becoming a standard description, the terms upon which surgeons explained the real activity of their work. So it was that surgeons such as Jacques Maliniak and Maxwell Maltz could rely on a sort of figural shorthand to rationalize plastic surgery. Writing for less specialized audiences (laymen, social workers, and physicians unfamiliar with plastic surgery), Maliniak and Maltz each used the classical statue as a conceptual touchstone, an established image of beauty that could help establish plastic surgery at the forefront of modern medicine. Maliniak's 1934 book Sculpture in the Living: Rebuilding the Face and Form by Plastic Surgery, for example, made the sculptural analogy into an identity. Using the terms "sculpture" and "plastic surgery" interchangeably in his title, Maliniak openly asserted that plastic surgery just is sculpture, that to talk of one is always also to talk of the other. This assertion is bolstered by the book1s frontispiece, a photograph of the Venus of Capua which, as an exemplar of "Perfect harmony of form and proportion," Maliniak holds up as the image of plastic surgery1s future, the statue that advancing surgical technique promises to bring to life in modern flesh (see fig. 5). Like Maliniak, Maxwell Maltz used classical statuary to represent the ideal face in his 1936 book New Faces‹New Futures: Rebuilding Character with Plastic Surgery, where a photograph of Praxiteles' Aphrodite of Knidos appears as a "typical example of the Greek nose as found in Greek art" (59). (Such noses, he acknowledges, "were probably no more common among the adults of classical Greece than they were anywhere else" [58].) But Maltz also used classical statuary to represent ideal deformities: a bust of Cleopatra appears as the epitome of hooked noses (see fig. 6), a bust of a Roman boy models lop ears (see fig. 7), and a head of an Olympic boxing champion sports a classic cauliflower ear (see fig. 8). (A more modern variation: Guido Mazzani's fifteenth-century terra cotta head of a man with a wart on his nose [see fig. 9].) For Maltz , statuary encompassed not simply the anatomy of beauty (as a model) or the aesthetic techniques of plastic surgery (as a metaphor), but the entire discourse of human appearance. Capable of imaging ideal deformities as well as ideal features, of immortalizing the absence of surgical intervention as readily as it could provide a timeless guide to intervention, classical statuary was the model metaphor for plastic surgery, an explanatory figure that was seemingly as plastic as surgery itself.

Sculpture thus shaped the new art of plastic surgery as a viable medical treatment by sealing it inside an aesthetic that was itself thousands of years old. The face Roe, Blair, Maliniak, Maltz, and others envisioned crafting on injured, ugly, or diseased heads was the face of classical statuary. The weight of tradition embodied in classical statuary anchored what seemed to many to be a flimsy specialty by redescribing its place in time and space: plastic surgery was the culminating moment not of medical science, but of art history, a clinical procedure that could realize an ideal beauty in the flesh. In this surgeons conceived of medicine not as an end in itself but as a means to an end: the art of healing is, in the hands of plastic surgery, a utilitarian approach to the transcendent, greater good of art. And the human body is the scene of a symbolic operation that casts it as a modern alternative to the marblous lineaments of a too, too solid flesh.

Though I have seen my head (grown slightly bald)
brought in upon a platter
I am no prophet--and here's no great matter

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