does it heal the mind?
PLASTIC SURGERY: A NECESSARY VANITY
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.
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
psychoanalyst knows everything but changes nothing. The plastic
surgeon knows nothing but changes everything.’
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?
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.
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.
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.”
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.”
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.
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
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.
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
was joking, but he hit on a change in Brazil’s therapeutic
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.”
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.
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.
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.”
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.”
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.”
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.