Short Notes in Plastic Surgery

June 11, 2014

47. Essays on Aesthetic Surgery

Filed under: Chapter 47 — ravinthatte @ 9:05 am

Essay on Aesthetic Surgery – Part 1

Assuming that liposuction is performed for either excess or unwanted fat the propositions that such accumulation of fat is the result of your genetic makeup, your lifestyle or is the result of disease or age needs to be sidelined. Instead what emerges is the principle of personal autonomy where you take decisions notwithstanding the above propositions in order to satisfy your ideas of how one should appear in front of the mirror and to the public at large. Frequently these ideas are moulded by what the society dictates or suggests in a subversive manner.

The example of liposuction was incidental because the principle extends to the whole body. The trenches of personal autonomy are now not only well dug but are also strongly fortified. The self-actualisation that is inherent to personal autonomy is also influenced by time, in another sense, in that, to quote a cliché, ‘time waits for no one’. A modern accent on youthful appearance had its origins in wanting to feel young as long as possible and that want is related to the instinct for survival. That instinct is as old as life. A paradigm shift in the recent past is to try and appear youthful either by medical or surgical means to match how one feels or conversely to feel younger by changing to a youthful appearance.

Perhaps a note on two philosophers of the 19th century might help us understand why aesthetic surgery has so taken over the human mind and his body as well. William James (1842-1910, USA) the originator of the pragmatic school famously said that we cannot reject any hypothesis if consequences useful to life flow from it, God hypothesis included. He was perhaps echoing what John Stuart Mill (1806-1873, England) said earlier, “pleasure is the only thing desired and therefore pleasure is the only desirable thing”. Bertrand Russell (1872-1970, England) of the mathematical party of philosophers, a libertine with a free spirit himself (from whose history of western philosophy I quote the above philosophers) would have agreed with them and the three of them would have endorsed today’s sexual revolution including gender assignment surgery (here too plastic surgeons now play a part).


Here in India, Mahabharata (written by the legendary Vyasa before the Christian era), the longest epic ever narrated in the history of mankind, a vast treatise on altruism also reveals hidden sinister nuggets such as only the rich and the powerful can think of philosophy, the poor and the wretched are too busy eking out a living to even think. That rule of averages in pediatric practice “one he walks and two he talks” can be altered to “first the existential walk, then soon money starts to talk”. Descartes (1596-1650, France) who promulgated the famous axiom in Latin, “I think therefore I am” forgot to tell us in plain English, “I look at myself in the mirror because I am”.


The Second World War exhausted many a country in the western world except the United States where the earlier mentioned William James, a pragmatist, lived before the wars. In fact he is one of the few noted philosophers from that country and he would have been pleased to see his pragmatic doctrine flower and bloom so luxuriatingly in his country. Aesthetic surgery fits his philosophy splendidly. As the rest of the world took to formal, liberal, capitalistic democracy and disposable incomes rose, even for the middle classes, the pleasure principle came into play. All in all even in the developing (!) world the demand for this surgery is burgeoning. And as one Indian plastic surgeon said recently, and perhaps inadvertently, but honestly, and I quote, “the customer is always right and we must cater to his needs as best as we can.”

The plastic surgeon now views this scenario as a fate accompli and not as a very undesirable one at that either. Money talks and talks loudly. Many a website of plastic surgeons frankly quote their fees and, as if this was not enough, even standard texts include this information. Fortunately, the plastic surgical principles are suited to this kind of surgery in terms of craft and skill and some plastic surgeons have scaled great heights in these specialities. One beneficial side effect of the emergence of aesthetic surgery has been a closer look that surgeons have taken at anatomy particularly that of the breast and the face.

Ravin Thatte
Compiler of these Short Notes


Essay on Aesthetic surgery  Part 2

“No man is an island”, said John Doe nor is a plastic surgeon. We might imagine that we are moulding and shaping human bodies but the under current is much deeper. It is the attitudes in the society which shape our actions. The end of the second world war was a watershed in the history of the modern world. The death of fascism gave birth to liberal values amongst the victors so much so that Churchill, the arch conservative who led England to victory was voted out even before the war was completely over and Atlee the liberal, labour leader replaced him because the voters were looking forward to reconstruction without a heavy hand. The thought about a new form of freedom was present in the whole of the western world and a new social contract was in the offing. The United States enjoyed an unprecedented economic boom and Hollywood was one of its symptoms. The middle classes formed a very broad swathe of the American society, they had disposable incomes and Hollywood as well as all other art forms which included advertising first showed and then moulded ideas of how to dress, how to appear and what constituted attractiveness. From mere cosmetics to cosmetic surgery was a natural progression. The words aesthetic surgery later gave it more dignity. The seeds of aesthetic surgery we in fact dormant in Germany (and probably Europe), for example, Joseph and his rhinoplastic. But Joseph had to flee Germany when the Nazis took over. This was an example of freedom in peril. Post war the ideas of freedom prevailed over most other things in the western mind and the colonies followed suit. During this era, Cronin introduced the silicone breast implant and the flood gates of aesthetic surgery opened. The rest is history. But even here the second world war has a connection. The polymer-silicone (from silica) was introduced by F.S. Kipping in England and was originally used in the windscreens of fighter aircrafts during the war. From there it became part of intra-ocular lenses or artificial joints and at one time was injected sub-dermally by plastic surgeons.

As aesthetic surgery became an important part of our speciality, it generated volumes and also money for professionals as well as healthcare providers and producers of various products. In the beginning and even to some extent now, training in accredited educational programmes in the western world, aesthetic surgery is not a compulsory part of the curriculum. But to a great extent the needs for training in aesthetic surgery are being met by many private clinics who offer fellowships or preceptorships which in turn are recognized by national bodies. Private wings of public hospitals also serve a training base.

Nature abhors a vacuum. When the demand is overwhelming, it gets fulfilled one way or the other. In India there is enough evidence to conclude that the worthies and heads of departments of plastic surgery in general hospitals performed aesthetic surgery in private hospitals but either hid the fact or denied it but what was worse, refused to reveal the tenets of the technique to their students. But that stratagem was bound to fail. Denial of knowledge never works. Those who seek that knowledge will get it any way elsewhere. All that happened in the Indian scenario was that the teachers fell in the eyes of the students. What was perhaps needed was to embrace the speciality, create small institutions to practice it and then create a body of students so that we would not have been overtaken by those who advertise the specialty surreptitiously, start fly by night clinics in which these characters employ ghost plastic surgeons for a pittance.

This essay cannot be complete without a word about ideas of beauty. It has now been proved that even children respond positively to attractive, well proportionate faces and bodies. This certainly does not come about by the influence of media. That a certain form or a figure or a face is more appreciated than others and are then reproduced is evident across the world be they be in India (Konark or Khajuraho) or as drawn in the Churches wherever Christianity prevailed through antiquity. Ideas of beauty are deeply entrenched in the human psyche and surgery is a recent tool by which man wants to enhance it. Does the plastic surgeon have a right to preside over that emotion and then deliver philosophical bombast?

I think not. However the plastic surgeon is perhaps best suited to decide on what is not feasible or what is dangerous. With these two exceptions everything else that a patient asks for should be provided if the price offered is suitable.

Mukund Thatte
Formerly, President of Association of Plastic Surgeons of India, also
Formerly, President of the Association of Cleft & Craniofacial Surgeons of India.


Essay on Aesthetic surgery  Part 3

Traditionally plastic surgery had come to mean reconstructive surgery for congenital or acquired deformities including those caused by trauma. Aesthetic surgery per se or in its pure form is probably the youngest and now a very vigorous branch of plastic surgery and was born out of a desire in people to improve their appearance from what can be labeled as “within normal limits”. The art and craft of “cosmetics” or adornment of bodies has been practiced for millennia probably stretching back to prehistoric times. Now we have aesthetic surgery as well which is only an extension of that age old urge and practice.

Life cannot escape evolution or change. Strangely, change is the only permanent thing in our affairs. From survival (of the fittest) and procreation in numbers (for safety and kinship) to long-term planning for food and shelter and later economic development, societies have gradually evolved into what is called stable civilizations. It was only when stability was achieved that man could turn his attention to himself and then come to scrutinize his “persona”. This was in fact waiting to happen because knowingly or unknowingly “aesthetics” rule all aspects of our life. Because economic development was not uniformly spread, attention to the “aesthetic” was also uneven. The more affluent societies turned to it earlier and even within single societies the wealthier had more time and opportunity to indulge in aesthetic pursuits.

Even in the field of reconstructive surgery when functional restoration was accomplished refinements in what was an adequate result were sought for and achieved. After micro-surgical techniques revolutionized transfer of tissue there has been a constant endeavour to achieve a pleasant result in terms of contour and colour match. Correction of a micro-form cleft lip, even the mildest form of ptosis of the eyelid without visual impairment, reconstructing a breast after a mastectomy at an age when it is not considering a functional organ, revision of burn scars which do not impair function or replanting the smallest distal bits of digits are only some examples where surgery is performed for aesthetic reasons.

A normal and pleasing appearance is sought by one and all because the aesthetic principle rules all aspects of our life, be it clothes or ornaments or the insides or the immediate outer environment of our institutions or homes. We are a very observant species and are attracted by the beautiful and repelled by the ugly. Our affairs are dominated by how people appear. We adore pleasant faces and well sculpted bodies and our society is inclined to give an extra quarter to those who please us with their beauty. Unfortunately the reverse is also true. Everything else being equal the not so good looking or ugly (!) is likely to lose in a competitive world.

A crooked or a flat or even a very large nose, a woman with very small or very big breasts, morbid obesity, a hanging lower belly, premature signs of ageing or tired looking puffed up faces or eyes, just to give some examples are subject to a second and not a very polite look. In fact they too look at themselves in the mirror suffering a great deal because they may be healthy but are not considered as acceptable. The purpose of aesthetic surgery is to improve the form and appearance of these individuals and thereby improve their image in the eyes of others and in their own minds. This ushers in a sense of confidence improving their prospects in society be it marriage, employment or relationships. This is also an existential phenomena.

Nothing survives in this world if it is not needed. That is how modern societies function. Supply is the result of demand and the fact that aesthetic surgery is booming simply proves those rules. On the way the plastic surgeon must be very vigilant about a psychological condition called ‘body dysmorphic disorder’ in which a patient imagines a blemish which doesn’t exist. These patients may not be easy to spot but can be almost always recognized if the surgeon spends enough time listening to them at length and with patience and also makes a point to find out their previous surgical history. On the other hand even small errors in this field can rarely be hidden and might raise the hackles of a normal aspirational patient. This speciality is exacting and demanding and so are the patients. Extreme diligence and exceptional skill however does bring handsome rewards.

The tendency amongst some, particularly of the earlier generations, to be smug about this speciality or even to smirk at it is not only doing no good to our speciality but might mean that aesthetic surgery will fall in the hands of those who have no aptitude or training to practice it, but indulge in it as commerce. Reconstructive surgery is not going anywhere. This is not about one against the other. To be ostrich like can only mean that we will lose out to those who are less equipped to practice this speciality.

Milind Wagh
Microvascular and aesthetic surgeon
Member, Executive council, Association of plastic surgeons of India, 

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