The History of Rhinoplasty ⑪ — How we came to change our noses at all

This is the hardest part of the series to write. Because I am inside it.

Korea is often mentioned as a country with a great deal of cosmetic surgery relative to its population. Among those operations the nose, with the eyes, is the commonest.

Two explanations usually go round about this. One is “because Korean doctors are skilled.” The other is “because of obsession with appearance.”

I think both are half right.

The skill was the result, not the cause

It is true that Korean rhinoplasty technique has become refined. But it is not that the technique came first and created the demand. The order is the other way round.

When there are more operations, the operator’s experience accumulates, difficult cases collect, and the methods for handling them grow finer.

When there are more revisions, revision technique develops. The technical accumulation of Korean rhinoplasty is in large part a product of demand.

So “we do a lot of it because we are good at it” comes close to inverting cause and effect. The question is still there. Why did so many people want to change their noses?

A society in which the face became a resource

From here on this is probably not a medical question but a social one.

Korea is a society that grew in a compressed span of time. The gap between generations is wide, the expectation that an individual could rise was strong, and the competition was fierce at the same time.

In a society like that people mobilise every resource they have. Education, qualifications, language scores. And appearance went onto that list too.

For a long time a photograph was attached to a résumé. Impressions were remarked on at interviews.

In hiring for service work, looks were sometimes written down as a condition. There was certainly a period when appearance was treated not as taste but as a qualification.

In such a society cosmetic surgery becomes not vanity but a rational choice. I really do hear this in consultations.

“I think I look all right, honestly… it’s just that people around me keep telling me I come across a certain way.”

Do you take that as one person’s vanity? Standing where I stand, hearing it as often as I do, it does not sound like that to me at all.

Part seven repeats itself here

In part seven I told the story of Jacques Joseph.

In early twentieth-century Berlin the shape of a nose was treated as a mark identifying a Jew, and people underwent surgery to escape that gaze.

There was a question I put then. Was it the nose that needed to change, or the gaze?

A hundred years later the same question repeats in Korea. What the mark consists of has changed; the structure is the same.

Society attaches a meaning to a particular appearance, the individual carries that meaning, and medicine resolves it for them.

There is a part here where I have to be honest. I work inside that frame, right at the front of it.

I say the gaze ought to change, and I make my living operating on the noses of people who find the gaze hard to bear. I am not going to claim I can do anything about that contradiction.

So what can be done

Still, I do not think there is nothing at all that can be done from where I stand.

First, to say that surgery is not the answer for everyone. If I judge in a consultation that surgery is unnecessary, I say so. This is less a grand conviction than the fact that if I became a doctor who could not say it, I would no longer be able to explain what it is I do.

Second, not to claim that what cannot be changed can be changed. Far more often than not, fixing a nose does not change a life. What surgery resolves stops at the nose. Anyone who comes expecting more than that has to be told so.

Third, to recommend choices that can be undone. This is what I have repeated in the earlier parts.

Finally

I am not especially glad to hear it said that Korean rhinoplasty is world class. Because the sentence stops people asking how it got that way.

The accumulation of technique is something to be proud of. At the same time, laid underneath that accumulation is the time of a great many people who had a hard time because of their faces.

The reason Sushruta gave a nose back, and the reason Joseph spoke of psychological effect while he operated, come to rest in the same place after all.

A person stands in front of the world with their face. Even if that is unjust, for the person standing there right now it is the reality.

What a doctor can do is probably about this much: not to disregard that reality, and at the same time to tell them it is not the whole of it.