It is important to note that most plastic surgeons practiced both reconstructive and cosmetic surgery during this period. In fact, Harold Gillies developed a robust cosmetic surgery practice after World War II, partially because he could not otherwise retire comfortably. Archibald McIndoe also developed a busy cosmetic surgery practice, becoming known for his “McIndoe Nose” which distinguished those patients who underwent rhinoplasty surgery with him.
Cosmetic plastic surgery was widely considered a “lesser” specialty and was ridiculed for focusing on largely healthy patients. The level of scorn directed toward the physicians who practiced cosmetic plastic surgery varied depending on their level of self-promotion as well as their level of engagement with the lay public. Facial plastic surgery in the late 19th and early 20th century was most often employed to “pass” in public, to blend in rather than stand out. This had both positive and negative connotations and may also have contributed to the fact that many of the plastic surgeons performing cosmetic surgery at the time were considered charlatans.
John Orlando Roe, an ENT surgeon from Rochester, became known as the father of cosmetic rhinoplasty, publishing papers on modifying the nasal tip and bridge in the late 19th and early 20th century. He initially became known for treating collapsed nasal bridges, called a saddle nose deformity, in patients who contracted syphilis. There were severe legal restrictions in the United States to advertising as a physician at the time. He was considered one of the more noble cosmetic facial plastic surgeons because he did not advertise and was not ostentatious.
The German plastic surgeon Jacque Joseph was a European contemporary of John Orlando Roe. Like Dr. Roe, Jacque Joseph espoused the psychological benefits of cosmetic plastic surgery. Dr. Joseph was initially allowed to operate only at Jewish hospitals due to the antisemitism prevalent in Germany during this time. In fact, Jacque Joseph maintained dueling scars on his face to better “pass” in German society and avoid this. He even had requests from others to create “dueling scars” on their face to better “pass” themselves. However, even the Jewish hospitals eventually banned him from operating because he was performing cosmetic plastic surgery.
Professional opinions about him changed when World War I broke out and his expertise was required to treat the war-wounded. He was recruited to work as the Director of Facial Plastic Surgery at Charite Hospital in Berlin during the war. He transitioned to private practice after World War I to refocus on cosmetic plastic surgery. His innovations included techniques to reshape nasal bones during rhinoplasty (osteotomies). He also performed facelifts and body plastic surgery. He became internationally renowned, drawing even Americans to visit him. He was reportedly very secretive, having his nurse keep his instruments under towels to prevent visitors from copying his designs. His great contribution to the medical literature was the textbook Rhinoplasty and Other Facial Plastic Surgery published in 1931. This textbook was the first to include photos of post-operative patients smiling after their recovery.
Another great European facial plastic surgeon of the early 20th century was the French physician Suzanne Noel. Born in 1878, she came of age in La Belle Epoque when the women’s rights were improving in France, which likely influenced her drive. She married Henry Pertat, a dermatologist 9 years her senior, at age 18. He was able to start a dermatology practice with family money. French law at the time dictated that women needed permission from their husband to attend medical school. Laws even required husbands to be informed of where their wives were going and the “general spirit” of any conversation they had with others outside of the house. Fortunately for the world, Henry encouraged Suzanne to pursue medicine.
Suzanne passed the externat to function as an extern at Paris Hospital in 1908 at age 30, the same year she gave birth to her daughter Jacqueline. After 2 years as an extern and earning high marks in her testing she started a 4-year internship as a resident physician. She worked in the public hospitals in the morning and at her husband Henry’s dermatology practice in the afternoons.
Her two most influential teachers during her internship were Hippolyte Morestin and Jean-Louis Brocq. Hippolyte Morestin was a French surgeon who became famous during World War I. He was especially concerned with reconstructive surgery and the concealment of scars. He taught Suzanne to be decisive and to take risks in the operating room. The Spanish flu would kill Dr. Morestin in 1919, a tragedy that would befall her daughter in 1922. Jean-Louis Brocq was a dermatologist who first exposed Suzanne to cosmetic plastic surgery. She developed an interest in cosmetic plastic surgery after being visited by the famous actress Sarah Bernhardt, who had undergone a brow lift by the plastic surgeon Charles Conrad Miller in Chicago. She felt she could have done a superior job. Dr. Brocq allowed her to perform cosmetic surgery procedures on volunteer patients during her internship.
Suzanne ran her husband’s dermatology practice when he left for the front lines during World War I. Unfortunately, he suffered from chlorine gas exposure while testing gas masks, which permanently disabled him. He was forced home from the front lines in 1918 where he died from respiratory failure.
Suzanne married Andre Noel, her medical school classmate and close friend, in 1919. Like her first husband, Andre pursued dermatology. In fact, Andre took over Henry’s dermatology practice after he died. This is partially because, at the time, a woman could only practice medicine under a male physician’s license. Suzanne could run the dermatology practice but was not allowed. Suzanne gave her medical school thesis – a device that used air pressure to spray jets of medication impregnated water on the skin of patients – to Andre so he could run the dermatology clinic. The couple would later commercialize and sell the device.
Andre became depressed after Jacqueline’s death and committed suicide in 1924. Left with a dermatology practice she could not run because she never submitted a thesis (women could practice independently with a license now), Dr. Noel quickly wrote a thesis on the topic of the big toe, partially to slight the leadership at the University of Paris for previously restricting her practice of medicine. She would acquire her medical license in 1925, allowing her to run the dermatology clinic.
Her cosmetic surgery practice quickly became popular, which allowed her to pay off the enormous debts Andre had accumulated during his depression. She operated out of her apartment in Paris near the Hotel George V, because cosmetic plastic surgeons were generally not allowed to operate in hospitals in France at the time. She eventually outgrew her apartment, moving her private practice to the prestigious Clinique des Bleuets. She also promoted the practice of cosmetic plastic surgery around Europe, advocating the psychological benefits of plastic surgery like Dr. Roe and Dr. Joseph. She travelled to Germany to advocate for the founding of a Department of Social Cosmetics at the Institute for Dermatology at the University of Berlin. Berlin was one of the few places in the world where cosmetic surgery was considered acceptable as a form of “mental hygiene.” This was during the time that Jacque Joseph was becoming famous for his rhinoplasty techniques while practicing in Berlin.
Dr. Noel published Aesthetic Surgery and its Social Significance in 1926. This textbook was immensely popular, being translated into other language and further establishing her reputation. Her contributions to the field of plastic surgery were numerous. They included the pioneering use of long, elliptical incisions along the hairlines during face lifting operations. She invented the craniometer, a device which allowed her to measure facial dimensions more precisely. She improved on a now-common approach to lower eyelid surgery and the facelift. Probably most importantly, she successfully combined local anesthetics with epinephrine to reduce bleeding and improve patient comfort during surgery, a generally accepted practice today.
She also took a more patient-centered approach to practice and teaching. She was one of the first surgeons to include actual photos of the steps of her operations in her textbook. She discussed surgical options and expected results with her patients. She allowed her patients to decide between local and general anesthesia. She was obsessed with concealing the effects of surgery, going so far as to formulate tinctures matching various hair colors to dye the bandages she placed on patient’s hairlines. She also provided tea and lunch to her patients after surgery.
It was for her accomplishments that she was awarded The Order of the Legion of Honor in 1931, a rarity for women in France.
In contrast with Drs. Roe, Joseph, and Noel, Joseph Sheehan was considerably showier and more ostentatious. He was born in Dublin, Ireland in 1885 and emigrated to the United States. Relegated to poverty after the death of his father, he managed to gain admittance to Yale Medical School and trained with Harold Gillies at Sidcup during World War I. He returned to the United States and practiced in New York City. He became enmeshed in bad press after inviting a New York Times reporter back to his office after a lecture he was asked to give to the New York City Police Department. The reporter described the extravagance of his office rather than the lecture he was being interviewed about. He also attracted considerable controversy because he was a supporter of the Spanish dictator Francisco Franco, helping to organize hospitals and train surgeons in Franco’s army.
Joseph Sheehan was deeply connected to the concept of the use plastic surgery to “pass” in society. Convicted criminals sought out facial plastic surgery in the early 20th century to escape detection by authorities. Dr. Sheehan was giving a lecture to the New York City Police Department about what could and could not be accomplished with plastic surgery at the time so that the police force could better detect individuals attempting to evade them. This panic is what led to European and American criminal authorities to tattoo convicted criminals.
One of the most famous examples of a criminal undergoing facial plastic surgery to evade the police was John Dillinger, the leader of the Dillinger Gang which robbed banks and police stations during the Great Depression. John Dillinger was arrested and killed in 1935 along with the plastic surgeon who performed a rhinoplasty and facelift on him to conceal his identity. Even J. Edgar Hoover became involved, warning plastic surgeons of the risks in aiding criminals. A more modern example is the drug trafficker Richie Ramos who underwent rhinoplasty, liposuction, and excision of gunshot scars from his face to evade the police. He and his plastic surgeon, Dr. Jose Castillo, were arrested in 1997 for obstruction of justice.
There was not only a concern in the early 20th century that criminals would undergo facial plastic surgery to conceal their identity. Some also theorized that one could change criminality by changing the appearance of criminals. In fact, some prisons offered to pay plastic surgeons to operate on jailed criminals. One example was a pilot project at San Quentin in 1927 examining the rehabilitative effects of facial plastic surgery which was initiated by the convicts themselves. As expected, this project would prove unsuccessful.