Contents
Cosmetic Treatment
in the Pre-surgical Era . . . 320 The First Operations
on the Eyelids with Cosmetic
Effects . . . 320 The Evolution of Face-lifting . . . 322
320
Cosmetic Treatment in the Pre-surgical Era People were using beauty treatment and trying to keep their youthful looks long before cosmetic surgery ap
peared on the scene. The Ebers papyrus [271] contains instructions for women on how to paint around their eyes with green pigments and Pliny the Elder [790] later wrote that the Roman women “…smeared white lead on their face and in their hair”. They also used arsenic sulphide on their faces in spite of the fact that it was known to be dangerous, for he wrote that it was “…useful for giving a woman a fair complexion but like scum of silver it is a deadly poison”. It appears that women have always been willing to accept some risks in order to appear beautiful.
Facial wrinkles were a topic of interest for Paulus Aegineta [3–5]. He suggested “…rubbing the skin with a lozenge made from shavings of ivory, fish gelatine [ich
thyocolla – isinglass] and frankincense”.
We have already seen how certain surgeons from the thirteenth century onwards paid attention to the aesthetic effects of scars. In the sixteenth century, Gaspare Taglia
cozzi who was probably the first to consider the psycho
logical effect of an ugly scar wrote “We restore, repair and make whole parts of the face which nature has given but which fortune has taken away, not so much that they may delight the eye but that they may buoy up the spirit and help the mind of the afflicted” (translation from the origi
nal by Robert Goldwyn). Tagliacozzi explicitly mentioned eyelashes and eyebrows, as well as the consequences of age on the face, but although he had suggestions on how to improve appearance he never contemplated surgery.
Throughout the centuries much has been written on beauty and how to preserve it and the works of Giovanni Marinello (sixteenth century) and Giovanni Tommaso Minodoi (1540–1615) deserve mention [610, 678]. The former suggested recipes for the face and for keeping one’s figure, declaring that a liquid extract of eufrasia leaves served to cure swollen eyelids while a wax prep
aration containing hioscyamus could eliminate any small wrinkles around the mouth. One hundred pages of his book1 deal with the appearance of the facial skin, and how to counteract the effects of ageing, sunshine, ill
ness and scarring (Fig. 14.1a,b). According to Marinello, powdered stags’ horn mixed with broad beans was an
efficacious remedy for facial wrinkles. Reading through his book one cannot help notice how the promises of cosmetic products have not changed much throughout the years and that female vanity has always been submit
ted to temptation.
In that same period, Minodoi did not consider beauty and remedies to preserve it but discussed the ugliness caused by diseases like trachoma affecting the eyelids and ageing producing senile ectropion. He suggested various remedies to hide these effects, but did not con
sider surgery.
John Bulwer (c.1654), while describing “the absolute perfection of the woman’s face”, expressed outrage at all the cosmetic remedies made available for avoiding the ef
fects of ageing, trauma and various diseases, saying “It is a wonder that this corrupted custom of painting hath so long escaped general law, both of the Church and of the State, which have been very severe against the exces
sive vanity of apparel. And the wonder is greater how it hath escaped Ecclesiastical censure, since all the fathers of the Church have strongly enveighed against forged and feigned beauty, and the practice of introducing other than the one provided by nature.” [143]
The First Operations on the Eyelids with Cosmetic Effects
From remote times physicians have understood the im
portance of beauty and have made attempts to help re
store and preserve it but there are no traces of surgery ever being performed for purely cosmetic reasons until the late nineteenth century. We have already seen that surgical procedures on the nose undertaken to cure dis
eases or to correct traumatic deformities also produced improvement in appearance but the same cannot be said of the face with certainty. All the procedures performed on the eyelids illustrated in the tablets found in Meso
potamia might possibly be included in this category and they were considered so delicate and difficult that their cost was “sufficient for paying for the construction of a house” [953, 954]
In previous chapters we have seen how Paulus Aegine
ta [3–5] devised special “scalpels for plastic operations”.
1 See Ornamenti delle Donne, Book III.
These were used for treating ectropion, entropion and lagophthalmos, all pathological conditions producing symptoms. The operations carried out by Avicenna (980–
1035 A.D. [41, 42], Ibn Roshd (1126–1198) and Albuca
sis2 (936–1013 A.D.) [15–18] would certainly have had beneficial cosmetic effects. In fact, these surgeons noticed that excess skin in the upper eyelids was a hindrance to sight, so they removed it and eliminated the bagginess.
Several centuries later, Lorenz Heister (1683–1758) performed surgical procedures to correct the effects of ageing on the eyelids, though he did not refer explicitly to aesthetic effects. He first applied various balsams (one was called Water of the Queen of Hungary) and when these failed, said “…then we have to rely on—and it is a wonderful effect—very cautiously cutting with the iron all excess of skin so that the skin itself is reduced closer
to a natural status” [422–424]. He did not say that his in
tention was to make the eyelids more beautiful, but that was the result. The technique he used was very simple:
“…when the eyelids were swollen and relaxed … excis
ing the excess with either the scissors or the knife”.
Another century lapsed before G.J. Beer [66, 67] pro
posed another similar technique for correcting baggy eyelids, and in the nineteenth century Alibert (1832), von Graefe (1836) and Ammon and Baumgarten (1842) used modified versions of this operation [24, 25].
This takes us to the period when general anaesthesia3 and antisepsis4 made major differences to surgical prac
tice. Before there arrival the risks of a painful operations for purely cosmetic reasons were too much for most pa
tients or their surgeons to contemplate. The coinciden
tal cosmetic benefits of surgery for pathological reasons
2 Albucasis used cauterization to treat relaxed eyelids.
3 Nitrous oxide was introduced in 1819 and ether in 1848.
4 Antisepsis was conceived by Lister in the 1860s but did not enter general use until the 1870s.
Fig. 14.1 a Frontispiece of Giovanni Marinello’s book Gli Ornamenti delle Donne published in 1574 in Venice. b A page from the book where he describes the nightly application of a herbal infusion to improve the effects of aging. Courtesy of Riccardo Mazzola, M.D., Milan
322
were well recognized but this did not induce surgeons to attempt surgery for merely cosmetic reasons. Further
more, this was the time when surgeons were becoming familiar with reconstruction of faces destroyed by can
cer. So, when anaesthesia and antisepsis started to make surgery a safer less painful undertaking the door was opened. These factors induced Denis Montandon and his colleagues to say: “The development of cosmetic surgery for correcting blepharochalasis is closely tied to … re
constructive operations on the face “ [687]. We will talk about Madame Nöel later in the chapter. She performed cosmetic surgery from the early 1920s and her eyelid operations are illustrated in her book (Fig. 14.2a,b).
The Evolution of Face-lifting
At long last, operations for the sole purpose of improv
ing appearances came on the scene in 1906. That year, Charles C. Miller [668–672] published his first work on the cosmetic correction of eyelids. This was followed by another a year later. The indications for his operations were purely to improve the looks of his patients. The fact that Miller started these procedures in Chicago was not just by chance. As Blair O. Rogers [853] pointed out, Chicago “… has always been the epicentre of North American folklore, folk songs, folk poetry and folk medicine”. Furthermore, this was the city where a series of instruments and gadgets were produced, promising outstanding results for eliminating wrinkles, reducing stout stomachs or increasing small breasts! Miller, un
like the charlatans of those days who worked the beauty parlours in various guises, had attended regular courses in medicine and had gained his MD. All the same, he was not averse to risky commercial pursuits like open
ing up a series of drugstores where prescriptions of a dubious scientific nature were dispensed. Patients were always willing to accept strange potions that promised to improve their looks, even if they were dangerous and sometimes lethal. This appears to have been the case of a wellknown farmer who died in 1911 after taking some of the socalled black pills sold in one of Miller’s drug
stores. A court case followed and Miller was accused of selling medicines without a physician’s prescription, but the prosecution was dropped.
Despite this rather shady side to Miller’s career, it must be granted that his influence had the beneficial effect of encouraging American medical spheres to accept cos
metic surgery. He accomplished this not only by working vigorously but above all by publishing his experience in highly esteemed medical journals and reviews. His most productive year was probably 1907, when he published a series of 29 articles on the cosmetic correction of the nose, eyelids, lips and ears (Fig. 14.3). In the following year he published again on blepharoplasty. As already mentioned in the introduction to this section, like many others he fell to the temptation of using paraffin though he caused no more damage than his colleagues.
Eugene von Hollander (1867–1932) was one of the German surgeons who helped introduce cosmetic sur
gery to the scientific world [444]. Among other oper
ations, he was a pioneer of facelifting. He excised 5cm
long strips of skin which curved along the hairline and the natural folds of the face so that the scarring was less conspicuous. He sutured without undermining, simply inserting oblique stitches to lift the skin laterally. At the time there were few other techniques but although he performed these operations in 1901 he failed to publish his results until much later and other practitioners were deprived of his experience.
Another author who reported on new facelifting techniques was Erich Lexer (1867–1937). Noticing that simple excision and direct suturing of the defect brought only shortlasting benefit and the wrinkles re
appeared he made Sshaped excisions in the temporal region in front of the ears and elliptical excisions along the hairline and the forehead. This was very similar to Hollander, but the important difference was that he undermined a large area of skin before suturing the wounds. In addition, he sutured the skin behind the ear to the rigid mastoid periosteum. Here again, Lexer could have promoted cosmetic surgery if only he had published his new technique and the improved results at the time. It appears that he used the technique for the first time in Würzburg5 during 1906 when he operated 5 Before studying medicine, Lexer had been a pupil of the Sartt College of the University of Würzburg where his father was a professor of German and where he learnt sculpture and painting.
Fig. 14.3 Diagram of Carl Miller’s face- lift procedure. From Cosmetic Surgery:
the Correction of Featural Imperfections, 1907 [670]. Courtesy of Riccardo Maz- zola, MD., Milan
Fig. 14.2 a Pre-operative and b post-operative views of Madame Nöel’s patient following a blepharoplasty. Courtesy of Riccardo Mazzola, M.D., Milan
324
on a famous actress. She had used a complicated system of sticking plasters and elastic bands around her head to tighten her facial skin for many years prior to the oper
ation. But Lexer delayed publishing these results until 1931, 25 years later, because he too was fearful of criti
cism from traditional medical spheres [561].6 Raymond Passot (1889–1933), a pupil of Hippolyte Morestin was another who played an important rôle in establishing cosmetic surgery [772–776]. The excellent reputation that he earned working on the wounded during the First World War encouraged him to continue with facial re
construction and he published his experiences in 1919 in Le Presse Médicale, one of the most important French medical journals. His technique involved excising mul
tiple small pieces of skin from selected points on the forehead, scalp and preauricle regions that held up the facial skin when sutured. He used delicate fine horsehair stitches in an attempt to produce less noticeable scars (Figs. 14.4, 14.5).
At this time the general public were aware of the im
pressive work done on the faces of the war wounded. But they still had difficulty making the step from necessary surgery to an operation done on the face with no medical purpose in mind. Their appearance was important and the psychological benefits of this surgery was recognized but there was still a good deal of reluctance perhaps borne out of the fear of criticism. Luckily, progress in other areas, especially in the United States helped reverse this situation but it took time.
The advent of effective local anaesthesia and surgery performed in the privacy of the surgeon’s private clinic helped. This was how Adalbert G. Bettman (1883–1964) worked. He employed 2% cocaine mixed with adrenalin and excised long strips of skin from the temporal region, down in front of the ears, curving below the lobes and ending behind them. He anchored the skin with very fine silver pins in the mastoid region, suturing the rest with fine horsehair [88]. He considered his bandaging 6 This delay was recorded by Converse, Morello and Guy in 1972 [193].
Fig. 14.5 Frontispiece of Passot’s book Chirurgie Esthétique Pure from 1931 in which he describes cosmetic surgery for the face, nose and breast. Courtesy of Riccardo Mazzola, M.D., Milan
Fig. 14.4 Passot’s face-lifting method using multiple skin ex- cisions. Courtesy of Riccardo Mazzola, M.D., Milan
method to be very important. The results were published in the respected journal Northwest Medicine and dem
onstrated that he had standardized a technique that pro
duced good repeatable results.
In 1919 Julien Bourguet was another surgeon who con
tributed in the field of blepharoplasty [126, 127]. He car
ried out meticulous anatomical studies on periorbital fat, describing two compartments in the upper eyelid and was probably the first to suggest the removal of herniated fat.
He used a conjunctival approach, a method that was also employed and publicized widely by S. Castañares [162].
J.R. Lewis [558] however declared that Sichel [923]
had already described herniation of orbital fat as far back as in 1844, but Bourguet was definitely the first to intro
duce its excision in routine blepharoplasty procedures.
He also deserves credit for the accurate photographic records he compiled.
Jacques Joseph (1865–1934), besides being a famous pioneer in the field of rhinoplasty also performed face
lifting procedures [477, 482]. Unfortunately, he was another who feared public castigation and delayed re
porting his first case, a 45yearold woman on whom he
operated in 1912 until 1921 (Fig. 14.6). This is surprising since Joseph was a supporter of correcting deformities to relieve psychological suffering. His firmly held beliefs led to his dismissal from the orthopaedic clinic directed by Professor Wolf, as it was in this department he had oper
ated on the child with protruding ears.
Harold Napier L. Hunt (1882–1954), who published a book on surgery in 1926, proved to be a great help to plastic surgery because he was editor of The American Journal of Surgery and other prominent scientific pub
lications [455]. His reputation gave weight to his opin
ion. In 1934 in The Task of the Plastic Surgeon he wrote
“…the cosmetic branch of plastic surgery is indeed a branch in itself. Though the facial work is of great valid
ity and value it is but a branch of an intricate, difficult and most interesting type of surgery.” Some years later in 1939 he gave an interview to the New York Times and said “Most of us think of plastic surgery as a sop to van
ity. Actually the plastic surgeon is kept busy more by the victims of accidents who need rehabilitation than by mo
tion picture celebrities who do not like their nose or their jaws are beginning to sag.”
Fig. 14.6 Joseph’s face-lifting technique. The incisions became widely accepted. Courtesy of Riccardo Mazzola, M.D., Milan
326
In Europe during the same period a lady surgeon came to the fore. This was a great novelty at the time as women rarely practised medicine let alone surgery. Her name was Susanne Blanche Marguerite Gross and she was born in Laon in the Aisne region of France. She used the name of her second husband, Andre Nöel, a physi
cian. With her book La Chirurgie Esthètique et son Rôle Sociale, which was immediately translated into German, Susanne Nöel (1878–1954) became a famous cosmetic surgeon not only in Europe but elsewhere in the world (Fig. 14.7). She pioneered the rights of women to under
go cosmetic surgery and helped establish facelifting as an accepted technique [736, 737].
Dr. Nöel began her medical career in the dermatol
ogy department of the wellknown Professor Brocq but in 1908 she began working in Hippolyte Morestin’s clinic and became interested in aesthetic surgery. During the First World War she treated the wounded and developed her reconstructive skills. Her first husband, Henri Pertat, died of gas poisoning during the war and she married Dr. André Nöel, one year later. Her interest in the ageing
of facial skin was kindled in Professor Brocq’s dermatol
ogy clinic and in 1923 she started performing operations on tattoos, protruding ears and keloid scars.
When Susanne was 35 she learned that Sarah Ber
nhardt, the famous actress, had undergone a facelift through a scalp approach in America. Mme Nöel had performed experiments on rabbits and believing their skin to be similar in elasticity and consistency to that of the human face, she began studying the effects traction had on different parts of her own face. Then inspired by the technique described by Passot she devised a series of tiny excisions that she called “interventions timides”
(Fig. 14.8).
In the end she plucked up courage and called on the actress. Here is the translation of her description “After experiments on anaesthetised rabbits, I noted that their skin was similar in thickness and elasticity to the human and I decided to operate on the aforementioned actress.
In a very charming way, she explained what they have done in the United States. This was different to what I had in mind. In fact they had excised a strip of skin from Fig. 14.8 Sarah Bernhardt by W. & D. Downey. (platino-type panel portrait, 1890s). National Portrait Gallery, London Fig. 14.7 Madame Nöel at her desk. Courtesy of the Soropti-
mists’ Club of Italy
one ear to the other within the scalp. If the result had been fairly good for the upper part of the face, mini
mizing the wrinkles of the forehead and abolishing the crow’s feet, the lower part of the face had not been modi
fied at all.” The actress “…captivated by the explanations of the means by which I hoped to correct ageing skin folds, became one of my first patients” [851].
She described her experience and techniques in her first book, published in 1926, which contains a large number of photographs taken before, during and after surgery. It also covers other aspects of plastic surgery besides the face. However, the most remarkable and revolutionary part is her psychological analysis of her patients.7 Nobody with the possible exception of Taglia
cozzi had ever considered this aspect and he expressed his opinion many years before in a simple yet sympa
thetic way.
It was admirable that a female surgeon, a rarity in it
self, had the courage to publish her ideas at a time when, as Stephenson said “… surgeons such as Vilray Blair, FerrisSmith, Robert Ivy, Sir Harold Gillies and others performed this surgery but did not it consider worthy of reporting… “ [954].
At times during the first half of the twentieth cen
tury, many modifications were described and classified as new techniques [517]. A list of names referring to all of these is unnecessary since T. Rees and G. La Tenta [831] published an extensive review of the literature in 1954, concluding that only inconsistent modifications to previous techniques had been described. But there were exceptions, like Castañares’ method for baggy eyelids [160–162] and others proposed by V.R. Pennisi and A.
Capozzi for transposition of fat in facelifting [789]. The most significant advances during this period were prob
ably those made in anaesthesia and the control of bleed
ing which allowed wider undermining of the facial skin.
The situation was different during the second half of the century and during this period very significant advances were made. One of the first was the suspen
sion of the muscular fascia, suggested by Fomon and then Fomon, Bell and Schattner [327, 328] in the 1950s and 1960s but carried out in 1969 by Tord Skoog (1915–
1977) (Fig. 14.9). In his articles [937, 938], Skoog ex
plains that nobody had realized the importance of J. Conley’s [189] theory that “…not only are skin and subcutaneous tissue intimately related to each other to form a compound morphology structure” but, above all, this includes “the superficial fascia”. The anatomy of this layer had actually been studied in 1919 by G. Sterzi [958]. He illustrated very clearly its important role but, as happened before and since, his paper on anatomy in Italian was overlooked by most surgeons. Skoog put these ideas into practice and noticed that by pulling on the orbicularis and/or platysma muscles the cutaneous wrinkles and folds were greatly minimized and the final result lasted longer. This revolutionary idea convinced surgeons that smoothing out the skin by simply excis
ing it was no longer sufficient in the long term. Repo
sitioning of the superficial fascia and the muscles be
came routine in facelifting and the new method was
7 Dr. Susanne Nöel was one of the founding members of the Soroptimist Club in France in 1924, taking part in pioneering cru
sades for equal rights and female independence.
Fig. 14.9 Tord Skoog (1913–1976), Professor of Plastic Sur- gery in Upsala from 1960. Courtesy of the Skoog family
328
acknowledged and accepted by many surgeons. Many articles on this topic ensued, and the anatomical study by Vladimir Mitz and M. Peyronie in 1976 coined the term Superficial Musculo-aponeurotic System now known as SMAS [680].
Another new technique that appeared during the early 1960s which is probably attributable to several American surgeons including Frederick Grazer was the bicoronal
incision in the hairline [193] a procedure borrowed from the emerging craniofacial surgeons.
Neck liposuction combined with facelifting as pro
posed by B. Teimourian [976] and by C. M. Lewis [557]
in the 1980s really falls outside this historical review.
This technique must join other more recent develop
ments like endoscopic dissection and subperiosteal lift
ing as sub judice for the moment.
