Dufourmentel, a pioneer in plastic surgery, said in 1948, "...If
I went to Picasso for my portrait, he would probably make me a
monster and I should be pleased because it would be worth a million
francs. But if Picasso came to me with a facial injury and I made
him into a monster, aha, he might not be so pleased."
This quote expresses the view of the exhibition
that plastic surgery can be a most challenging art form, since
a surgeon's materials are not canvas or clay, but rather the human
body. However, not everything in plastic surgery is necessarily
art. Some procedures are rote, technical mechanics, operations
that can be taught to almost anyone and, if they are performed
as they are taught, the results will always be the same. But those
same routine surgeries can also become something that requires
a great deal of artistic skill depending on the patient's need.
A facelift is a good example. If one understands the anatomy,
performing a facelift is a basic reversal of the process of aging.
Over the years, the procedure has changed from simple skin lifting
to complex plane lifting techniques, where incisions are made
and various degrees of undermining of the skin are performed,
resulting in the deeper layers of the face being lifted. While
this is a routine surgery and there is nothing particularly creative
in the basic process, finding the proper vectors of pull and reestablishing
lost volume in the face does elevate it to an art. Occasionally
there is additional pathology, at which time a surgeon has to
rely on his or her creativity and experience to solve these problems.
When we must borrow tissue from other areas, hide scars in natural
lines that already exist, or create something from nothing, the
more creative the surgeon, the less obvious and apparent the procedure.
There are some procedures that are inherently
creative, whether because of the anatomy involved or the surgical
plan, and always because of the fact that the surgeon is working
with parameters that are bounded by blood supply, type of tissue,
and the quality of skin. Rhinoplasty (a nose job), for example,
can be an extremely altering procedure requiring a keen artistic
sensibility in the surgeon. This is often considered one of the
most difficult procedures to teach in plastic surgery because
each nose is unique, sharing only the similarities of having a
bridge and a tip. Older surgical techniques involved shaving off
the hump, cutting down the cartilage and then breaking in the
walls of the nose, leaving it lacking structure and support. This
was standard procedure and it was done relatively inartistically
by plastic surgeons for decades, leaving many patients unable
to breathe through their noses. However, modern plastic surgery
addresses rhinoplasty in a much more creative and functional manner.
Noses may have a bulbous tip, or a large hump, or a wide bridge
with essentially no hump, and to recreate and reshape such a nose
becomes an artistic process with an architectural fundamental
principle of "form follows function". The surgeon must reestablish
a bridge that is contiguous by reducing a dorsal hump and rebuilding
from cartilage from within before infracturing the bones. In order
to design a tip, a stable tripod must be created out of the existing
anatomical structures. The surgeon has to sculpt it from one side
to the other, shorten it, shape it, actually carve the cartilage
and score it to help it bend in certain places, and then secure
it with sutures and sometimes additional cartilage. For this,
a surgeon must have an innate three-dimensional vision in order
to create a defined tip that may be vastly different from what
one is starting with. The surgeon must also reduce the nose in
a proportion that fits the uniqueness of the face and adheres
to the "rule of thumb" by da Vinci (locating the nose at one-third
of the face). The surgeon must then streamline the nose so it
balances with the remainder of the face to create a pleasing aesthetic.
Interestingly, sometimes this also involves adding a chin implant
to achieve balance so that the focal point of the face as a whole
does not suddenly point towards the nose. In the end, all aspects
must come together to create a new proportion and balance to the
face, one that is defined as an aesthetic within our society.
Another example is breast reconstruction
from cancer. Today, we perform "immediate breast reconstruction"
where the breast is rebuilt immediately following a mastectomy
(breast removal). The general surgeon leaves most of the skin
envelope into which the plastic surgeon places a breast implant
or tissue from another area of the body. While this requires skill
and experience, it has limited creative potential. On the other
hand, there is a far greater challenge when the patient has had
a complete mastectomy and has been treated with radiation and
chemotherapy. Not only will the patient's chest now have an unsightly
crater from the breast removal, but her body has also been visually
ravaged from the drugs, radiation and scarring. The plastic surgeon
must rebuild a breast by establishing a new skin envelope, creating
something from nothing because the radiated tissue must be cut
away as poor blood supply generally limits its use. Tissue with
its own blood supply must be fashioned using a paddle of skin
and fat from the patient's belly based on a muscle "leash". The
paddle of skin is shaped into a breast that matches the other
breast, in a constant balancing act so that the final result will
be symmetrical and natural in appearance. This is a creative process
that extends to almost all levels. The surgeon uses a perfect
blend of reconstructive and aesthetic techniques to reestablish
a balanced bosom and take advantage of the donor site to create
a rejuvenated abdomen. Liposuction can then be used to fine-tune
the sculpture of human flesh back into a woman who is no longer
just surviving but now "living."
For surgeons, some of the most artistic
procedures are found in microsurgical techniques where tissue
is transferred from one part of the body to another based on establishing
a new blood supply. This allows the surgeon to reestablish tissue
in another location that can be rebuilt into something else; for
instance, in a situation where a tumor has been cut away in the
mouth, a leg bone can be transplanted in the face to recreate
a mandible bone, along with a paddle of skin that is cleverly
placed to recreate a new internal lining of the mouth. This is
all dependent on the blood supply, and the new tissue is sewn
into arteries existing in the neck whereas originally the arterial
blood supply came from the leg. In such situations, surgeons must
have the knowledge and the sensitivity to be able to harvest the
bone with profound knowledge of the anatomy and limited donor
deformity while also reshaping the bone to emulate the mandible.
The initial patient evaluation and the surgery
plan requires the studied eye of a trained artist. Leonardo's
anatomical drawings and investigations are not dissimilar to the
scrutiny of this process. The execution can best be described
as a well-choreographed ballet of many different steps. Through
this dance of medicine and art, science and aspiration, surgeons
seek an outcome as beautiful as any painting or sculpture. Every
day, we strive to outdo Pygmalion. Is perfection possible? We
know it's not, and yet, that's our calling. We work with terrible
constraints, not the least of which is the subjective nature of
art itself. Nowhere are human feelings more various and more complex
than in perceptions of the body and of the self. We are, all of
us, acutely aware of how others see us. Physical things become
emotional things. Some patients want to regain the beauty of their
youth; others require reconstruction after illness or physical
trauma; and still others seek a means to correct natural deformities.
All hope to be able to look in the mirror and see what they expect
to see. The restoration of confidence and self-esteem that surgeons
witness in post-operative patients is an art form in its own.
Our field is sometimes associated with excess.
This exhibition aims to convince you otherwise. For each individual
committed to our charge, the stakes could not be higher. This
show conveys the great care with which surgeons diagnose, counsel,
prepare, execute and maintain our artistic creation, with vision,
clarity, passion, ingenuity, compassion and, yes, art. Certainly
there are pictures of the grotesque scary traumas and cancer defects.
There are also pictures of the beauty that is the human form,
in all of its various shapes and sizes. As surgeons, we sometimes
have to take two steps backward to take one step forward in generating
a plan to bring tissue from one part of the body to another part
of the body, essentially bringing the clay to the sculptor, where
it will be shaped and molded, created into what it needs to be
for the patient. In the gallery space, you will have a glimpse
into our world, which is never our world alone. Ours is truly
the most intimate, the most personal, of arts. When we are finished,
the product of our labors can turn to us and say, "I am art."
That, at least, is what we strive for.
Anthony Berlet, M.D.
The doctors and apexart
would like to thank all of the patients who agreed to allow their
images to be used in this exhibition.
This exhibition contains content that may
not be suitable for all viewing audiences. Please use your discretion.
and public programs are supported in part by the Andy Warhol Foundation
for the Visual Arts, Carnegie Corporation of New York, Edith C.
Blum Foundation, Mary Duke Biddle Foundation, The Greenwich Collection
Ltd., The William Talbott Hillman Foundation, and with public
funds from the New York City Department of Cultural Affairs and
the New York State Council on the Arts. Special thank you to Direct
Dimensions, Inc. (3D model).