An Old Idea Revisited: Reflections on the Role of Aesthetic Surgery in Behavioral and Social Change

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On May 26, 2015, Plastic Surgery News featured the article from the Burnaby Now, “BBC Team Searching for Prisoner-Patients Given Cosmetic Surgery for Behavior Modification,”2,3 regarding a 1950s study that observed the impact of cosmetic surgery on the recidivism rates of criminals. As the Burnaby Now article references, in North America at that time, the Oakalla prison study was one of several ongoing projects looking at similar issues. Although the notion that an individual’s morality can be changed from bad to good solely with a procedure that improves physical appearance is controversial, the relationship between appearance and behavior is complex and pertinent to an individual’s psychology and quality of life. Where plastic surgery comes into play, as either treatment or adjuvant therapy, remains to be determined.
In the 1950s, the philosophic mindset was framed by Darwinist influences of the nature-versus-nurture debate,4 Healey’s theories of adolescent psychology,5 and Lombroso’s individualization of punishment.6,7 These revolutionary ideas in social theory, highlighting the importance of physical appearance, sparked the interest of plastic surgeons. With this in mind, Dr. Bankoff in 1952 performed a pilot study using four inmates who underwent cosmetic surgery for congenital and acquired facial deformities.1 He reported strikingly positive behavioral changes immediately after surgery, including the cessation of criminal behavior.1 This positive behavioral change was accredited to the patient’s improved self-esteem and confidence. Thus began a series of studies performed from 1950 to 1980, investigating the impact of surgery on behavioral change in prisoners.1,8
Dr. Lewison in Vancover, British Columbia, Canada, conducted a study at the Oakalla prison published in 1965. The project was entitled “Project in Reconstructive Facial Surgery” and involved 450 subjects from 1953 to 1963.8 Male and female inmates volunteered to be evaluated as potential subjects for cosmetic surgery. Over a 10-year period, 450 elective operations were conducted at the prison. The procedures were performed mostly for nasal deformities. Lewison reported a general improvement in the behavior, with an immediate increase in cooperation with authority and participation in prison activities. The recidivism rate was 42 percent for the 450 subjects, compared with the general population rate of 75 percent at that time.
Examining the rationale and outcomes for studies such as Bankoff’s and Lewison’s exposes the fundamental significance of physical appearance in our behaviors and our perceptions of behaviors. The relationship between an individual’s physicality and their morality is unclear. However, many agree that physicality contributes to personal self-beliefs and our perception by others, which in combination shape our behaviors. For example, efforts are made to encourage the removal of tattoos in former gang members, to help them integrate into society.3 Removing visual signs of a person’s past, such as tattoos, scars, and needle tracks, can help him or her make a new start in life.
The old question of nature versus nurture in the formation of an individual’s psychological framework remains unanswered. The power of self-esteem makes physical appearance an influential force in our lives. How surgery can be used for positive psychological and behavior change warrants further investigation.
Criminals may be merely unfortunate people who, because of some congenital or acquired defect, have a grudge against the World.… In such cases, almost from the hour the disfigurement is corrected, the cause of the long-held grudge disappears, and, with time and patient understanding, the man concerned is encouraged to take his place in society again.
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