The anxious production of beauty: Unruly bodies,surgical anxiety and invisible care

Abstract

This study is based on ethnographic fieldwork at a plastic surgery clinic in Seoul, South Korea. Examining the three phases of plastic – consultation, operation and recovery – I show how surgeons work to shape not only patients’ bodies but also expectations and satisfaction. Surgeons do so in part to assuage their own anxieties, which arise from the possibility of misaligned beauty standards and unforeseen anatomies, as well as the possible dissatisfaction of the patient. I offer the concept of ‘surgical anxiety’, which occurs in relation to inherently unruly patient bodies in which worries, fear, frustration, self-pity, cynicism, anger and even loneliness are symptomatic. The unpredictability and uncontrollability of patients’ bodies, which generates anxiety for both patients and surgeons, work to constrain the power of plastic surgery and making it inherently vulnerable. This study also pays attention to the invisible work of taking care of surgical anxiety, as practised by female staff members, and surgeons’ dependence on these workers. My focus on anxiety is a kind of remedy for the predominant concern with ‘ambivalence’ in constructivist science and technology studies; rather than continue to highlight the power differentials between experts/practitioners and lay people/patients, this study illuminates surgical anxiety as their shared vulnerability. Thus, this study proposes a new politics of care in technoscience and medicine, which begins with anxiety.

Keywords

body affect care feminist science and technology studies plastic surgery

Introduction: ‘I did this to be pretty but…’

Ms Ahn,¹ a professional woman in her mid-20s, was suffering from an infection after having ‘two-jaw surgery’² 3 months earlier. When I cautiously asked about conducting a formal interview with her about her experience of plastic surgery, she said, ‘I came here because of the infection. The level of my satisfaction with surgery is extremely low at this moment. I did this to be pretty but … [silence] I don’t think I’m in the right condition for an interview.’ At her follow-up consultation, her surgeon, Dr Kim, examined the inside of her mouth, and then told her that his month-long antibiotic treatment had failed to cure her infection; he would now have to resort to surgically removing the infected tissue from her cheeks. Dr Kim explained, ‘As I did for the previous operation, I will open the surgical site again, scrape out the infected tissues, and close it. It’s basically the same process as the operation you had before.’ I was struck by the hardship that Ms Ahn had to endure. The surgery would be performed under general anaesthesia, take hours to complete and it would be weeks before she was fully recovered. Most patients who had undergone two-jaw surgery told me that they would never do it again, no matter what. Ms Ahn’s face gradually became distorted and tears started to run down both her cheeks. Dr Kim let her cry for a few seconds, and then made a nurse beside him wipe the tears from her face.

During this consultation, I was reminded of an informal meeting with Dr Kim a couple of days earlier. Dr Kim had invited me and a few other staff members to have dinner with him after work, something he did on occasion. When I arrived at a local restaurant near the clinic, he had already drunk a half-bottle of Soju – a high-proof Korean liquor – by himself. ‘Shit, I’m out of luck!’ he said. ‘I’m afraid that she will file charges against me.’ He then said that plastic surgeons were haunted by the fear of lawsuits, and that they rarely received gratitude or respect from their patients although they made the utmost effort to perform operations to the highest standards. I felt for him, and for Ms Ahn.

I was not the only person who cared about them; staff members and nurses, whose job was actually to care for both the surgeon and the patient, were also affected. At the plastic surgery clinic, people called ‘patient managers’ are involved in all pre-operative and post-operative processes, arranging operating schedules, caring for patients before and after surgery, and assisting communication between patients and surgeons throughout the process. Ms Suh, Dr Kim’s patient manager, knew the most about Ms Ahn, including her family relations and personal schedule. Ms Suh was also aware of some of the factors that influenced Ms Ahn’s decision to have plastic surgery, and of the latter’s efforts to take care of herself after surgery; these led Ms Suh to suspect a lack of self-care during Ms Ahn’s recovery period. Ms Suh said,

I was worried when she texted me to ask if it was ok for her to drink wine only fifteen days after the operation. Then, it was not even a month after surgery when she went on a trip to Australia!

Ms Kwon, a nurse who routinely assists Dr Kim in surgery, told me that she did not see or do anything abnormal during Ms Ahn’s operation, but was told by Dr Kim to re-sterilize all the surgical tools to prevent future infection. Making beauty involves dealing with unpredictable bodies, which demands care from practitioners such as patient managers and nurses behind the scenes. Neither the unpredictability of the body nor the work of care involved in the production of beauty has received much attention in the scholarship of plastic surgery.

This is a story of how beauty is produced, as a simultaneously standardized and individualized outcome of plastic surgery, and of the anxiety that such production entails. In contrast to previous work on female patients and their consumption of plastic surgery, which focuses on the ‘the downstream effects on women’, this article pays attention to the production of plastic surgery, and the male plastic surgeons and female workers who work ‘upstream’ (Clarke, 1998: 24). I followed what surgeons did every day in their clinic, as opposed to how people talked about plastic surgery. The main parts of this article are two-fold. First, I show that plastic surgery realizes neither socially forced beauty norms nor personalized beauty ideals, but it produces a beauty somewhere in-between them. Plastic surgery is not a mere technology: the patient and the practitioners choreograph multiple practices to create beauty. Second, I reveal anxiety-producing situations for both patients and surgeons during plastic surgery practices. Throughout the whole process of plastic surgery, unpredictable and uncontrollable human bodies make plastic surgery networks inherently ‘leaky’ (Ormrod, 1995). This kind of leakiness requires the work that female care practitioners do to relieve ‘surgical anxiety’. The relation of anxiety to care provides new insight into the gendered dimension of plastic surgery and points to some vulnerabilities of male and medical power. Before going to these two main sections, I introduce the concept of ‘anxiety’, particularly instead of ‘ambivalence’, as a tool to make new accounts for medical practices and then briefly describe my ethnographic fieldwork. In my conclusion, I suggest some political implications of writing about the anxiety surrounding sociotechnical and biomedical practices.

‘Surgical anxiety’: Beyond ambivalence

This study emerges out of feminist ambivalences towards plastic surgery: one either criticizes or celebrates it. Most studies of plastic surgery have focused on women and their use, or consumption, of medical technology, their motivations in pursuing beauty and the political implications of having a plastic body. While many studies have highlighted structural forces along ethnic and gender differentials as forcing women to seek medical intervention,³ some have called attention to women’s rational decision-making and agency in actively reconstructing the body as they desire (Davis, 1995, 1997; Gimlin, 2006; Pitts-Taylor, 2007). A few scholars have gone further, proposing that plastic surgery allows women to alter their bodies in resistance to dominant beauty norms, those defined around whiteness and the male gaze (Balsamo, 1996; Morgan, 1991). The French artist Orlan, for example, made her face monstrous and grotesque through a series of plastic surgery performances, which were seen as ‘the feminist redeployment of cosmetic surgery’ (Negrin, 2002: 31).⁴ Plastic surgery has thus been interpreted as a powerful tool both for and against women. Indeed, the ambivalence of science, technology, and medicine in general is found in the history of feminist science and technology studies (STS). For instance, Judy Wajcman (2004) expresses concerns that feminist STS has unproductively oscillated between optimism and pessimism and proposes examining sociotechnical practices in more concrete ways to overcome this binary thinking.

Attention to ambivalence resonates with feminist critical engagements with the agency versus structure frame, which is also found in recent studies of plastic surgery (Fraser, 2003; Pitts-Taylor, 2007). As meanings of plastic surgery and subjectivities of plastic surgery patients are unstable, negotiable and changeable, the ambivalence becomes inherent in plastic surgery practices (Pitts-Taylor, 2007).⁵ Plastic surgery is seen as both ‘desirable and problematic’ for women (Davis, 1995: 180, italics in the original): it can be both structural and individual, oppressing and emancipating, and forced and actively chosen. Exploring these ambivalences has been productive in revealing complex features of practices of plastic surgery (Davis, 1995; Pitts-Taylor, 2007). In the end, analyses of ambivalence lead to attempts to make it otherwise.

Despite its usefulness, ambivalence has shown its own analytical and political limits. The foregoing stories of ambivalence have tended to focus on differences rather than connections between laypeople (in this case, usually women) and experts. Successful scientists are described as negotiators and strategists: for them, therefore, ambivalence can be generated and used as a social device to justify experts’ knowledge or practices (e.g. Gieryn, 1983, 1999; Latour, 1988). The story of ambivalence can be a good tool to show how a network is made durable (Singleton and Michael, 1993); however, it is a story of weak construction because it neglects connections between experts and laypeople – not only of their interests and capacities but also of their sufferings and vulnerabilities – and thus leads to a political impotence because it tends to secure power differentials between them (Hirschauer and Mol, 1995; Lohan, 2000; Whelan, 2001). For instance, scholars have shown that UK general physicians made their cervical screening programme effective both by making their female examinees feel empowered as active participants and also by capitalizing on examinee’s feelings of disempowerment as objectified, sexualized bodies (Singleton, 1996; Singleton and Michael, 1993). In this kind of study, a network is reduced to a matter of translations, legitimization and negotiation among different actors and women’s ambivalent engagement with medical technology is subsumed under the power of scientists and doctors.

This study offers a different kind of story, that of anxiety, and more particularly, surgeons’ anxiety. In common usage, ‘anxiety’ has many different meanings, including ‘a state of agitation, being troubled in mind, a solicitous desire to effect some purpose, and uneasiness about a coming event’ (Tyrer, 1999: 3–4). During plastic surgery practices, surgeons feel agitated over, troubled by, and solicitous or uneasy about their patients (see also Mol, 2008b, 2009).⁶ Anxiety is inherent in the condition of being a medical doctor as their knowledge, expertise and practices always require the existence of the other – patients. In this study, I call anxiety caused by the uncontrollable and unpredictable nature of the body during surgical practices ‘surgical anxiety’. A number of previous studies have attempted to humanize medical doctors and challenge the image of biomedicine as an abstract and rational system (e.g. Gothill and Armstrong, 1999; Graham, 2006; Nettleton et al., 2008; Wallace and Lemaire, 2007). Surgical anxiety in this study, however, is not reduced to a psychological or emotional trait. Anxiety is neither specific to an individual nor dependent on contexts: it is an affect, not an emotion, which is structured beyond situations (Schrader, 2015). To put it another way, surgical anxiety explains surgeons’ psychosocial and emotional responses to unexpected choices, bodies and patient actions, which I illustrate in the later parts of this article. It directs attention to the assembling of neglected elements, experiences and relationships (Puig de la Bellacasa, 2011). This study suggests surgical anxiety as a useful concept for engaging seriously with scientists and medical experts, and for enhancing the accountability of their practices (Gomart, 2004; Mol, 2008a; Waldby, 2000).

Surgical anxiety leads to a new story of medical power, a story of a surgeon’s dependence on other, rather than his management of them. Along the way, I pay attention to actors who have received less scholarly attention than have surgeons and patients: female practitioners who perform care work. Expressions of surgical anxiety, such as frustration, loneliness and fear, demand spontaneous responses of care, involving ad hoc discernment of and judgment about contingent and heterogeneous conditions. A plastic surgery clinic thus needs ‘invisible technicians’ (Shapin, 1989), such as patient managers and nurses. Susan Leigh Star (1991, 1995) argues that a formal, stable network cannot be maintained without the ‘private suffering’ of actors, and describes the ‘invisible work’ required to reduce those private struggles, such as the work of nurses behind formal medical networks. Building on Star’s research, I introduce surgical anxiety, to connect surgeons’ work both to patients’ unruly bodies and also to other practitioners’ care work. Surgical anxiety is thus a device to make invisible care work visible and to find connections among different actors in everyday medical practices.

Lastly, surgical anxiety has broader political implications. Paul Atkinson (1995) argues that most clinical studies only reinforce boundaries – between the professional and the layperson, biology and culture, disease and illness – by focusing on the asymmetric and hierarchical relationship between doctor and patient. Unlike the story of ambivalence, which often highlights differences or confrontations between laypeople and experts, the story of surgical anxiety points to the connections, mediations or entanglement between them, through their shared vulnerability. Surgical anxiety is shared by doctors and patients because the unruliness of the body affects both of them: what is not controlled or predicted by medicine means undesired results. For instance, if surgery fails to cope with unruly bodies, patients may end up with no medical options to fix their problems, may suffer from unexpected side-effects or health risks, or feel unhappy with the final result. Surgical anxiety is ‘being able to suffer’ (Derrida, 2008: 28, cited in Schrader, 2015: 674), which is not a matter of knowledge and power. Shared vulnerability thus creates possibilities for new power dynamics, while also acknowledging existing power differentials (Oudshoorn, 2001). By exposing the anxiety of the expert, this article shifts plastic surgery from a ‘matter of concern’ for women to a ‘matter of care’ for all, including medical experts, practitioners and patients (Puig de la Bellacasa, 2011).

Situated fieldwork at a plastic surgery clinic

I conducted intensive, long-term ethnographic fieldwork at Y Plastic Surgery Clinic (pseudonym) in Seoul, South Korea, from October 2008 to September 2011. I participated in clinical practices, social gatherings and various events, inside and outside of the clinic. I observed numerous operations, pre-operative consultations and post-operative care procedures, and often had casual conversations with patients, surgeons and other staff members, in operating rooms and consultation offices. I attended internal staff training events, medical conferences, promotional seminars organized by pharmaceutical companies, beauty industry-related expositions and business meetings with foreign business associates and surgeons. My observation, photography and recordings of clinical practices were permitted by all surgeons and relevant staff members in advance. Sometimes, I asked for ex post facto approval of my uses of private conversations for research purposes.

My fieldwork is partly auto-ethnographic. Like Ms Ahn, I underwent a two-jaw surgery and mandible reduction surgery on 10 May 2010, at Y Clinic. During the operation, my maxilla and the mandible were rearranged, in order to correct problems with my oral structure and to improve my facial contour. Mandible reduction is a procedure to reduce the width of the lower jawbone to create the so-called slim chin line. This surgery was accompanied by pre- and post-orthodontic treatment, which spanned about 23 months, and I had to do extensive self-care for 2 months after the operation.

At Y Clinic, there are three surgeons, Drs Park, Lee and Kim. All are Korean men in their mid-forties, board-certified plastic surgery specialists and educated by reputable medical schools at private universities in Seoul.⁷ Although the number of staff members varies due to high turnover, there are usually four patient managers, one or two patient coordinators (assistant patient managers) and three or four nurses at Y Clinic. During my research, all nurses and patient managers were women.⁸ Among them, three patient managers, Ms Choi, Ryou and Jung, held university degrees; two nurses and one of the patient managers, Ms Suh, studied at a 2-year college; and two nurses were high school graduates. In South Korea, there are two types of nurses, auxiliary nurses (ANs) and registered nurses (RNs): ANs obtain a license after 1 year of training in private nursing institutions or upon graduating from 2-year colleges, while RNs hold a bachelor’s degree in nursing from 4-year universities. All of the nurses at Y Clinic were ANs. The only patient manager with expertise in medicine was Ms Ryou, who used to work as a head nurse at a mid-sized gynaecology hospital. Patient manager Ms Suh had years of experience working at one of the major Korean airlines, Ms Choi had worked for a hair salon owned by Dr Park’s wife and Ms Jung was trained in acting. There were visible markers that distinguished patient managers from nurses: while nurses wear a casual uniform of loose T-shirts, trousers and comfortable shoes, patient managers dress up, wearing tight-fitting skirts, blouses and shoes with heels. Patient managers had a certain amount of autonomy to negotiate surgery fees with patients – plastic surgery is fully commercialized in Korea.

By having multiple roles in the clinic, I was able to build strong rapport with surgeons, nurses and patient managers. At the beginning of my fieldwork, Dr Park offered me a position that entitled me to perform the administrative duties of the patient coordinator role, assisting patient managers. While I answered phone calls, gave directions to visitors at the reception desk and delivered messages and orders between staff members, I was called ‘Coordi L’. But when surgeons and other staff wanted to have personal conversations with me, they often called me ‘Doctor L’. There were multiple, shifting hierarchies in the surgeons’ relationships with me, from surgeon-to-staff member (very unequal) to senior-to-junior colleague (somewhat unequal) to medical-to-social-sciences-expert (relatively equal). Not least of all, there was the surgeon-to-patient relationship, in which I became a vulnerable body. As I encountered the uncontrollability and unpredictability of my own body and engaged in the process of rebuilding post-operative bodily integrity, I experienced anxieties, worries and frustrations, as well as a sense of accomplishment and empowerment.⁹ As a semi-practitioner, researcher and patient, I was able to have ‘touching vision’ (Puig de la Bellacasa, 2009), to see the anxieties that linked medical work and the different bodies of patients, surgeons and other practitioners.

The multiple production of beauty

Plastic surgeons act on multiple bodies – the body that a patient has, the body that a patient is and the body that a patient does (Mol, 2002b; Mol and Law, 2004). Beauty is produced and maintained through self-conception, physical being and consistent effort (Featherstone, 2010). At Y Clinic, the surgeons’ day is divided between pre-operative consultations, operations and follow-ups (or ‘dressing’). During the consultation, the surgeon negotiates the patients’ expectations around appearance. The operation is a unique intervention on both the anatomic and the metabolic body. Follow-ups involve encouraging a recalcitrant, recovering body to align with expectations. In this section, I describe how surgeons interact with the multiple bodies of the patient and, in turn, how the patient constructs beauty in multiple ways. I have found the doctor–patient relationship more cooperative than not, as both actors generally work towards the same objective of making beauty (Mol, 2002a, 2009).

Consultation: Synchronizing ways of seeing

The consultation is a prerequisite for any surgical operation. It is a decision-making process for both the surgeon and the potential patient, to find out whether the latter will become a good plastic surgery patient (Pitts-Taylor, 2007). During the consultation, the patient’s body is abstracted from everyday life, and recontextualized in a medical space. Some of this abstraction is accomplished before the consultation, because Korean popular culture is rife with both idealizations of beauty and advertisements for plastic surgery. Nonetheless, patients’ observations of their bodies are biased by personal judgements, psychological issues or norms associated with self-esteem, opinions of family and friends, and workplace expectations. Consultations make the body commensurable with a fixed aesthetic vision, by synchronizing the patients’ perspective with the surgeon’s.¹⁰ This process is especially critical for Dr Kim, whose operations mostly involve cutting facial bones and modifying facial structure.

When the consultation begins, Dr Kim takes photos of a patient’s face, from the front and the side. Then, he frames a computer-generated sample of a human face as a geometrical grid and, with reference to photographs of celebrities, defines beauty in terms of facial geometry:

We can make patterns from anything. We can for faces too. … If we look at someone’s face from the front, his or her face can be divided into three spaces, such as upper facial part, middle facial part, and lower facial part. We can say the normal proportion of three parts is 1:1:1; however, in a beautiful face, the ratio of lower facial part is usually less than 1. … It’s said that this part [below the lower lip] should be longer than that part [the philtrum] to look beautiful.

At this point, he displays the photos of the patient’s face on the computer screen, and proceeds to dissect her facial geometry and explain how to make it conform to the beauty standards he has just established:

The biggest characteristic of your face is [that] the middle part of your face is long. Your philtrum is long too. Most people think double eyelid surgery and a nose job make you pretty, but no, if you want to look pretty, the balance [of your face] is the most critical.

By the time a patient decides to have surgery, it is assumed that she shares the surgeon’s view of her face. In the case above, the patient went in thinking she needed fat injections in her cheeks. Dr Kim convinced her that she needed to adjust the vertical proportion of her face. He finally advised her to undo a previous rhinoplasty, and forego fat injections. Another patient praised Dr Kim’s consultation in an exaggerated tone, saying, ‘he totally changed my eyes to see the world’. Before changing the patient’s body, the consultation works to change the patient’s vision.

Surgery: Routinized double depersonalization

The cooperative work between the surgeon and the patient continues in the operating room. Before surgery, the surgeon employs basic medical procedures, like chest X-ray and blood tests, to collect and record information about the patient’s physical body – diseases, allergies or a surgical history. During medical operations without general anaesthesia (e.g. injections or double eyelid surgery), patients are often prompted to open and close their eyes, and asked whether they feel pain or discomfort. If the operation requires general anaesthesia, it gets more complicated for both patient and surgeon.

During surgery, both patient and surgeon are depersonalized in a highly routinized ways, involving rituals, tools and technologies. The high-level expertise of the surgeon is not only acquired, though medical education, licenses and experiences, but it is also performed through rituals of the operation, such as wearing appropriate attire, scrubbing with germicide and using specialized tools (Hirschauer, 1991; Moreira, 2004; Prentice, 2007; Thompson, 2005). The surgeon’s body is extended and connected to a patient’s body, through diverse surgical devices (Hirschauer, 1991), designed and manufactured so precisely that they not only connect comfortably with the surgeon’s hands, but also facilitate specific surgical techniques. For example, osteotomes, tools used to cut nasal bones, are designed to function as a pair, one for cutting the left part of the bone and the other for the right. During the operation, the surgeon constantly uses his eyes, ears and hands in conjunction with equipment that connects his body with the patient’s, such as a ventilator, an electrocardiogram monitor and an oxygen saturation monitor (Goodwin, 2008; Woodgate, 2006).

Recovery: Discipline and cooperation

At Y Clinic, except in complex cases, most patients are sent home on the day of the surgery. They are given several items to facilitate their recovery, including a document called ‘post-surgical care instructions’. As a mainstay of both the surgeon’s management of the patient and the patient’s self-management, the document specifies detailed regimens to be followed (e.g. the number of pillows to use in bed), and addresses most everyday activities (e.g. exercise, make-up, face washing, showering and driving, not to mention drinking and smoking). The instructions are expressed in language that simultaneously directs the patient, while implying she is responsible for her recovery: ‘As the surgery was completed successfully, postsurgical management is critical. Please come in at the appointed time for treatment. You must follow the instructions carefully.’ Here, Y Clinic expresses ambivalence towards the patient, who is both an unruly body that requires discipline, and an active potential self-caregiver (Heyes, 2006; Throsby, 2008).

The length of the recovery period depends on the surgery. During this time, surgeons see their patients on a regular basis for follow-up care (e.g. removal of stitches, sterilization of the surgical region and monitoring). These treatments take only a few minutes, and both the surgeon and patient are prepared for them by the postsurgical care instructions and the patient managers. One patient manager is assigned to oversee the care of all of one surgeon’s patients: Before and after every visit, the patient manager communicates with both surgeon and patients, informing them about follow-up schedules, recovery status and satisfaction.

At Y Clinic, post-operative treatments called ‘dressing’ are performed in a room called the ‘post-treatment room’ (or, more casually, the ‘dressing room’). The dressing room is a transitional space between the medical and social world. It is as if the patient in this room is transformed from medical object to beautiful subject: the operating table is placed at the centre of this room, illuminated by an astral lamp affixed to the ceiling and accompanied by a simple set of medical supplies (e.g. gauze, tweezers, saline and alcohol). There are also pictures of Y Clinic members, with smiling faces, dressed in fancy gowns and tuxedos, and the operating table is covered with a colourful, fluffy, animal-print blanket, instead of green, stiff, operating drapes.

Dressing is considered less significant than ‘consulting’ and ‘operating’ at Y Clinic. Although all the surgeons, patient managers and nurses are involved in them, dressing appointments are frequently not mentioned during daily morning meetings. Perhaps this is because dressing is less fraught with tension than operating, or because dressing lacks the excitement and visual spectacle of consulting. During dressing, both the patient and the surgeon are hovering between satisfaction and dissatisfaction, and working together to move on. Their sense of cooperation and the shared hope for a good outcome make the whole scene of the dressing room peaceful.

Anxious surgeons, unruly patients and caring women

This section traces the trajectory of surgical anxiety from the surgeon’s response to the unruliness of a patient’s body, to the care work of women. On analogy with Brian Wynne’s (1988) idea of ‘unruly technology’, I embrace the uncontrollability, unpredictability, dynamism and multiplicity of bodies, highlighting how this unruliness disrupts the rules and routines of plastic surgery. As I have shown, consultations synchronize standards of beauty, and surgical routines and postsurgical care stabilize and materialize this synchronicity. However, the bodily unruliness of patients undermines the potential of such efforts to yield aesthetic, physical and social certainty. Each patient has a unique self-perception, a particular anatomic history, and personalized ways of caring for herself. Patients’ bodies thus act in idiosyncratic ways, and this unruliness makes surgeons anxious. This context of surgical anxiety makes the ‘invisible work’ of patient managers and nurses visible (Shapin, 1989; Star, 1991; 1995).

Frustrated with ‘cheap looks’

Western news reports and mass media exoticize the homogenization and Westernization of Korean women’s faces, suggesting that all Korean surgeries aim to produce faces characterized by big eyes, a sharp nose and slender cheeks. So, it may seem that Korean people, and other Asians, modify their facial features to mimic Caucasian features (Gilman, 1999; Haiken, 1997; Kaw, 1993). The American celebrity Oprah Winfrey, on one episode of her television show broadcast in 2004, noted that Korean women were the world’s most likely plastic surgery customers, seeking to change their bodies to resemble those of White women.¹¹

But this logic of racialization in plastic surgery does not cohere with perspectives from actual practices (Aizura, 2009). Ethnographic research shows that norms of beauty are made through practice (Plemons, 2014). For example, surgeons at Y Clinic have negative views of Caucasian bodies. Dr Kim strongly criticizes racialized standards of beauty in plastic surgery, and describes the Korean obsession with sharp noses as based on the ‘wrong perception that a flat nose decreases the attractiveness of a whole face’. He goes on to say that this notion ‘originated from Japanese traditions in plastic surgery to assimilate Japanese to white people’. At Y Clinic, ideals of facial beauty are expressed in affective and ambiguous terms, such as ‘bright’ and ‘animated’ eyes, a ‘sophisticated’ nose, and a ‘baby-like’, ‘graceful’, ‘glamorous’, ‘elegant’ and ‘refined’ face. These features make a ‘favourable impression’ and have a ‘natural three-dimensional look’.

Consultations that fail to synchronize the patients’ choices with the surgeons’ are the first type of site of surgical anxiety. Plastic surgery is a competitive business: only some surgeons’ beauty standards catch on. Although several of his articles on jaw surgery are in established international medical journals, Dr Kim remains deeply frustrated that his peer-reviewed approach to the science of beauty does not rule the market. For him, ‘kinds’ and ‘degrees’ of facial changes are both critical to the patient’s decisions around surgery. There are certain kinds of surgical modifications that the surgeons at Y Clinic will not do: ‘charming flesh’, the realignment of fat tissues or filler injections under the eyes; horizontally widening the appearance of the eyes through lateral epicanthoplasty (removing the lateral folds of eyes); and flattening cheekbones. Although Dr Kim markets himself as an expert in lower-jaw reduction surgery and two-jaw surgery, he is strongly opposed to surgeries that involve major excision of the jawbone, such as ‘V-lining’ (a popular term for creating an oval face) and ‘square-jaw surgery’ (a popular term for mandibular angle reduction surgery to make a ‘V-line’ jaw). At Y Clinic, these kinds and degrees of facial features are overtly labelled ‘cheap looking’, and stand in contrast with ‘noble and natural looking’ features. Cheap-looking modifications are those that blindly follow Western aesthetics, and are considered artificial as well as unethical.

Surgeons confessed to having internal conflicts, in which they sometimes considered offering operations that patients wanted although they ran against the surgeons’ aesthetic standards. They claimed that this was because they did not trust some of their peers, and they further lacked trust in uncertified performers of plastic surgery. Drs Park, Lee and Kim thought that some patients would not give up their ideal of beauty despite the ethical diagnosis given by the surgeons, and thus could be easily lured by ‘unethical’ practitioners who do not mind ‘selling’ whatever kind of plastic surgery that patients wanted.

Patient managers work hard to produce their surgeons’ ideals of beauty, but nonetheless often criticize surgeons – not only for following contemporary beauty trends, but also for failing to respond to patients’ needs. Patient managers strive to shape patients’ decisions, but their tactics are different than those of the surgeons for whom they work. The relationships between the mostly female patient managers and mostly female patients tend to be noticeably different than the relationships between the mostly male surgeons and the patients. The conversation between patient manager and patient that immediately follows the pre-operative consultation is more casual and less hierarchical than the consultation.¹² In these encounters, patient managers carry out three kinds of care work. First, they try to relieve patients from negative feelings of objectification. Most patients flush or sigh with embarrassment when Dr Kim presents the photo of a patient’s bare face on the computer screen. This kind of discomfort or displeasure is what Charis Thompson (2005) calls ‘the oppositional tension between objectification and agency’ (p. 201), and it may make patients reluctant to pursue a technological makeover (see also Thompson, 1996). The patient manager, who usually stands beside a patient, softens those adverse moments by smiling and making supportive comments, such as ‘[when Dr Kim took photos of me] mine was much worse than yours [so you should not feel too bad]’. Second, the patient manager relates to the patient on a personal level, asking about her economic situation, and sometimes using this information to negotiate her surgical fees. Ms Suh also often used her own surgical experiences to tell her patients both how painful it was, and also how she recovered and how the process worked. And each patient manager at Y Clinic models evidence of a particular surgeon’s ability to make beauty: Dr Park called the patient managers ‘flowers in the clinic’. Their ‘natural-looking’ and ‘elegant’ feminine appearance symbolizes Y Clinic’s aesthetic, in contrast to women in other clinics who, in Dr Park’s words, look ‘artificially fixed’ and ‘cheap’. Except for Ms Ryou, all of Y Clinic’s patient managers are considered highly attractive. Among them, Ms Choi and Ms Jung are deemed ‘natural beauties’ in that they have not received any major plastic surgery, except for Botox injections, cosmetic tattoos and skincare. Ms Suh is known to have had a rhinoplasty, fat injections and other non-invasive cosmetic treatments.

Alone with an opened body

While plastic surgery clinics operate on the basis of repetition of familiar, well-rehearsed routines (Collins, 1994), they also inevitably encounter uncertain, contingent and irrevocable conditions to which surgeons must respond (Katz, 1981). Each body has unique, unpredictable anatomical characteristics. Indeed, Drs Park, Kim and Lee all say that unique features of individual bodies are the most common cause of surgical difficulties. As one of them puts it, ‘you never know it before actually opening it’. Moreover, there are uncommon but real instances of serious complications during surgery, such as difficulty breathing, unusual blood pressure and excessive bleeding. Clinics depend on patients to provide details of their medical histories and health concerns, and to pass the basic exams, such as a chest X-ray and blood tests. However, patients sometimes neglect pre-operative safety measures. For this reason, Dr Park says that he is cautious about going through with an operation, even though he may lose money for stopping a surgery. Dr Lee also states that he immediately ceases an operation if his gut feeling tells him that something may go wrong or is unusual.

Solitariness is commonly identified as a psychological trait of surgeons, who often describe operating as a form of ‘solitude’. The three surgeons from Y Clinic often drank heavily. To be sure, heavy drinking is not uncommon among Korean professional men, but in conjunction with statements like ‘each operation shortens my life by one hour’, the surgeons at Y Clinic expressed intense tension and stress (Cassell, 1996). One plastic surgeon, in an essay in a newsletter of the Korean Society of Plastic Surgeons, likens himself to ‘a gladiator who fights by throwing his whole body [into his work]’ and confesses ‘even when I have heart-sinking experiences during an operation, I have to get my shaking hands back [under control] with nobody who can help me and finish it all by myself’ (Lee, 2007: 13).

Loneliness may be related to another apparent tendency of surgeons – having paranoid delusions that everything is against them (Cassell, 1987). Consider one of Dr Kim’s posts on Facebook,

Surgeons live with a divine punishment called solitude carried on their back. A surgeon is especially solitary in the operating room because he is solely responsible for all the things that may happen inside an operating room. There is no mutual responsibility inside an operating room. Therefore, a surgeon is always by himself. … We eat rice every day but sometimes bite our lips by accident. If surgeons are humans, can they be perfect?

Dr Kim has a fatalistic sense of his ‘solitude’ and ‘sole responsibility’ for each operation, which he connects with common human mistakes in everyday life – he bites his lips while eating rice. His post expresses the surgeon’s heavy sense of anxiety in relation to the perceived situation of being solely responsible for the unruliness of surgery.

Yet nurses, typically women, do physical and emotional care-work, not only for patients, but also for surgeons. For patients, nurses prepare and clean gowns, offer tender smiles and hold hands at the operating table, and provide post-anaesthetic and post-operative assurance. While the patient is under anaesthesia, the nurse is the surgeon’s extra hands and conversation partner. But the bulk of the nurse’s emotional work is to provide post-operative assurance to the surgeon that he has done a good job. For example, after Dr Park finishes inserting breast implants, or just before Dr Kim puts a bandage around a patient’s head after the final suture, a nurse will make a complimentary remark: ‘[the surgical result is] incredible’, ‘[due to surgery] she’s so pretty’, ‘she’s a totally different person’.

Fear of complaints

Patients have scheduled appointments after their operations (e.g. to have their dressings changed). However, for surgeons, an unscheduled post-operative visit indicates trouble, namely complaints. Surgeons divide patients’ complaints into two categories: infections (physical) and dissatisfaction (psychological). Patients with infections may report pain, severe swelling or lumps under the skin. Dissatisfaction covers a broad spectrum of issues: some patients do not see any difference in their appearance after surgery, others think their new appearance is unnatural or asymmetrical, others still say they look worse than before surgery.¹³ Surgeons are especially afraid that patients with complaints will raise their voices, demand compensation or even file lawsuits. In this sense, plastic surgery patients are potential time-bombs, who could ruin a surgeon’s career and business at any moment.

The surgeon’s constant nervousness around his patients generates a persecution complex. The surgeons in Y Clinic openly express fear of patients. Dr Kim said, ‘So far it has been the investigation of taxable income that plastic surgery clinics are the most afraid of; however, it is nothing compared to a class-action lawsuit,’ He was afraid that a wave of lawsuits by patients would be a new feature of the plastic surgery industry in the future.¹⁴ Dr Park said,

I’m scared to see [post-operative] patients [in the lobby of the clinic]. The first thing that comes into my mind is ‘Oh my god, there must be something wrong,’ It is even scarier to see a patient with her chaperone who looks like a good fighter. Among plastic surgeons, there’s a saying that no news is good news. That is, if no word comes from a patient, I can tell myself, ‘Oh, it’s well done.’ If I ask patients ‘How are you?’ or ‘Do you like your new look?’ I’m sure none of their answers would be positive. If I did ask those questions, they would either think, ‘Oh, is he asking me because there’s something wrong?’ and start worrying, or jump at an opportunity to complain about the surgery, as in ‘Yeah, I like it but …’

Beyond financial or legal considerations, surgeons have anxiety about patients who complain rather than compliment, and fear challenges to their medical authority and power.

Dealing with patient complaints also falls to patient managers. As plastic surgery is a highly commercialized, market-based medicine, a plastic surgeon has to have the double identity of medical professional and independent businessman (Rylko-Bauer and Farmer, 2002). Patient managers are hired to care directly for patients as ‘customers’ or ‘consumers’ (Conrad, 2005; Conrad and Leiter, 2004; Fishman, 2004). One patient manager at Y Clinic described her job as ‘supplementing’ the surgeon’s work ‘like his wife’.

Patients’ most frequent complaint was dissatisfaction with surgical results. Patient managers could often apply a social fix – conversation, persuasion, reassurance or conciliation – to this kind of complaint. A social fix often included monetary compensation as well. Ms Suh gave a few examples of such unpredictable and uncontrollable complaints: a call about a ‘crooked nose’ from the father of a patient who had rhinoplasty 7 years ago; a middle-aged patient who firmly believed, unlike her surgeon, that she was more beautiful before surgery than after surgery; and a university student who sent Mrs Suh long, frightening texts, including enlarged photographs of her goggling eyes, claiming that her double eyelids had reverted just a couple of days after the operation. Patient managers were polite and friendly to these patients, but sometimes referred to them behind their backs as ‘psychos’. To pacify both a worried entrepreneur and a dissatisfied customer, patient managers have to know how to ‘be nice’ around all kinds of unruly bodies (Hochschild, 1983).

Conclusion: Anxiety and beginning to care

This study of the anxious production of beauty is a story of affect, care and power in medicine. It shows that the unruliness of the body makes the production of beauty an inherently anxiety-inducing process. Rather than attempting to determine whether ideals of beauty are universal or locally constructed, I have argued that the production of beauty is fraught with challenges that exceed (universal or local construction of) beauty ideals: it must grapple with bodies that are unruly, recalcitrant, contingent and multiple. This point problematizes most previous studies on plastic surgery, which frame plastic surgery as a powerful technology to inscribe medical and social norms onto the material bodies of women. I have suggested that although the surgeon attempts to control the patient’s body in multiple ways, the surgeon cannot foresee or control the aesthetic vision, physical condition or satisfaction of the patient. This challenges the presumed power dynamics of plastic surgery, both medically and politically: the surgeon does not have unyielding control over his patients’ personalized beauty ideals, he lacks complete knowledge of their unpredictable anatomic structures and he cannot exercise perfect discipline over their post-operative lives. By illustrating the unruliness of making beauty and surgeons’ struggles with it, I hope to offer an example of ‘affective construction of biomedicine’, which shows that affective elements, experiences and relationships are part of a larger movement within neoliberal medicine.

Invisible care maintains the operation of plastic surgery clinics. Women caregivers, such as patient managers, play a critical role in making surgical anxiety invisible. In fact, the emergence of new care workers can be expected from recent transformations of medicine. For example, the commercialization of medicine fragments medical services, and workforce structures shift (Clarke et al., 2003; Conrad, 2007; Nancarrow and Borthwick, 2005).¹⁵ The feminization and invisibility of care work make clear that gender remains a powerful organizing principle in the medical workplace (Bulan et al., 1997; Faulkner, 2000; James, 1988; Salzinger, 2004).¹⁶ New feminine-coded jobs, such as research coordinator or clinical trial coordinator are critical to making biomedical research and ethics better. With interpersonal, communicative skills, the women in these roles mediate interactions between patients and biomedical companies, negotiate ethical choices with candidates and take care of patients (Fisher, 2006; Mueller and Mamo, 2000). Women caregivers can be also significant ‘others’, who perform the politics and ethics of medicine in unprecedented ways. Ms Ryou, for instance, refused to act in the role of a caring wife to her surgeon and instead built her own networks with patients through Internet marketing. She owned and managed several online communities, which have members numbering from several thousands to tens of thousands of potential patients. While providing medical information and reporting on surgical experiences for these members, she also has held various promotional events targeting potential patients. She acted like a self-employed professional and considered the surgeons to be her ‘partners’. She explicitly and exclusively identified her online members as ‘my patients’, negotiated with surgeons to offer them attractive surgery fees and sometimes hired surgeons from other clinics to operate on her patients. Combined with various social and technical elements, such as new marketing tools outside of the clinic, these care workers may disturb gender hierarchies within the medical workforce (Deutsch, 2007).

Surgical anxiety is also connected to the politics of care, which has recently been discussed among feminist STS scholars. The concept of surgical anxiety is not only a useful analytical tool for understanding neglected features of the assembling of medicine, but is also a useful political resource to contribute to politics of care, especially concerning ‘how do we begin to care’ (Schrader, 2015: 667). While the story of ambivalence portrays science as constructions of different interests, strategies and negotiations, this study of anxiety acknowledges that science involves affect, response-ability and shared relationships (Viseu, 2015). While, in previous studies, care is mostly associated with positive elements such as love and nurture, this study recognizes that care is moved by negative affects such as anxiety; thus like other scholars interested in the politics of care, I am of ‘staying with the trouble’ (Haraway, 2012: 311; Martin et al., 2015; Murphy, 2015). Starting from anxiety as a shared vulnerability between different actors, we can begin to care without knowing who the subject or the object of care is, who has the power to care, who and what determines whom to care and what kind of care are needed (Atkinson-Graham et al., 2015; Martin et al., 2015; Schrader, 2015). Attention to the politics of care is critical in responding to situations in which care has become commercialized and feminized. By revealing the invisible work of female practitioners in caring for surgical anxiety, this study also problematizes care as affective labour appropriated by markets.

Ms Ahn’s infected body, Dr Kim’s fear and Ms Suh’s care work are all integral elements of this story, and none should be left behind or separated from another. Once these elements of surgical anxiety are brought to the surface and shared, they may become major components of reassembling the whole network of plastic surgery into a better one (Jackson and Everts, 2010; Latour, 2005; Puig de la Bellacasa, 2011). Despite cutting-edge developments in technoscience and medicine, individual bodies always remain unruly, evoke anxiety and require care. We have no choice but to accept this anxious mode of life and learn to live with it (Fitzpatrick, 2014; McCarthy, 2012). This study is not intended to determine who should care, who should be cared for or what care practices should be done to live better with anxiety. Rather it is only a beginning of caring. Care begins when we – not only surgeons, patients and patients managers but also researchers – listen to, respond to or learn our shared anxieties.

Footnotes

Acknowledgements

I want to thank Sergio Sismondo and three anonymous reviewers for their extremely helpful comments, critiques and suggestions. I also deeply appreciate the invaluable guidance and encouragements of Charis Thompson, Vinh-Kim Nguyen and Jongyoung Kim, who helped me to revise earlier versions of this article. Special thanks go to three surgeons as well as all the nurses, patient managers and patients at Y Plastic Surgery Clinic for sharing their everyday works, concerns and feelings with me throughout the fieldwork.

Funding

The research leading to these results has received funding from the European Union’s Seventh Framework Programme (FP7/2007-2013 - MSCA-COFUND) under grant agreement 245743 - Post-doctoral programme Braudel-IFER-FMSH, in collaboration with the Chair d’anthropologie et santé mondiale, Collège d’études mondiales - Fondation Maison des sciences de l’homme. The fieldwork for this research was also supported by Bo Jung Kim Dissertation Fellowship (2008) from the Program in History and Philosophy of Science, Seoul National University, South Korea.

Notes

Author biography

So Yeon Leem is a Lecturer in the College of Liberal Studies, Seoul National University. Her research interests include affect and care in technoscience, cyborg technology, and globalization and the body. She has published on medical ethics of commercialized care, digital imaging technology and plastic surgery, Hwang’s stem cell research, feminist STS, and ethnographic methodologies. Her latest article, ‘The dubious enhancement: Making South Korea a plastic surgery nation’, is forthcoming in East Asian Science, Technology, and Society: An International Journal.

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