Kader Attia:
The issue of repair is now one major focus in my artistic research. I thought about it watching a mere piece of raffia cloth a friend gave me in Congo, in 1997. The peculiar thing about this traditional loincloth is that it is scattered with small western fabric “patches”, reminding of Vichy fabric. For years, I thought these elements were “just” decorations with unexpected aesthetics, bits of eastern modern material added like some sort of transplant on a traditional African piece of cloth. One day, I turned this ambivalent item around and discovered that behind each patch there was a hole due to excessive use. The patches are actually signs of both an aesthetic and ethical act: it is a repair. From then on I spent my life looking for such signs… It enabled me to discover the complexity of fixing, in traditional extra-western societies and in modern western societies as well. Objects, masks, intentional or unintentional physical injuries, all carry a repairing purpose changing from one culture to another. As a surgeon working in Paris, how do you understand this description of an inanimate, lifeless object; this loincloth mended by Kuba people in Congo with elements from a western culture? You also worked in Africa, if I am not mistaking.
Bernard Mole:
The repair you are talking about is a passive one, it is the same as what we use in reconstructive surgery when we have to make up for a lack of skin with a self-transplant (meaning taken from the patient themselves). The result is quite variable on a cosmetic point of view because the skin always keeps the characteristics of where it came from; even if it sometimes perfectly merges with the surrounding skin, it can also leave an “imported part” impression, which is obviously not the expected result for a patient, who always dreams of an ad integrum restoration. The most elegant repairs often make use of what can be very complex scraps allowing true reconstruction of several tissues at the same time; these can perfectly mimic the original one. The most ancient repairs go back to three thousand years BC, in India, and to the 15th century, in Italy, back when “traditional” punishment consisted of completely amputating one’s nose.
The ultimate stage for this kind of operations was reached a few years ago in France with a complete facial homo transplant (from someone else), under the guise of a very heavy anti-rejection treatment, bringing into light as many technical and ethical issues: as a matter of fact, spending the rest of your life with someone else’s face is not easy at all! However, by checking on the first cases several years later, it appears this integration is absolutely possible. Let us not forget such patients are completely disfigured before the operation and have, therefore, already “lost their original face.”
To some extent, mending a piece of clothing with bits taken from another eventually falls under the same process: you keep one alive thanks to the other and inasmuch as you can sometimes be quite emotionally attached to the former. This reminds me of a Sicilian story I heard from Dominique Hernandez about that very poor woman who owned an apron since her wedding day, and it had been sewn back up so many times that her husband ended up giving her a new one as a gift: as a reaction she did not replace the old apron with the new one but used the latter to cut new bits and complete her patchwork up “to the end” (all in all meaning death)!
K. A.:
I always felt the polysemous characteristic in the repair concept. For from the act to the result, possible interpretations are infinite, as much in who sees the repairing as in who carries it out and who/what is being repaired. Yet, some fixed up cloth has no self-awareness of having been so, just like it is not conscious of being fabric. As for the seer, can they think about the piece of cloth as repaired in itself? Impossible.
What enables the human mind to picture one thing and/or concept, like fabric or wound fixing, is the intellectual and experimental relation existing between the repaired item and its repairer, just like between the repaired item and the seer. This relation called “correlation” by “modern” philosophy is what structures and rules over knowledge. What I find fascinating in this idea is the way the link established between two independent things is what distinguishes them just like it ties them to create knowledge of the thing by inference. Without correlation, knowledge would not exist.
Do you think correlation is a conceptual form of repair specific to intelligence, that it fills the abyss between intelligence and things? Speaking about modern western thought, could we say that, up to our contemporary days, modern western reconstructive surgery would be looking for the ethics of ad integrum restitution as the one and only standard for perfection, because it seems (according to your earlier example) to be the effect the patient wishes?
B. M.:
I humbly admit my intellectual inability to give answer to such a question. Usually, surgeons are pragmatic, not to say down-to-earth people, they are artisans interrogating themselves before, and sometimes even during, the operation. Yet, what distinguishes them from any other craftsman is that they must absolutely “finish the job” once they started! Despite what could be said, even when the patient as a demand for perfection, modesty should make us recognize the fact that the best result also comes from some personal part played by the person undergoing the operation. Ambroise Paré said this astonishingly humble and clear-sighted quote that proves to be a sort of guiding light throughout a practitioner’s career: “I bandaged him, and God healed him.” By the way, on a legal perspective, the final result matters less than what was done to get to it.
K. A.:
I spent a lot of time watching the amazing formal analogies one could find between soldier’s facial reconstructed wounds, such as the “gueules cassées”, or broken faces, during World War one, and African traditional masks. I show particular interest in the early years of the conflict because at the time, physicians like Hippolyte Maurestin, in France, or Dr J. Joseph, in Germany, quickly got overwhelmed by the increasing number of casualties. They had to fix fast and with rudimentary means, because they lacked equipment due to war and certainly to the technology available at the time.
What is striking in those reconstructions is their ethical and especially aesthetic dimension, their expression echoes African masks traditional repairs in which other constraints fashioned almost similar aesthetics…
That aesthetics was limited by the means at hand, and Claude Levi Strauss even called it a “patch-up job.” In Europe, that expressive aspect inherent to reconstructed war injuries, inspired expressionist painters like Otto Dix and Georg Grosz. By seizing it they condemned the horrors of war and gave birth to an important artistic movement: German expressionism…
As I carried on my research, I discovered, especially with Dr J. Joseph from Berlin, that reconstructive surgery developed during World War one. A four year conflict is long, for soldiers and doctors as well. I was baffled by the physicians’ talent, not only by their skill but also their creativity that, sometimes thanks to single patch-up work, could do miracles…
Does your story about nose reparation fall under this kind of odd-jobs? What are the results? Could a patient attempting to hide his outlaw past manage to do it?
B. M.:
As terrible as the injuries were and as imperfect as the repairing was, a broken face led to certain respectability (for it brought to mind bravery, sacrifice and self sacrifice for your country, etc.). But things changed during World War two. After this conflict, priority was given to not showing signs or to hiding injuries the public could not have born to look at. At the same time, surgeons’ status changed as well: amputation champions under Napoleon (only chance of survival for soldiers with wounded limbs), claiming rightful status with the creation of the Red Cross by Henri Dunant who had been horrified by the butchery in Solferino, they benefitted from the shy but meaningful progress in anesthesia and the tottering surgery of bits seen during World War one and later managed to establish real rules in taking care of serious injuries during World War two.
I do not know if repairing amputated noses gave the operated victims a chance to change their social integration. We can assume it did whenever the result was skillful and discreet, but it must have been rare… Seeing the evolution of surgeons’ status throughout history is funny: during Antiquity, they were respected for their knowledge and boldness, then they were despised and put down to the same rank as barbers up until Renaissance (it is true they owned intellectual power in colleges but what they knew was based upon absolutely crazy theories that surely took more sick people to the grave than the disease itself). It would have taken surgeons to finally be able to cure Louis XIV’s anal fistula for them to win back a social position worthy of their talent!
K. A.:
Tracking down how some trades evolved in their social position throughout history is fascinating. Architects too have known various levels of acknowledgement depending on the time they lived in. I remember an interview of Auguste Perret complaining about architects’ status in the 20th century. They are not as praised as they used to be. In Ancient Egypt, Pharaoh would greet them almost like demigods, while nowadays they are just employees for local elected representatives or company managers… Still, apart from this acknowledgement you are mentioning with Louis XIV and his doctor, Félix de Tassy, to me, architecture sometimes seems to be sharing the same reason for being as surgery. You can find some kind of repair work in building. I am not only talking about reconstructing ancient ruins or renovating old modern buildings. I mean, what truly animates the human mind as both the factor and messenger of the evolution of its superiority over other species, through instinctive ethics urging it to compete against the laws of nature: building, enhancing, transforming, recreating, etc.
There are many possible analogies between the human body and architecture. According to philosophers like Michel Foucault, who expressed it in his lecture “Utopian Body”, body and mind are almost dissonant. The mind would be an inhabitant in the body the same way a body inhabits an architecture. Bernard, Kader, your relatives, mine, people outside, all the people you assimilate to their earthly body, are something else in reality. What you can perceive, their shell, only is a puppet controlled by their mind. Every living person is above all a “thinking mind.” Your body is not you, but the shell inhabited by your spirit. This idea can be contradicted, and Michel Foucault himself does it in the second part of his lecture.
Nevertheless, I would like to come back to an example you quoted earlier. This story raised up several questions I would like to ask you…
It was about a transplant on somebody who had been attacked by a dog, causing the said person to be disfigured. The operation consisted of transplanting someone else’s face. You said both body and mind could react negatively to such a graft, hence the necessity of complex medical disease prevention along with serious psychological follow-up care. Is there a double consciousness of the repair by the body and also the mind, or is it just a matter of medical ethics? I particularly recall a Cameroonian friend’s father who had been transplanted with someone else’s organ. He never psychologically accepted having something he could not see but that seriously felt like some alien presence inside of him… Eventually, his body never managed to accept the graft and he died. Are there situations where the mind welcomes the graft while the body does not, or vice versa? Does this particular face transplant, along with what it implies in matters of “acceptation and reject” by body and mind, fall under repairing or is it pure creation? In other words, when you transplant a new face, or new hands, on a body that has lost its original parts, does the surgeon only fix it or does he create some new being?
B. M.:
I would like to reassure you right away: there is no such thing as a “Pygmalion-surgeons”…or if there is, such a physician’s behavior is clearly due to pathological perversion. Literature is full of these kinds of myths, from Faust to Frankenstein, where man thinks he can act like God. In this respect, I cannot resist telling you a joke: “do you know the difference between God and a surgeon? There is not, except that God does not think he is a surgeon.” There is a tendency to fantasize about our power as surgeons. Actually, we have none, we only have duties, and the most important one is to act properly for the sake of whoever gave us their trust. Everything else is but literature… We have been overwhelmed for several years now with so many fantastical visions – that tend to be more or less pathological – and they do not help in improving our image. About this (is it coincidence?), for our next convention, set in Tours in late May, ORLAN will deliver a lecture I would gladly attend, but more out of curiosity than real interest mind you. Her trade is not mine, I leave her with full responsibility for that and do not want to be involved in that kind of approach. Still, I know some fellow physicians cannot resist such an extra, and perhaps they would need a bit of psychoanalytical flashlight, too!
No face transplant falls under creation, or maybe “re-creation”, meaning restoration-reparation. Nevertheless, this does not prevent one to wonder, of course, for our actions sometimes have an unexpected impact on a patient’s behavior. We always hope it will be a positive one, but with experience, you get to learn it can also be deleterious, probably because we did not really get what lied underneath this demand for reparation. Once you are more experimented, such consequences are seldom but one never knows! As far as I am concerned, I also chose this specialty for the psychological support it implies, as well as the impossibility to cheat with the result.
K. A.:
Perhaps the myth of Pygmalion surgeons comes from the fact they walk alongside death, and most of the times, cast it back to where it came from. They sometimes have out of size ego. Artists too have variable ego sizes, in the difference that they do not save lives. Their works create a vanishing point with the horizons of thought and emotion, but it remains mere representation, staging. Mankind’s superiority lies in the ability to bring science and art both in harmony and dichotomy… Everything can be measured and then explained with mathematics. Everything but Art. Not only contemporary art, but truly all artistic initiative without exception, from arts wrongly called primitive to the ones excessively considered as “major.” This is the reason why I am interested in the incursion of artistic process into the field of science. I mean, for example, a sculptor reconstructing and imagining down to the last detail what a broken face torn up part looked like in order for the surgeon to follow that lead and fix that face or order resin prosthesis. I saw such prosthetic items from World War one in Val de Grâce Hospital, in Paris.
What I find interesting here, is not only what you humbly mentioned as the artisanal part of your profession, but also the borderline between art and science, and honestly, between beauty and its opposite. All in all, the issue of beauty.
You work in Paris, but I heard you also go to Africa with an association aiming at fixing children’s smiles (or do you also perform all kinds of surgery on adults and children there?). Could you tell us a little more about this fantastic action you carry alongside your Parisian activities? What does it imply to help people who do not have the means to access facial surgery? I guess you involve your professional experience in both an ethical and aesthetical perspective…
And secondly – this question is a bit more sensitive – what can you say about beauty with the example I am about to give you? For several years now, I have been working on what is called “sickness masks” in Central, West, East and Southern Africa, and Asia (from Tibet to Indonesia), and I would not be surprised to find some in Japan as well. A mask representing a sick person’s face has got a very meaningful place. Some of these objects had a real impact on the evolution of 20th century western thought…
Pende people from Congo, even created the legend, and it might be true in fact, that such items directly influenced Picasso’s “The Young Ladies of Avignon”, the iconic painting of cubism golden age. If extra-western societies show sickness, it is surely in order to exorcise it, but especially to give it a noticeable position in public space: it is like acknowledging illness and giving it a social and material, as well as immaterial, almost divine, value. Sickness masks faces are misshapen, twisted and expressive, not to say expressionist. With off-the-wall aesthetics, they mark what the modern western mind finds asymmetric, anomalous, almost repulsive… They remind me of aesthetics concerns and social issues broken faces had to undergo in their after war life. Jacques Derrida said that human physical beauty is certainly what is truly rare. Perfect face symmetry is seldom, therefore it is beautiful…beautiful and rare, perhaps as much as a totally asymmetric face could be.
According to you, what is beauty in reconstructive surgery, is it primarily born from the surgeon’s personal choices or from societal codification?
B. M.:
Now, this is some delicate inquiry, and it questions the very notion of beauty: is it a gift from nature, a product of personal effort, a cultural footprint? Certainly a bit of all that. On the contrary to what people usually think, you must first approach the idea of beauty with lots of doubts and yet, some certitudes. First, beauty transcends the ages: even when you want to bring into contrast Rubens’ voluptuous Venus and Giacometti’s ascetic ones, you soon realize beauty is immanent, it imposes itself throughout history. Be it Nefertiti’s famous bust exhibited in Berlin, Praxiteles’ reproductions, faithful paintings of Agnès Sorel and so many others…who could possibly have a look at them and think “peuh, not that good…” ? Beauty is fascinating and repulsive, attractive and frightening, it is a grace one must use carefully, or a destructive weapon to whoever gets to be seduced (the devil’s beauty).
Strangely, it is rejected by our Judeo-Christian society…and yet it is worshipped by it. To those who tell me “after all, it is nature that made us the way we are, so we should not try and question God’s work”, I reply “our religion allows us to represent God, his son and his sanctified disciples in a glorified way: oddly enough, I never saw a painting of Jesus with sticking-out-ears, a crooked nose, or as a fat person.” And if you happened to be in such disgrace, would not you ask for “reparation” (also meaning “redressing injustice”)? Of course, as far as I know, there are several levels of appreciation according to civilizations…and needs. However, when you travel around the world, you soon realize beauty sometimes compellingly stands out by itself. Like a sort of masterpiece that is unfortunately temporary, but that you agree to behold without jealousy. I find it hard sometimes, but then I just play the part of the spectator who is simply happy to meet grace and exception!
I will conclude by saying that the purpose of aesthetic surgery is not to “bring beauty” (because what standards should we follow?) but harmony. By the way, such a demand is quite reasonable in France and only very few patients come with tabloid pages to use as model! Plus, those kinds of needs are quite dubious because they can lead to dysmorphophobia, which cannot be solved.
K. A.:
I always believed the apex of human civilization was ante-monotheist. As soon as the notion of a unique God appeared, human beings never stopped dogmatizing relations between people, from the social sphere to the intimate one, to finally control them through morals. Homosexuality, for instance, only was stigmatized and demonized after the advent of monotheisms. Greco-roman civilizations left us obvious proof about that. As a humanist photograph, I found interest in people from all confessions and sexual identities. A few years ago, I directed a movie with a transsexual friend of mine, who had been dreaming for years of going in India or Pakistan to meet with the Hijras. Originally, Hijras are men who enter an Ashram where they live with other men who took the decision never to live as males again, but as Hijras. When you do not know about them, they seem to live as women, but when you happen to spend some time with them, they will tell you “I am neither male nor female, I am hijras.”
Progress in plastic surgery does not only concern face, but body and genital organs transplants as well, it goes way further than breast implants we all know about. What does it mean, to a surgeon, to graft elements that were not on a body, but that people want because they utterly need them for personal reasons? When Dr Joseph, in Germany, or Dr Maurestin, in France, fixed broken faces during the war, I guess their actions embodied some sort of an ethical mission, and also some kind of exhilaration, a technical challenge for them to take up. And especially, they mended something that had been destroyed by a bullet or shrapnel. Sometimes, the purpose of transplantation is for a missing part to be replaced. I really like yours mentioning the artisan’s thorough mind and I have one final question for you.
To you, and on the perspective of repair, what does it mean to take male genital organs off a man who always felt a woman deep down inside, or to add flesh on female genital organs on a woman who is convinced to be a man? Unless I am mistaking, for I am not really knowledgeable on the technical parts of the matter, it appears that on the one hand, the surgeon is taking parts off, and on the other hand, he is adding things. From that on, could we say he is repairing?
B. M.:
From a technical point of view, a man-woman transformation is relatively easy and often so well done that it can even deceive your most intimate relatives, even gynecologists. Meanwhile, the other way around is way much harder, even though complicated and bold tricks may give partial illusion…but hardly…
In France, this sort of surgery follows serious rules and the procedure takes a lot of time. Indeed, you need a surgical-psychiatric-endocrinologist collegial permission for the act to be taken into consideration; this requires years of patience, mostly because of the psychiatric expertise, which actually is the key in such a situation. Once you have this permission, change in identity must be granted by State administration before the operation. The operation proves to be a major part of the process, but when making a man a woman, it is common to perform a reversible act, such as grafting breast implants or reducing Adam’s apple, in order for patients to get used to inhabiting their new personality beyond mere clothing. Also note that if you follow these official rules, the intervention is taken care of by healthcare services.
In margin of this “authentic” process certainly are less official operations with no psychological or psychiatric care. Those can lead to dead ends you have absolutely no control upon, to utter sexual misery and often suicide. So, as far as I am concerned, it seems fundamental to wrap this process up with long and thorough follow-up care during which the surgeon, though he seems to be playing the most essential part, has no right to say anything about the actual decision.
As for saying we mend things, this is what a psychiatrist could say about our trade. At best, surgeons bring balance between patients’ personal convictions and the attributes they are claiming! This enthralling issue inspired so many pieces of literature, and it obviously has nothing to do with what the public usually confuses with transvestitism. Then again, the fantasy box is wide open and the technical surgeon must remain careful…yet open-minded!
Bernard Mole, Plastic Surgeon, in France, is a founding member of the French Society of Plastic and Aesthetic Surgeons (SOFCEP). Former Paris Hospitals’ intern and later head of the Faculty Clinic, he has conducted research and fellowships on several topics such as clinical applications for the human epidermis growing. A precursor practitioner, he’s the main IMCAS Paris Course Coordinator regarding Plastic Surgery teaching materials for several years. As of today, he’s a renowned physician, specialized in plastic and reconstructive surgery. He is the national secretary for France of the International Society of Aesthetic Plastic Surgery (ISAPS). He divides his time between his local practice and his humanitarian activities.
Published in the Kader Attia Catalogue : Signes de réappropriation, BlackJack Edtions
