THR Web Features   /   September 29, 2022

Saving Face

How one surgeon fixed the Great War’s “broken gargoyles.”

Leann Davis Alspaugh

( THR illustration, Harold Gillies at center.)


The Facemaker: A Visionary Surgeon’s Battle to Mend the Disfigured Soldiers of World War I
Lindsey Fitzharris
New York, NY: Farrar, Straus and Giroux, 2022.

Fans of the HBO series Boardwalk Empire (2010–14) will remember hit man Richard Harrow played by the devastatingly handsome Jack Huston (grandson of Hollywood director John Huston). Harrow was anything but pleasant to look at, having lost half of his face while serving as a sharpshooter in World War I. It is easy to imagine that just the sight of his unnatural, bisected face made his dying victims think they were already in hell. 

If only Harrow could have come under the capable hands of the surgeon Sir Harold Gillies, the protagonist of Lindsey Fitzharris’s new book, The Facemaker. Born in New Zealand in 1882, Gillies was a one of nine children, whose father, an amateur astronomer, had an observatory installed on the roof of their Victorian villa. At Cambridge, Gillies chose to study medicine to set himself apart from his lawyer brothers. An avid golfer, he was also known as something of a maverick, once spending his entire scholarship fund on a new motorcycle. His first position as a physician was with a private practice in London where he was called on one evening to bandage the bottom of a ballerina who had sat on a pair of scissors during a Covent Garden production of Aïda. The commencement of the Great War gave Gillies a chance at frontline surgery, and it was his work on facial reconstruction that earned him a place at the forefront of modern plastic surgery. 

Fitzharris’s book is neither a biography of Gillies nor a comprehensive history of plastic surgery but, instead, a look at a practice of battlefield triage that went beyond merely patching men up to return them to the front lines. For all its popular history narrative smoothness, The Facemaker focuses thoughtfully on the serious question of personhood. The face we present to the world—young or old, male or female, clean or dingy, whole or damaged—is the primary signifier we possess. To the stranger, it is our entire identity; to friends and loved ones, it is what makes us precious, distinctive, and, well, more than just a face. Unlike many other surgical procedures, the work of facial reconstruction requires a distinctively artful and humanistic form of care, because the surgeon is seeking nothing less than to restore the outward and visible expression of the inner character of a human being. What Gillies and his colleagues had to do was consider their patients’ shattered faces at length and in depth to discern a roadmap to recovery—a task not for the faint of heart.

Early in her account, Fitzharris, an author, medical historian, and television host, points out that soldiers who returned from the war with disfigured faces were not generally considered heroes. Unlike those missing an arm or stumping along on a wooden leg, men with maxillofacial wounds were upsetting to onlookers, indeed often repulsive. Subject to a profound sense of alienation, these men broke off engagements, hid from their families, and often became recluses. While the government might assign these soldiers a full pension, society at large was unwelcoming, unsure how to honor a sacrifice that seemed an affront to basic human dignity. There still lingered at the time the idea that a marked face signified some form of moral or intellectual degeneracy. Men were expected to enlist, anything else would have been suspicious—recall the famous World War I poster “Daddy, what did you do in the Great War?”—but what to do with the returning soldier with a disfigured face? Bodily, he might appear to be whole, but the psychic toll was deep and lasting. Could anyone burdened with the experience of trench warfare and the devastating injuries of a destroyed face return unchanged?

Masks were one solution for these horrific injuries, but Gillies found them barely acceptable, even as a short-term fix. They were unnatural, uncomfortable, difficult to secure, and liable to fall off. More significantly, the mask made its wearer into something less than human. It could only represent the prosopon or, in Greek drama, the persona, that is, an outward manifestation of the individual, a character, or an emotional state—never the essence of the human person.11xI am grateful to Father Mikel Hill for pointing out this aspect of the mask. A mask ambiguously provides a public face to the world while, at the same time, concealing the wearer. The wartime mask to cover facial disfigurement—even one so capably made by artists such as American sculptor Anna Coleman Ladd—was designed not for theatrical purposes but for naturalism. But even if these masks were designed to restore dignity and allow the wearer to resume his place in society, they were so obviously artificial that even the youngest child could sense something amiss. The mask thus saddled its wearer with an identity based on concealment. It became an untrustworthy token, an emblem of equivocation.

Gillies’s success hinged on his understanding of repairing first the face’s substructure and then its soft tissues. Most triage surgeries in field hospitals concentrated on stopping bleeding and closing wounds. Gillies often had to undo this earlier work before he could begin his own back home in England. He began with repairs to the substructure of the face through dental surgery and bone grafts—“disappointment is in store for him who would confine his repair to the surface tissues, heedless of Nature’s lessons in architecture,” Gillies wrote in a 1920 textbook on plastic surgery. Without the use of antibiotics, the risk of infection was high so plates, rods, wires, and screws could not be implanted internally. Rather, these had to be anchored externally. Next, Gillies would reconstruct the face using skin flaps, bone and skin grafts, and pedicles (a stalk-like skin graft). In 1917, a Liverpool journalist related watching Gillies transplant a man’s face using skin from his chest augmented by cartilage from the ribs and shoulders. The chest skin with penciled-in eyes, mouth, and nose was removed from the patient’s upper body and laid down on his featureless face, gradually to be built up into a new face. “Now surgery has its own sculptor,” the journalist wrote of Gillies’s miraculous work.

Gillies recognized that he could not work alone, that the best results were achieved through a multidisciplinary approach in a facility dedicated to one kind of patient. He realized that hospitals where every patient was facing the same kind of injury increased the speed and quality of recovery. In his quiet, capacious hospitals first located in the town of Aldershot and then the London neighborhood of Sidcup, Gillies’s patients endured multiple surgeries and passed months-long recovery periods in a cozy environment where they stayed occupied with workshops, sports, lectures, delicious meals—and no mirrors. Artists, sculptors, and photographers helped the doctors and assistants envision the treatment regime and then chronicle its progress. Gillies credited his fellow surgeons and their advances in dentistry, burn treatments, anesthesia, psychology, and cosmetic surgery as vital to his wartime success.

After the war, Gillies went on to a busy career in cosmetic surgery until his death in 1960. Reshaping noses, breasts, and other bodily “deviations,” including, in the case of one patient, gender reassignment. Although his wartime experience had involved genital reconstruction, Gillies was approached in the mid-1940s by a patient who wished to make a full transition from female to male. According to Fitzharris, Gillies gave this patient a “false diagnosis of acute hypospadias,” or a misplaced urethral opening. This protected the patient’s identity and allowed the surgeon the legal standing to perform a phalloplasty. Gillies was the first such surgeon to perform this procedure and his pioneering work laid the groundwork for modern gender reassignment surgery.

Fitzharris does not spend much time on an inquiry into the nature of face and character. This is outside the scope of her book but what we learn about Gillies seems to indicate that the surgeon, like many of his peers especially those in today’s modern age of curated appearances, had great confidence in his ability to read a face and, through his reconstructions, to impose a certain reading on that face. Because Gillies seldom, if ever, saw his patients before they arrived in the surgical suite he could only guess at their former, undamaged appearance. As he developed his “roadmap” for a new face, Gillies would have employed a repertoire of proven techniques and experience—knowing he could never fully restore a face to its original condition. The new face would forever bear evidence of human hands. He had the tools—an almost godlike power really—to inscribe a certain narrative on his patient’s face. How might this have affected the individual’s sense of self, his ideas about his own authenticity? How much truth about a person resides in the face and what is lost when that face is altered? Although the field of physiognomy has elicited much criticism, it still has much to tell us about the equivocal position of the face and our interpretations of its “immanent subjectivity,” in the words of art historian Joseph Koerner.

Fitzharris’s book is filled with engaging asides on, for example, medical treatments from ancient times to the present, the achievements of Civil War battlefield surgeon Gurdon Buck, and Gillies’s many colorful mentors. Gillies himself comes across as optimistic, sensitive, and relentlessly curious—a man cheered by his successes and undaunted by his failures. He was that rare combination, a gifted surgeon and healer.