Reconstructing identity: Defining medical necessity in the context of facial surgery

During the first World War, the amount of facial disfigurement resultant from nascent trench warfare was unprecedented. And because the face is so intricately linked with one's sense of identity, the psychological impact of such disfigurement was devastating for veterans returning home from war. It was in this backdrop that the father of plastic surgery, Dr. Harold Delf Gillies, pioneered innovative new reconstructive techniques that revolutionized the field of facial surgery. Following the war, Gillies expanded his practice into the civilian realm, working on facial reconstruction for those marred by congenital defects, disease, or trauma. Controversy arose when he began work in the cosmetic realm, sparking debate on what is and should be considered essential surgery. This debate continues into current day, most notably in the context of gender confirmation surgeries (GCS). While many forms of GCS for transgender individuals is now recognized as essential surgery, facial GCS (FGCS) remains predominantly classified as cosmetic. Despite current beliefs, there is increasing evidence showing marked quality of life following surgery, with official standards published by the World Professional Association for Transgender Health recognizing FGCS as medical necessary. Looking to historical precedents, many parallels between the movement of wartime facial reconstructive surgery from the realm of elective into essentiality can be drawn in comparison to FGCS. Using these two prominent examples in facial surgery, this paper explores the question: what should constitute essential surgery?