Design Surgeons

Marcos Cruz (2008)

Article published in AD – Neoplasmatic Design
(guest-eds Marcos Cruz; Steve Pike),

November/December 08, Vol. 78 No 6, John Wiley & Sons, London, pp. 46-51
Text © 2008 John Wiley & Sons Ltd.

There has been much discussion about the increasing interdisciplinary synthesis between various research disciplines, but less said about the emergence of new professions that result from contemporary advances in biomedical sciences, especially in respect of the impact of design in these fields. In this context, the creation of synthetic neoplasms1 as shown in David Cronenberg’s movie eXistenZ (1999)2 is a noteworthy example, prompting fundamental questions about where and how the featured game-pods are created, and who is the designer behind such hybrid constructs: a professional, who uses tools and techniques, as well as possessing expertise that certainly goes beyond the training of a conventional surgeon, extending to the design of ‘semi-living’ conditions.3

The Surgeon as a Sculptor

To contemplate the evolution of this new professional figure it is worth reflecting on the practice of the great German-Jewish plastic surgeon Jacques Joseph and his invention of the Senn-Joseph flap technique4 that enabled him to reconstruct the face of a patient who had lost half of his own one during the Crimean War. Without surgical precedent and using very rudimentary instruments, Joseph anticipated the results of the procedure using a virtual template that he conjured up through the power of his imagination alone, and his pioneering method is still used today in the practice of reconstructive surgery. Although the technique was born of honourable intentions, Joseph’s intervention raised questions about the aesthetic parameters he was following during the reconstruction procedure, which exposed latent cultural anxieties about the surgeon’s instrumental power to redesign the human body, such as those conjectures made by the medical historian Sander Gilman who questioned the validity of a surgeon as a sculptor.5

The American novelist Mary Higgins Clark explained this functional dualism, of artist and surgical technician, as the ‘Pygmalion fantasy’ of a surgeon,6 referring to the figure of a sculptor in Greek mythology who falls in love with his own creation and wishes to bring it to life. The highly subjective nature implicit in such an act confers the plastic surgeon as possessing ‘dangerous’ powers of inflicting deliberately chosen parameters that enable him to work outside the confines of medical ethos and, in turn, challenging the conduct of certain surgical interventions within the medical sciences. This is of particular importance when considering how the impact of rapidly emerging technological advances is enabling contemporary surgeons to perform ever more complex and, until now, unimaginable operations. Ultimately, these procedures could lead to fully redesigning the human body, or even to the creation of completely new living beings, as shown in Patricia Piccinini’s provocative artwork Science Story (2002).

The speed of technological progress is reflected in the increasing sub-specialisation within the practice of plastic surgery, which has led to the loss of an overview regarding what is happening within the field as a whole. The exclusive territories of plastic, aesthetic, cosmetic and reconstructive surgeons are being challenged by developments in other surgical, medical and allied-medical specialities such as transplant, dermatological and cosmetic surgery, along with the specific practice of cosmetic dermatologists, aestheticians or cosmeticians currently exploring the emerging territory of anatomical design.7 This blurring of professional boundaries provokes further discussion about deontological priorities, which distinguishes between an understanding of medicine that ‘does not acknowledge “beauty” as one of its goals … [or] in which the creation of a “beautiful” face and body is asserted as a legitimate medical goal’.8 In other words, it is a debate that goes beyond the implication of the surgeon’s practice as a reconstructive sculptor, introducing design as a new method and conduct.

The Operating Theatre as an Art Studio or Workshop

The French multimedia artist Orlan employed surgeons to transform her aesthetic identity into one of her own creation during a series of operation performances in which she considered her flesh to be the artist’s canvas, and effectively surrendered her body as an object of design. The sci-fi clinician Rachel Armstrong described it as ‘the beginning of a new phenomenon in medicine: designer anatomy’,9 a concept that precedes the idea of Designer Surgeons. Orlan’s challenge to the medical profession, however, went beyond the confines of medical aesthetics. She set a new politics for the operating theatre where surgery became a mediatic event and the operating theatre was subverted to become a new kind of art studio, democratising the place of surgical practice. It is already a quite common practice that physicians, whether acknowledged specialists or not, can carry out surgery, especially plastic surgery, away from the visible control of medical institutions.10 This means that surgery is returning to its once controversial professional state, in which almost any practitioner could undertake operations at any site or place.

This decentring of surgical control is revealed in Cronenberg’s eXistenZ with a variety of backyard environments in which surgery takes place, where unconventional sites are used to treat and operate the game-pods, including a car mechanic’s workshop, a ski club and a converted barn.11 These places do not just host a series of rather suspicious individuals who give the impression of having the expertise of surgeons, but also challenge the clandestine and grotesque nature of Cronenberg’s neoplasms with a technological sophistication required in such design and manufacturing processes, most of which is already available today.

Design of Synthetic Neoplasms: New Methods of Planning in Surgery

Scale is a fundamental precondition of designing synthetic neoplasms. Recent developments in biological and medical sciences have shown that molecular design has the potential to manipulate genetic codes that can alter cellular growth as well as the functions of cells. When combined with nanotechnological devices, it is possible, for example, to revitalise or manipulate the longevity of living systems. Research on biomaterials has shown how the growth of natural or artificial organs and skin tissue can be accomplished on a cellular level by combining biological systems and synthetic materials.12 Contemporary surgery has also reached the point where the transplant of organs and tissue has become a daily practice. Immunological as well as technical problems, such as keeping organs alive, and the assembling of the different connective organs or ducts within the host body, have gradually been overcome – see performance artist Stelarc’s recent implant of his Extra Ear.13

Micro-machinery and larger-scale devices are also being inserted in the body, hybridising human flesh with machine supplements – see Kevin Warwick’s recent implant.14 The manufacturing of biocompatible prosthetics, advances in visualisation techniques, and high-precision operation tools such as the da Vinci Surgical System15 are increasingly been implemented in surgery with the help of complex computer software. Furthermore, the possibility of planning and rehearsing the operations through new 2-D/3-D digital techniques is allowing surgery for completely unprecedented operations; a realisation that the American historian Timothy Lenoir recognised is giving medicine not just immense predictive, but also experimental, power,16 which is obviously of great importance for the creation of new and synthetic life.17

The Surgeon as a Technician Versus the Surgeon as a Designer

Designer surgery, however, is currently beyond the scope of traditional medical education and practice.18 As Lenoir has shown, apart from more conventional ‘background knowledge in the texts and practices of anatomy, biochemistry, physiology, and pathology, including some traditional practices from earlier generations … new fields such as biophysics, computer graphics and animation, biorobotics, and mechanical and biomedical engineering’ are necessary. ‘They will also need to be aware of the importance of network services and bandwidth issues as enabling components of their practice.’19 That means that such evolution is forcing ‘the last generation’s heroic surgeon’ like Joseph to be upgraded to a new type of ‘techno-supersurgeon’ as Lenoir has suggested,20 simultaneously imposing an inevitable division of the profession in a multitude of different yet complementary professional experts.

The creation of a supersurgeon has further implications in as much as ‘…creativity will be of a different sort, as many of the functions now internalised by surgeons are externalised into packaged surgical design tools just as computer-aided design packages such as AutoCAD, 3D Studio Max, or Maya have reconfigured the training, design practices and creativity of architects. Some surgeons with access to resources will undoubtedly engage in high-level surgical design work, but that process will be mediated in teamwork involving software engineers, robotics experts, and a host of others.’21

What is significant in this comment is that Lenoir predicts a multi-task performance in the surgeon’s practice that involves hands-on operations and simultaneously the act of design. Performed by more than one single surgeon suggests a split in the profession that brings about mutually dependent surgeons that work with a team of other specialists, including traditional surgeons, and new types of designer surgeons. The former stand in the tradition of surgeons as interventionist agents who are able to restore and alter the human body, whereas the latter envision and prepare the operations in terms of modelling and visualisation techniques. Although familiar with practical operation procedures and in direct contact with interventionist surgeons at all times, such surgeons remain rather theoretical and conceptual and with the crucial responsibility to overview the whole process. This is clearly seen in eXistenZ in the role of Allegra Geller who is the ‘designer’ of the game-pods without, however, being able to manufacture and operate them. In other words, to create Cronenberg’s synthetic neoplasms the traditional interventionist surgeon as a remodeller and reconstructor complements the job of the designer surgeon as planner and modeller.22

In the end it is worth questioning what the importance of all this is for architecture and how this might affect the way in which we understand our profession in a near future where our built environment might become hybridised with biological systems that require medical interventions. Considering the complexity and scientific expertise that will be inherent to such systems, which a designer is by default not trained to handle, one has to assume that the role of surgeons who increasingly embrace new tools of design will become of particular relevance. On the other hand, architects and designers are utilising news tools, such as sophisticated CAD/CAM processes that were originally implemented in the medical sciences,23 as well as considering completely new scales of operation that they acknowledge are becoming of ever growing importance for their projects. In fact, their workstations are becoming conspicuously similar to those used in contemporary surgery.

William Mitchell gives an interesting account on the potential intermingling of different work procedures and scales in a variety of research fields, arguing that:
Today, [traditional] scale chauvinism makes little sense. The solution to a given design problem might be found at any scale or combination of scales ... It makes even less sense to draw sharp distinctions between non-living and living systems. As biology, materials science, mechanical engineering, and electronics all get down to the molecular scale, they deal with the same types and sizes of structures, and there is a growing crossover of interests and goals. As biologists engage ideas of modular recombination, slicing, and cloning, they begin to think like designers. Conversely, as designers tentatively embrace concepts of emergence, self-organization, self-assembly, and self-replication, they start to sound like biologists. Increasingly, the CAD console meets the wet lab, and the circuit shop keeps company with the chemistry bench.24
With this comment, Mitchell does not just call to mind a professional fusion that is already in place with the work of biochemists and bioengineers, for example, but also clearly predicts the advent of Designer Surgeons who have already conquered sufficient freedom in terms of ethics, work place and know-how (combining simultaneously scientific and artistic work methodologies) in order to realise the biologicalisation of architecture that so many envision.

1. The concept of synthetic neoplasms is discussed in another article in this issue by the same author: see ‘Synthetic Neoplasms’, pp xx–xx.
2. Director: David Cronenberg; Production: Screenventures XXIV Production Ltd/Alliance Atlantis Company and Existence Productions Limited, 1999.
3. This expression was originally used by Oron Catts and Ionat Zurr of the Tissue Culture and Art Project (TC&A). See
4. A primitive version of this technique was invented by Nicholas Senn in 1903 and later accomplished by Jacques Joseph in 1918 without having any knowledge of his predecessor. See Paul Natvig, Jacques Joseph: Surgical Sculptor, WB Saunders Company (Philadelphia, PA), 1982, p 10.
5. Gilman talks about this problem when referring to the relationship between the surgeon as a sculptor and the patient as a classical statue. See Sander L Gilman, Making the Body Beautiful: A Cultural History of Aesthetic Surgery, Princeton University Press (Princeton, NJ), 1999, p 235.
6. Ibid, p 318.
7. Gilman lists numerous specialisations, including mentoplasty, otoplasty, blepharoplasty, rhytidectomy, rhinoplasty, brachioplasty, mammaplasty, matopexy, posthioplasty, lipectomy, gynecomastia, abdominoplasty and more general terms such as ophthalmic surgery and otorhinolaryngologic surgery. Ibid, pp 5–7.
8. See the passage ‘Why is it Aesthetic Surgery?’ in Chapter 1 of ibid, pp 8–16.
9. Rachel Armstrong, ‘Anger, art and medicine: Working with Orlan’, in Joanna Zylinska (ed), The Cyborg Experiments: The Extensions of the Body in the Media Age, Continuum (London), 2002, p 173.
10. See Gilman op cit, p 6.
11. In eXistenZ the backyard workshop of a petrol station is used to implant bioports in the human spine, necessary to plug the game-pods into the player’s body. A ski club, on the other hand, is the environment where game-pods can be surgically repaired, while a barn is transformed into a factory where mutated amphibians are dissected, their organs extirpated, redistributed and then reassembled into newly created synthetic organisms.
12. See Buddy D Ratner, Allan S Hoffman, Frederick J Schoen and Jack E Lemons, Biomaterials Science: An Introduction to Materials in Medicine, Academic Press Inc, 1996, p 1.
13. See
14. For more about Warwick’s implants, see
15. While at SRI (formerly the Stanford Research Institute), Philip Green was instrumental in the initial development of this medical device for use on the battlefields. This eventually led to the design of the surgical robot used in operating rooms all over the world, which is now known as the da Vinci Surgical System and produced by Intuitive Surgical, Inc.
16. See Timothy Lenoir, ‘The virtual Surgeon: Operating on the data in an age of medialization’, in Phillip Thurtle and Robert E Mitchell (eds), Semiotic Flesh: Information and the Human Body, University of Washington Press, 2002, p. 28
17. Ibid.
18. Ibid, pp 43–4.
19. Ibid.
20. Ibid, p 43.
21. Ibid, p 44.
22. The removal of the prefix ‘re’ in common terms such as re-construct or re-build represents a meaningful change in attitude and performance of the traditional surgical practice and changes it into a new role of Designer Surgeon.
23. It is not a coincidence that the first CAD/CAM machines used at the Bartlett School of Architecture where purchased second hand from the medical department at UCL where they were originally used to produce complex bone prosthetics.
24. William J Mitchell, ME++: The Cyborg Self and the Networked City, MIT Press (Cambridge, MA), 2003, pp 71–2.