Surgery as ritual

An "only-in-California" practice leads to altars in the OR — and perhaps smoother recoveries

Angela Wyant


It’s a day almost like any other in the operating room. A nurse sets up an IV, a technician lays out shiny instruments and an anesthesiologist makes last-minute checks. But patient and surgeon are occupied with less-conventional preparations. The patient, who has come for a new breast, walks in and positions two small rocks and two photographs on a rolling surgical tray. She then sits on the operating table, knee-to-knee and hand-in-hand with her doctor. The two talk softly, glancing now and then at the altar-on-a-tray. The physician asks her patient what today’s surgery means to her, beyond the addition of a body part. They talk about femininity and energy and healing. After about 10 minutes the patient lies back and calmly spreads her arms. The medical team moves in, and the reconstructive surgery begins.

The surgeon is Loren Eskenazi, MD, class of ’90, and that moment of pre-op connection is one way she honors the age-old urge to engage in ritual. Noting parallels between elective plastic surgery and ancient rites of passage, she says many Americans are using plastic surgery, consciously or unconsciously, as an initiation rite to mark significant transitions in their lives. Approaching surgery as ritual — what she calls “transformational surgery” — can benefit patient and physician, she says.

“Plastic surgery is more about what’s going on in patients’ lives and less about their body parts than most people are willing to admit,” says Eskenazi, a board-certified plastic surgeon in San Francisco and a fellow of the American College of Surgeons. She specializes in cosmetic and breast surgery for women and is a contributing author to Consciousness and Healing, a 2005 collection of essays on health, healing and mind-body medicine.

 Transformational in more ways than one

Lydia Barrett, a 42-year-old software executive from Pleasanton, Calif., says she knew in March, after her 14th unsuccessful infertility treatment: “It’s time.” Within months she was in the OR with her two small rocks and the photos. “I had been living for four years with one breast and I could have continued to do that,” says Barrett, who had a mastectomy in 2001. “But the reconstruction is for me really more than just surgery. It’s almost a gaining back of something around my femininity.”

Having taught about cross-cultural practices of body modification when she was a Stanford resident, Eskenazi says that the timing of these elective surgeries is an initiatory process. “The whole surgical sequence is the exact same as any ritual sequence in any culture at any time throughout history.” She notes:

  • The occasion of a rite of passage is often some social or personal crisis. Similarly, patients are brought to surgeons’ offices by illness, accident or other potentially life-changing event.
  • Formal rites of passage often begin with fasting and contemplation. In the surgical sequence, the patient follows the doctor’s “NPO” order — nothing by mouth for hours before the operation.
  • Ritual initiates are ceremonially cleansed with smoke or water. Surgery patients wash with antibacterial soap.
  • Initiates are stripped of outer garments and redressed in ceremonial garb. Patients relinquish street clothes and don standard-issue hospital gowns.
  • Initiates ceremonially proceed to a temple or other sacred ground and lie down on an altar. Patients bid family a temporary good-bye, proceed to the “otherworldly” space of the OR and lie on the operating table.
  • Initiates undergo the transformational ceremony — often a blood ritual — in an altered state, induced perhaps by dancing, drumming or hallucinogens. Patients yield consciousness to sodium thiopental and undergo surgery, which Eskenazi characterizes as “a modern blood ritual enacted for the purpose of healing.”
  • Initiates rejoin their community as newly reborn into a different role: Perhaps a boy has become a man or a widow is available for re-marriage. Patients emerge from the recovery room, forever visibly changed, to undertake healing and rejuvenation.

Eskenazi emphasizes she does not recommend using surgery as an initiation rite. Rather, she believes that while other societies engage in ceremonial ear piercing or tattooing to mark life transitions, plastic surgery has become something of a substitute ritual for Americans. “We don’t have the communal witnessing of a person stepping from one position in their life to another,” she says.

“If we had more ritual, there would be less plastic surgery in our society,” says Eskenazi, who is writing a book about cosmetic surgery and ritual to be published next year by HarperCollins.

The breast specialist says the surgery-as-ritual notion doesn’t fit every patient, but it resonates for some. So once a month Eskenazi performs “transformational surgery.” A good candidate is someone receptive to the idea that a hankering for a perkier nose or smoother brow might have some deeper meaning. The patient spends several hours with a collaborating counselor, exploring the emotions behind the desire for surgery and designing a modest ritual to accompany the procedure. “We encourage the mind to be in line with what the body is about to go through,” Eskenazi says. After surgery, patients meet again with the counselor.

Barrett had not heard of transformational surgery before, but she leapt at the opportunity. “It let me manage what the surgery meant in my life,” she says, “as opposed to feeling like a victim of the circumstance. Here I was just two weeks before a major surgery, and I felt almost excited about it.” Another cancer survivor symbolically chucked her “patient identity” by locking old medical records in a suitcase Eskenazi tossed into a hospital trash bin.

Patients often conduct a brief ritual right in the OR. “It’s very moving to have an entire operating room stop and be quiet and listen to someone saying something very intimate before they have surgery,” Eskenazi says. “It completely changes the tenor of what goes on during the surgery.”

The patients’ pre-op exercises have post-op effects, Eskenazi says, based on her post-op clinical observations and patients’ follow-up interviews. “The people who do that work beforehand have less nausea, less pain, less bleeding and less need for repeat surgery.” The surgeon has plans for a formal, quantitative study.

Inspired by the power of ritual to touch lives and effect healing, Eskenazi recently founded the non-profit Institute for Transformational Surgery. She intends to expand her practice of surgery as ritual. “It’s made me feel like much more of the healer that I was trying to be when I went to medical school.”


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