In war, amputees might be celebrated as heroes. But those with damaged faces endure a far different reception.

They “often caused feelings of revulsion and disgust,” says medical historian and author Lindsey Fitzharris. Her nonfiction book, “The Facemaker” (Farrar, Straus and Giroux, $30), is this summer’s FYI Book Group pick.

Fitzharris is a Chicago native living in England — she fell in love with the country while doing graduate work at Oxford University 20 years ago. Her book tells the story of plastic surgery’s World War I roots and the pioneering doctor who, she writes, “may have restored these men’s faces, but figuratively, at least, they remained faceless due to their great number.”

That’s 280,000 soldiers from Germany, Britain, and France, alone, who sustained facial trauma of a totally different nature from soldiers during any past conflict due to trench warfare and innovations in weaponry.

Harold Gillies is the surgeon at the heart of Fitzharris’ narrative. A New Zealand native, Gillies was a London otorhinolaryngologist (or ENT) who excelled in every pursuit, be it medical or athletic — and he loved a challenge.

At the start of the war, he left a cushy job to volunteer with the Red Cross and soon met an eccentric dentist who drove a Rolls-Royce retrofitted with a dental chair and equipment for fixing or pulling soldiers’ rotting teeth.

The dentist clued in Gillies to the incredible need for wartime facial reconstructive surgeons.

What developed was a then-unusual cross-specialty collaboration that came to include not only Gillies and the dentist, but an international mix of illustrators, sculptors, photographers, early radiographers and trailblazing hematologists and anesthesiologists all working not only to save lives, but to restore soldiers’ faces.

While healing any battlefield injury was urgent — particularly during what one medical officer in the book described as “a war of faecal (sic) infection” — the men in Gillies’ care took urgency to a new level.

In many cases, these particular soldiers were on their feet, organs intact, but were missing entire sections of their faces, exposing brain tissue or leaving them unable to blink, eat or drink.

To make matters worse was — and still is — the stigma of facial disfigurement.

“You just have to look at Hollywood to know that we have problems with disfigurement. A lot of villains are disfigured: Darth Vader, the Joker, Harvey Dent becomes evil after he’s injured and disfigured,” Fitzharris said on a call from her home on the outskirts of London.

Additionally, derogatory terms used during WWI persists today, such as “two-faced” and “losing face.”

Gillies understood that victims of atrocities needed not only a serviceable repair job but as close to a “regular” face as was possible. Fitzharris writes that the surgeon worked from the inside out, achieving the greatest cosmetic results only after restoring the function of the area.

However, he and his colleagues strove toward that goal without textbooks, mentors or, really, any type of useful precedent, though records show attempts at eyelid reconstruction, for instance, in Rome as early as the first century.

And while rhinoplasty, Fitzharris notes, dates back 2,000 years to an Indian surgeon named Sushruta, ideas and techniques for reconstructing the rest of the face were harder to come by, especially in light of the devastating damage many of the soldiers had sustained.

Fitzharris, who describes herself as a strange child and even stranger adult, said she grew up dragging her grandmother to cemeteries to hunt ghosts. Those around her thought she was morbid and possibly obsessed with death, but it was really that she was fascinated by people who lived long ago — reading gravestones was her first form of research.

The author said that medical history, as far as she’s concerned, is the most relatable kind. “If you don’t like history, you may like medical history, because everybody knows what it’s like to be sick.”

For “The Facemaker,” as well as for her first book “The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine,” she searched for voices from the past in archives rather than graveyards.

She located plenty of medical accounts to draw from, despite a fire caused by a WWII air raid that destroyed many of Gillies’ notes and thousands of anatomical specimens. It was the patients’ voices she had to dig for and, when she found them, she couldn’t always be sure they were reliable.

Fitzharris unearthed war poetry, war diaries, and many letters, but “the disfigured soldiers themselves didn’t often write too much about their experiences. … And even when patients talk about their experiences, they’re not always as open, or maybe even as honest about those experiences.”

Again, that may have been because of the stigma of facial injuries.

She writes that for centuries a marked face was “interpreted as an outward sign of moral or intellectual degeneracy. People often associated facial irregularities with the devastating effects of disease, such as leprosy or syphilis, or with corporal punishment, wickedness, and sin.”

In many cases, Gillies or one of the other fledgling plastic surgeons, succeeded in giving their patients new faces — some better than others, particularly toward the end of the war. But in other cases, or sometimes in between procedures, the patients resorted to custom-made masks reminiscent of “The Phantom of the Opera.”

The masks were heavy, made of silver or other metals and weighed as much as three pounds. They were hard to secure and the paint eventually flaked off. Worse, the masks, obviously, couldn’t age with their wearers, and their fixed expressions could be unsettling.

Yet, at the time it seemed a mask was better than the “disfigurement,” as it was called, and kept people off the blue benches.

On the grounds near Gillies’ hospital sat several blue benches designated for the patients undergoing facial reconstruction with the goal of signaling passersby to avert their eyes. The men also wore blue hospital uniforms with the same objective.

“Unfortunately,” Fitzharris writes, “this further contributed to the othering of disfigured people and must have made some patients feel even more isolated during their time there.”

Yet the men unintentionally acted as catalysts for advances: to plastic surgery, to anesthesiology, to hematology and to other areas of medicine.

Nurse Catherine Black, as quoted by Fitzharris, said, “[T]he Great War in which millions of lives were sacrificed was indirectly responsible for saving millions of others.”

But, ironically, these advances in medicine also worked to prolong WWI, keeping armies stocked with soldiers.

“(Medical advancement) was a double-edged sword during the war and certainly did serve to prolong the war in some instances,” Fitzharris said. “Also, it was awful for the nurses and the doctors to work on these men for months, sometimes years, send them back to the front and then find out they died from some other kinds of injuries.”

By the armistice, however, the new art and science of plastic surgery wasn’t so embedded in the culture that those who’d laid its foundation were certain of continued work in the field; doctors who wanted to open private practices would necessarily transition from treating victims of armed conflict to elective, but often no less life-changing, cases.

For instance, in 1949 Gillies was the first surgeon to successfully perform a female to male gender-affirmation surgery, and his technique became the foundation for modern phalloplasty.

Fitzharris quotes that particular patient as neatly summing up the work of plastic surgery as performed by Gillies: “…one aim had always been to make life tolerable for those who either Nature or man had ill-treated without regard to conventional views and to many a one he must have given renewed hope and a new start.”

Today’s soldiers in Ukraine have dug trenches winding through the 600-plus miles of the front line and are sustaining injuries similar to those of WWI. Fitzharris said she couldn’t have foreseen a modern war equivalent as she worked on “The Facemaker.”

Even as she wonders what advancements will come of today’s wartime reconstructive surgery, she hopes that readers of her book will question what war does to the human body.

“We think about casualties, we think about death, of course,” Fitzharris said, “but not about the people who are wounded and survive. That gets even more complicated when those wounds are socially unacceptable, when they’re wounds to the face.”

Join the Group

The Kansas City Star partners with the Kansas City Public Library to present a book- of-the-moment selection. We invite the community to read along. Kaite Mediatore Stover, the library’s director of readers’ services, will lead a discussion of Lindsey Fitzharris’ “The Facemaker” at 11 a.m. Sunday, Aug. 20, at the National WWI Museum and Memorial. The author will join the conversation via video call. Email Stover at kaitestover@kclibrary.org to join in or to learn about other discussion dates.

View Event Details »

An Excerpt

Bell’s features were swollen beyond recognition, but Gillies wasn’t concerned. He could see beyond the angry swelling to what Bell would look like once the reconstructive process was complete. Gillies was excited by the result, since he felt that it underlined the value of a fundamental principle of plastic surgery. “The first step toward filling a tissue gap was to keep what was normal in its normal position,” he wrote, “or (as in Private Bell’s case) … move it back into its original normal position and retain it there.” This, he believed, was the cornerstone of this strange new art. …

Bell’s case was a difficult one, given the severe loss of tissue exacerbated by the hasty closure of his primary wounds at Valadier’s hospital. The reconstructive work required specialist skills that most surgeons at the time simply did not possess.

Stitching a large cut on a leg was nothing compared to the delicate task of sewing together a deep cut to the face. “A good style will get you through,” wrote Gillies. “Surgical style is the expression of personality and training exhibited by the movements of the fingers; its hallmark – dexterity and gentleness.” As Harold Gillies illustrated time and again at Sidcup, the plastic surgeon was more than just a competent craftsman. He was, above all else, an artist.