Flesh Wounds
by Virginia L Blum
384pp, California, £19.95

A maddeningly small author photograph adorns Virginia L Blum's investigation of plastic surgery, made yet more annoying by the hank of wavy hair that partially obscures one side of her nose. For this is not just any nose. It is a "rescued nose". It inspired the very promising first line of Flesh Wounds, her investigation of cosmetic surgery: "My first nose job was performed by an otolaryngologist (otherwise known as an ear, nose and throat doctor) who, in concert with my mother, encouraged me to have surgery."

Reading on, Blum's mother will have been left in little doubt that Virginia L is still extremely pissed off. With the otolaryngologist, at any rate. "I remember him as a monster, as the slayer of my nose, the creator of a surgical subject." The more fury Blum expresses, the more desire her readers may feel to see the relevant cartilage in the various stages of its career: before, then the after that looked more like a "before", then the after that is her current nose. For after the slayer had trashed Blum's original, she was obliged to seek further, corrective rhinoplasty, from a surgeon who, as she was going under anaesthesia, remarked to his nurse: "Look what some joker did to this poor girl's nose."

The nose experience has left this American academic so "damaged and vulnerable" that she is always close, she confesses, to reverting to the passive "patient position" - in defiance of "half a lifetime of cultural inquiry and feminist protest". Still, it seems safe to say that no reader of Flesh Wounds will be left in much doubt about the latter enthusiasm. Her zest for cultural inquiry and feminist protest is so great that, without the victim-legacy of her nose jobs, Blum's book might be consistently, instead of sporadically, unendurable. For instance: "While the order of the simulacral is the consequence of western styles of power, specificially capitalism's, it also constitutes the fundamental undoing of power, as Baudrillard shows."

Still, Blum asks some good questions. Such as, however did cosmetic surgery get to be so big? In 2000, she reports, "roughly two million people risked death for the sake of their appearance". What makes women - and increasing numbers of men - so amenable to spending their life savings and being carved into pieces in order to disguise their true age? Why do so many come back for more?

The techniques of cultural inquiry do not always offer very clear answers. Interviewing cosmetic surgeons, Blum is most interested in speculating on their subconscious relation with patients. Such as herself. "It is possible," she writes, after one or two of them have been a bit uppity, that "plastic surgeons are acting out in a socially sanctioned way their aggression on bodies that have been shaped by forces other than their scalpel." Yep, it's possible - but it hardly begins to explain the vogue for surgery. After all, by the time they book an appointment with the surgeon who is about to experience a clear case of countertransference, most patients have already decided to get their face or bottom done. Something else brought them to the waiting room. A combination of longevity and omnipresent age discrimination? Wealth? An epidemic of body dysmorphia? The obsession with looks that is currently being denounced by Britain's ugly duckling turned drop-dead gorgeous anti-abortion campaigner, Joanna Jepson?

Blum proposes, by way of many wearisome digressions about films, novels and television programmes, that the boom in plastic surgery is associated with the emergence of psychoanalysis, that other route to personal fulfilment, and with the simultaneous rise of celebrity culture. Seduced by celebrity images we have come, she argues, to locate our identities on the surface of the body, as opposed to believing, like our ancestors, that the face and body express inner character. "Before the 1970s," Blum says, "mental health professionals generally believed that cosmetic surgery-patients suffered from some kind of pathology and were better off treated with therapy than surgery." Today, "many of us are convinced that internal feelings and even character can be transformed by interventions on the surface. Such a conviction is central to the practice of plastic surgery." Then again, back in the 60s they'd never heard of Botox.

Almost as central to the practice of contemporary plastic surgery - and, surely, to the potential of her own theory - is the question of whether it actually works on the "many of us" hoping to achieve a transformation. After all, many people's conviction that their lives could be changed for the better by surgery will falter each time they see a picture of Michael Jackson, or closer to home, the immobile visage of Mrs Jeffrey Archer, or Leslie Ash's "trout pout".

Blum herself appears curiously uncertain about plastic surgery's power to effect physical transformations, and has not interviewed enough plastic surgery patients to be very enlightening on levels of satisfaction. Occasionally, her own doubts are enough to make anyone who might be considering a bit of surgery think again. She describes a facelift operation in deliberately repulsive detail: "Hearing the scalpel rasp against the bone unnerved me ..."

Perhaps it is her damaged patient persona talking, but elsewhere Blum becomes so positive about surgery that resistance comes to look perverse. One surgeon's portfolio of reshaped faces is described as "impressive". She does not argue with another, who says: "You can talk about all the inner beauty you want, but the fact of the matter is that appearance makes a tremendous difference insofar as sexual appeal or for jobs." She says: "If your nose turns up, if your thighs are thinner, if you look younger - you can have a better life. You will in turn feel better. The inner you - however you describe that being - will be transformed."

So a book that begins with the cautionary tale of the wrecked nose ends, perhaps inadvertently, by suggesting that it is not so much the democratisation of plastic surgery that requires an explanation, as the fact that so many people who could afford a surgical transformation stubbornly preserve their wonky noses and crumpled skin.