The Making of a Plastic Surgeon- Two Years in the Crucible Learning the Art and Science
Chapter 5- Introduction to Cosmetic Surgery
Chapter 5- Introduction to Cosmetic Surgery
“The high profile, high profit stuff makes it possible to do reconstructive surgery on needier patients.”
Michael J. Fox as Dr. Benjamin Stone, in Doc Hollywood
Of all the things I was learning about for the first time at Jackson, cosmetic surgery was, by far, the most unique and the greatest departure from anything I had ever done. On Okinawa, I had done some skin grafts and small flaps, but beyond a few simple scar revisions, nothing cosmetic. Cave’s practice in Oakland was mostly reconstructive.
Cosmetic surgery is the cause of much confusion regarding the specialty of plastic surgery. For many, if not most, people, including many doctors, plastic surgery is synonymous with cosmetic surgery. This all-too-common misconception has several causes. One of these is plastic surgeons themselves. Until the early 1980s plastic surgeons who confined their practices to cosmetic work grew their practices in the traditional way, slowly, through word-of-mouth referrals from satisfied patients. That changed forever in 1977 with the United States Supreme Court decision allowing professionals, such as lawyers and doctors, to advertise their services. The ruling opened the floodgates of advertising by professionals and proved a boon to cosmetic surgery with some plastic surgeons taking full advantage to market their cosmetic services.
In 1987, a glossy ad spread across eight pages appeared in an issue of Los Angeles magazine. The ad featured a two-page color photograph of a comely model in a revealing white bathing suit standing next to a red Ferrari. The text was simple. It read, “Automobile by Ferrari, body by Forshan.” The ad made major waves with some plastic surgeons saying, “Right on!” and others decrying it as unprofessional. The Federal Trade Commission investigated the ad for deceptive advertising but ultimately took no action. The American Society of Plastic Surgeons, however, censured its member, Dr. Vincent Forshan, because he did not perform any surgery on the model in the photo. She was actually the patient of another plastic surgeon. If the reader doubts that such advertising is effective, consider that over three decades later, I remember that ad like it was yesterday.
The license to advertise was largely responsible for an explosion of interest in cosmetic surgery, a fascination that the decades since have not dimmed. Over the years, growing acceptance of cosmetic surgery has made it increasingly popular, however controversy still surrounds it with widely differing opinions among the general public and physicians alike. At one end are those who believe that it should be available to everyone and is simply a logical extension of grooming ourselves to look our best. For others, it is the extreme expression of a shallow society obsessed with youth and superficial appearance over substance. Among surgeons, some find it appealing and challenging while others regard it as a frivolous misuse of the surgeon’s training and skill. I believe that a measured view would place it somewhere between these two extremes.
Few things are as fundamental in life as our identity, and identity is inextricably tied to appearance. Plastic surgery, at its core, is the surgery of identity. We have a genetically determined physical appearance which we see every time we look in a mirror. It may change with time and circumstances, but it is always uniquely our own. Physical features set us apart as individuals but they can also unite us, as members of the human race and, more specifically, as part of a particular race, ethnic group, or culture. Our physical appearance changes over time mostly through the complex, multifactorial process we call aging. Changes can also occur through weight gain, one of the most common issues of modern life in the U.S.; accidents, which can leave scars and alter our appearance; and medical/surgical intervention, which can do the same. These changes in appearance can have far-reaching consequences. The supermodel with a small but potentially career-ending facial scar; the housewife, whose self-image and sexuality are threatened by the loss of a breast to cancer; and the middle-aged executive, whose droopy eyelids make him look prematurely old and place him at a disadvantage competing with younger individuals, are all dealing with appearance as their primary concern. In some cases appearance alone can precipitate an identity crisis.
Reconstructive plastic surgery, as the name implies, involves surgery to restore appearance, function, or both to some part of the body that has been altered by an accident of nature, trauma, or illness. This deformity can be congenital, as in a baby with a cleft lip. It could be a worker whose hand has been crippled from a severe accident, a woman whose breast has been removed to treat cancer, or an adult whose face has been disfigured by removal of a large skin cancer. The goal of reconstruction is to restore normalcy, or something as close to normalcy as possible.
Cosmetic plastic surgery is surgery to improve on a feature that is natural and would be regarded as normal, although not necessarily attractive or desirable. The common denominator of all cosmetic surgery is that it is both elective and, strictly speaking, unnecessary. Otolaryngology is the only other surgical specialty that includes a significant amount of cosmetic surgery as part of its core residency training, however, this is confined to the head and neck. Only plastic surgeons are trained to perform cosmetic work anywhere on the body.
There are gray areas between reconstructive and cosmetic surgery. The dividing line between socially acceptable and unacceptable normal features can be subjective. A large, hooked nose in an otherwise attractive face, can be psychologically crippling. Some operations have both a reconstructive and a cosmetic component to them. Rebuilding a breast after cancer treatment is clearly reconstructive, however the reconstructed breast is not functional. The goal is a result that looks as cosmetically natural as possible. Simply putting an amorphous blob of tissue on the chest will not do.
Cosmetic surgery is based on a simple premise: people want to look their best. This innate human desire runs throughout recorded history and undoubtedly goes back much further. Everything we call fashion stems from this. As a married man, I can imagine this exchange between Adam and Eve as Adam leaves the house. Eve looks at him and says, “You’re not wearing THAT are you?”
Cultures and societies have long been identified by their clothing and other adornments. For many people, altering their natural physical features is nothing more than the logical extension of this desire to look more attractive and desirable, or simply to fit in. In some primitive cultures, members go to extreme lengths in this regard. Women of the Surma and Mursi cultures in Africa and Kayapo men in Brazil, stretch their lips to extreme degrees by cutting them and inserting increasingly larger flat, round, wooden plates in a primitive form of tissue expansion. Even today, some people do this by inserting progressively larger gauges in their earlobes and other places as well. In the Sudan, Dinka boys and girls subject themselves to scarification, the process of purposefully creating patterns of scars on their faces and bodies as a rite of passage into adulthood. They scratch their skin and pack clay or ash into the wound to stimulate inflammation, producing a thickened scar. This practice often celebrates a rite of passage, such as puberty, increasing the individual’s attractiveness to members of the opposite sex, and cementing identification with their tribe. Modern day tattoos and piercings speak to our desire to modify our physical appearance for all sorts of reasons.
I must admit that cosmetic surgery was a stumbling block for me in deciding to pursue plastic surgery. From the perspective of a general surgeon, cosmetic surgery appeared trivial and unworthy of a real surgeon’s time and effort. It was difficult to reconcile all my training in surgery with the idea of doing cosmetic nips and tucks on healthy people who just wanted to look more attractive. I rationalized this concern away by reasoning that I could devote my practice to reconstruction if I chose, so I put aside that reservation in pursuing a residency in plastic surgery. After starting my residency at Jackson, I learned that, in addition to his extremely busy reconstructive practice, Dr. Millard did a great deal of cosmetic surgery and had a waiting list of patients that stretched nearly two years into the future. In the days before social media, it was a rare surgeon who commanded such a devoted following. I posed my dilemma to him and asked him how he justified his cosmetic work. He gave the question some thought and answered, “Rick, if you cannot take a normal feature and make it better, you will never be as good as you can be in making a deformed feature look normal.” One of the plastic surgery principles he espoused was: know the ideal, beautiful normal. Without knowing this, we would have no benchmark by which to measure our reconstructive work. It made sense, and greatly eased my mind regarding cosmetic surgery. The surgical skills we honed on our cosmetic patients often had direct application in our reconstructive surgery.
Another argument advanced for cosmetic work is that the income from this, which is usually better than income from insurance companies for reconstructive work, can help free plastic surgeons to offer reconstructive surgery to the indigent and uninsured at little to no cost. For some surgeons, this argument is specious as they spend little to no time on anything other than cosmetic work and building up their financial portfolio, but for Dr. Millard, this was quite true. He regularly traveled to Jamaica to provide free reconstructive surgery to the poor in that country and, toward the end of his career, was awarded the Order of Distinction by the Jamaican government for his many years of voluntary service.
The volume of cosmetic work at Jackson, like the volume of reconstructive work, was huge. The volume of cosmetic work available to us was such that we had to take care not to schedule too much of it lest Dr. Millard feel that we were spending an inordinate amount of time on this.
While we did all our reconstructive work in the main operating room (OR), available time there was at a premium so, for most of our cosmetic work, we had access to a small operating room on a floor above the main OR. Although we had this reserved strictly for our use, we had no anesthesia support from the main OR. This meant that all cases were done with local anesthesia, with or without intravenous sedation. We did have a nurse to assist us, monitoring the patient, circulating, and administering medications under our direction. Periodically, we had medical students rotating on our service for a few weeks at a time. The better ones provided a welcome extra pair of hands in surgery.
In a typical case, the senior resident and I would be scrubbed in, with me assisting him or vice versa, and the nurse would monitor the patient and administer intravenous drugs per our orders to keep the patient comfortable. We used a cocktail of Demerol (a narcotic), phenobarbitol, and Valium (both sedatives). A large preliminary dose was given to get them sedated after which small doses were periodically administered to keep them quiet and comfortable throughout the surgery. Administering intravenous sedation like this is an art because every patient responds differently to the medications. Young, healthy patients can be deeply sedated with minimal doses. On the other hand, middle-aged and older patients, who regularly take any of the many available prescription sedatives, sleeping aids, or anti-anxiety medications, may require doses that would put down a horse. There can be a fine line between over- or under-sedation. Even today, with better drugs, it still requires attention and finesse. Because sedation alone was not sufficient to perform surgery, we also injected a local anesthetic into the surgical site. Looking back, with the perspective of decades performing surgery, I marvel that we did as much, and as well, with this rudimentary anesthesia.
Raiffe and I did our first facelift together eight days into my residency. He was the principal surgeon and I assisted. After the first couple of patients, he would do one side and assist me doing the other side. We did a traditional facelift, but with a number of innovations. It was, and remains, the gold standard for the procedure. Contrary to popular belief, a facelift does not tighten or lift the entire face; it tightens and lifts only the neck, jawline, and lower cheeks. We made incisions on both sides of the face that began in the temple, ran around the ear, and back into the hairline at the nape of the neck. The resultant scars were very inconspicuous; they might be seen by a hair-dresser, but not by anyone else unless they were actually looking for them. Through these incisions we would release the skin from the underlying muscles over the cheek, jawline, and neck from one side to the other.
The next step was to tighten the loose muscles with sutures. The muscle tightening avoided the need to pull the skin so tight and produced a more natural result. One of Dr. Millard’s innovations was to remove fat from the inner aspect of the cheek to flatten the natural crease there, the nasolabial fold, which can add to the aged appearance. Our facelift produced a very natural, lasting result with an acceptably low rate of complications. It is still used today.
We performed some incredibly long cases using this technique. On one patient we performed a facelift, browlift, and both upper and lower blepharoplasties (eyelid tucks). This totaled approximately 7 hours of surgery. She came through this amazingly well and obtained a beautiful result. The challenge with long cases was that patients would sometimes become restless, and it was difficult to titrate the medications to keep them quiet without over-sedating them. Although we asked all patients to empty their bladders before surgery, sometimes surgery had to be stopped so they could use a bed pan. This was not an easy thing to do in the middle of surgery. A full bladder could create real problems. In addition to making patients restless, the discomfort can cause a patient’s blood pressure to rise, and this could start bleeding in the operative field. This happened to one early patient.
Raiffe had to leave before the case was done so I was finishing up the second side. I was well into closing this when the lady began to complain of a full bladder. I tried to finish quickly to avoid the need for the bed pan maneuver. Sometimes, if the need was dire, our nurse would pack a few towels between the patient’s legs and tell them to “just go” to get relief immediately. Just as I put in my last stitch, I noticed that the left half of her face was visibly swelling, a sign of active bleeding. I removed some stitches and, when I reflected the skin back, this revealed several small, bleeding arteries, most likely due to a rise in her blood pressure from the discomfort of a full bladder. Once she used the bedpan and was comfortable, I was able to stop the bleeding and re-closed the skin incision. Happily, she had no memory of the flurry of activity at the end of her operation. I was so concerned about her that I made a house call that evening to satisfy myself that all was well. Her result was wonderful and remains among the best I have seen.
Sometimes this use of local anesthesia with IV sedation backfired as happened with one patient who probably aged me a couple of years. Lena had come to us seeking to have her upper eyelids tightened because she felt her eyes made her face look older and angry which, in fact, they did. The problem, however, was not her eyelids but the low position of her eyebrows which, in turn, caused the eyelids to droop and made her look both tired and angry. Her situation underscored the importance of knowing the ideal, beautiful normal and properly diagnosing the problem before offering a solution, another of Dr. Millard’s principles. Her eyelids were fine. What she needed was to have her eyebrows and forehead lifted.
A traditional forehead life is done through an incision that extends from ear to ear, across the top of the head and behind the hairline, where the scar will not be visible. The forehead is then freed from the underlying bone, peeled down to the level of the eyebrows, and pulled up to elevate them. It is essentially the same incision we used for Dave’s blowout fracture. The redundant skin is trimmed and the incision is closed. Despite many variations over the years designed to minimize the magnitude of this surgery, a full brow lift of this type is still the gold standard against which all other forms of upper face rejuvenation are measured. We offered this operation to Lena and she decided to go ahead. Her result was remarkable and changed her face dramatically for the better. She looked younger, happier, and strikingly much more attractive.
Lena’s low brow was apparently familial as her younger sister, Angela, had the same issue. When she saw Lena’s result, Angela came to see us. We scheduled her surgery fully expecting the same great result. We gave her the usual medications and injected our incision site with the local anesthetic. Shortly after we began, she started to move a bit. We gave her more sedation but instead of sedating her, it had the opposite effect. Some patients have this paradoxical response and it posed a practical dilemma. If we backed off on the sedation, she might become more agitated. If we continued to administer ever increasing doses of drugs, she might stop breathing. The best solution would have been to put her to sleep under a general anesthetic, but this option was not available to us.
Angela began trying to sit up on the operating table. Because of the sedation, reasoning with her was useless and the situation threatened to get out of control. Our only option was to abort surgery and get her off the operating table as quickly as possible. Lance had already made the incision so we closed this as quickly as possible. It was an object lesson in just how fast things can go downhill in cosmetic surgery, just as in any surgery. Angela was disappointed, but very understanding when we later explained why we had to abort surgery. I have found that when we are honest with patients, they tend to be very understanding and reasonable. We told her that the only way we would be able to do her surgery would be under a general anesthetic. On a rare occasion, we were able to find a block of time in the main OR for a cosmetic case requiring general anesthesia. We were unable to reschedule her during my remaining time on the Jackson service and I don’t know if she ever underwent her brow lift later.
At Miami, we had the unique opportunity to observe some of the top plastic surgeons in the country. Just a few miles down the road from Jackson, on a quiet residential street lined with Poinciana trees, was a house that, to outward appearances, fit in perfectly with the other upscale homes around it. The main house, however, had been converted into a medical office and the detached, two-car garage was now a cosmetic surgery center with two operating rooms. This was the office for Drs. Thomas Baker, Howard Gordon, and James Stuzin. All three held appointments as Associate Clinical Professors in the Division of Plastic Surgery at Jackson. The two senior members were highly respected in the plastic surgery community. Their practice was entirely cosmetic although the young associate, Stuzin, still did some reconstruction.
Baker was perhaps best known for popularizing a chemical peel which bore his name. The Baker Peel was a procedure in which a caustic mixture of chemicals was painted onto the skin of the face to produce a controlled burn. The healing process from this would result in skin that was smoother and more youthful looking. It was widely used and produced results that were unsurpassed, even by today’s skin lasers. Samples of skin taken from patients before and after a Baker Peel showed that the microscopic architecture of the skin looked years younger after the procedure. The procedure was simple, but the healing was messy and uncomfortable. Patients’ faces would swell impressively for several days and take upwards of 10 days to heal fully during which time we often described their appearance as resembling someone who had been “bobbing for French fries.” Once the peeling agent was applied, the face was covered with a mask of cloth tape, an adjunct which deepened the peeling effect. In a few days, the tape would come off and the patient would keep the skin moist with Vaseline ointment to avoid dry, cracking scabs. The Baker Peel produced sometimes astounding results in rejuvenating a sun damaged, wrinkled face. One 75-year-old woman whose peel I performed could have passed for 20-30 years younger after she healed. One of the limitations of the peel was that it permanently lightened a person’s normal skin tone. The skin bleaching was due to the toxic effect of the peeling agent on the skin’s pigment cells. It was only appropriate for persons with a relatively light natural complexion, otherwise the discrepancy between the peeled and adjacent, unpeeled skin in persons with darker complexions was just too great to be acceptable. Chemical peels were yet another new thing to me.
Residents were welcome to come over to the Baker and Gordon practice anytime to observe surgery, but we had to be discrete about this. Drs. Baker and Gordon were not on close, collegial terms with Dr. Millard, the reasons for which I never really knew but could surmise. The clash of egos between three very prominent surgeons combined with Dr. Millard’s abrasive personality was understandably volatile. There was undoubtedly some history there as well, which we were not privy to. As long as we were circumspect in visiting the group and these visits did not interfere with our duties in the residency, it was tacitly understood that we did this and the operative principle was “don’t ask. don’t tell.” Each year, Mrs. Millard went to their summer home in North Carolina to escape the hot Miami summer and Dr. Millard would join her for two to three weeks of vacation, the only time he took off. During this period we took advantage of his absence to spend a bit more time at the Baker and Gordon practice when the schedule at Jackson, the VA, or Victoria allowed. Although we did not scrub in and assist the surgeons, we could observe every detail of the surgeries and were thus exposed to different ways of doing things.
This was one of the strengths of the residency program at Miami when it came to cosmetic surgery. The residents who came to Miami had varying degrees of prior surgical experience. Some, like me, were fully trained and even board certified in specialties such as general surgery and otolaryngology. We scrubbed with the Drs. Millard, Wolf, and Mullin in their cosmetic cases and had access to Drs. Baker, Gordon, and Stuzin to observe them in surgery as well. Thus, we had many opportunities to see very skilled surgeons perform a procedure and then try it for ourselves on patients on the resident’s service at Jackson. This system of observation, then application, had been in place for years before I arrived and had shown itself to produce very competent plastic surgeons, many of whom went on to illustrious careers of their own. Like all residency programs, the one at Miami produced graduates with varying degrees of competence and skill. A few were exceptional, some were marginal, and most were competent. Which of these I would become remained to be determined.
Richard T. Bosshardt, MD, FACS, Senior Fellow at Do No Harm, Founding Fellow at FAIR in Medicine
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