by Cap Lesesne
Asian women consider scarring a horrible stigma. A scar is “impure” and damages their chances of marrying. A Chinese flight attendant, accompanied by the managing director of her airline, came to see me for a consultation. She had been burned in a crash in China, and had a two-by-three-inch scar on her forearm. In the grand scheme, the burn was hardly huge, and many people would have adapted psychologically. Not her. And not him. He spoke respectfully about his employee. “Dr. Lesesne,” he explained to me “in our culture a scar like this is devastating. To remove it is extremely important not only to our employee but to our company.”
Korean women want three procedures more than any others, one of which I won’t do. Because Koreans have a genetic disposition to bowleggedness, many wish to reduce the outer bowing of the lower leg (the tibia and fibula bones), and some women request that the legs be broken and then set straighter. I know there are surgeons in Korea who will do this. I won’t. There’s a high chance of complication and a mal-union of the bones. If the leg doesn’t heal right, they may have trouble walking.
Koreans also have square mandibles, or lower jaws, and want the jaw narrowed. This requires making an incision inside the mouth, using a bur or sanding tool to shave off part of the jaw, then cutting it in the back and resetting it. Koreans also want to reduce the width of their cheeks, which also requires sanding down bone (the maxilla and zygoma, the two bones that make up the cheek). These procedures I do.
Many Japanese women like to have their faces appear more oval; they never ask for cheek or chin implants, which make the face look angular. Nor do Japanese women ask for upper-lip augmentation; the geisha, a still-prominent beauty icon, paints her mouth so that the lower lip looks full but the upper lip thin.
Asian women also often want nasal augmentation, which entails adding cartilage to build up the depressed bridge of a relatively flat nose. In many places in Asia, doctors will do something we don’t do nearly as much here – augment the nose with a silicone block. Since it’s impossible to completely sterilize the nasal passages during surgery, bacteria can get on the silicone and the body can’t clear it, which can lead to a long-term infection. The body’s natural response to a chronic infection is to extrude, or push out, the material to the surface. Several Asian women have come to the office with nasal implants so infected, they were starting to poke through the skin.
The Chinese women I see tend to be taller than the Japanese and Korean women, not as genetically isolated, and seem more willing to change their bodies than the Japanese, in particular (though Korean-American women are moving more in that direction, too). Chinese women are more likely than other Asians to want their eyes Westernized. They like breast implants. At least once a year I’ll go to Hong Kong to do consults (though most of my native Asian patients I’ll see when I consult in Los Angeles). In Hong Kong, many of the consults come in with their boyfriends, having expressed interest in only face and nose work. But as soon as they’re in the hotel room, the women – clearly at the urging of their boyfriends – ask for breast implants, too. A common refrain is “My tai tai” – their phrase for a wealthy and Westernized Hong Kong man – “thinks I’m too flat.”
What are some of the regional plastic surgery preferences of Americans?
Few patients want overly pulled face-lifts, but occasionally I get someone who requests it – and invariably she is from either New York or L.A.
Midwesterners and New Englanders are the most reserved personally and are emphatic that the work be undetectable. When they come in for rhinoplasties, they rarely want me to do anything to the tip. Midwesterners just want the bump removed, thank you. I’ve noticed that Midwesterners tend to influence their family: If a woman comes in and she’s happy with the results, soon enough her sister will come in, too. Midwesterners also tend to get lots of lipo, and more breast reductions than women from other regions. (Because of the long, harsh winters, they tend not to exercise as much as those in other parts of the country.)
Northeastern women want breast implants but (generally) not big ones. When they have nosejobs, they’ll want more tip work.
Because they are so diverse, it’s hard to generalize about Californians. Southern Californians typically seek body sculpting, breast implants, and injectables, especially to the lips. These injectables can be fat grafts, collagen, Restylane, or the more permanent Radiesse. Although the plastic surgery aesthetic in Southern California, particularly around Los Angeles, tends to be overt, the patients who come to me from that region are looking for subtlety (or else they’d just find someone in their own backyard).
Texans are attractive and well put-together. They want face-lifts, face-lifts, face-lifts. Texans do not have breast reductions. In all my years of practice, I have yet to do one on a Texan.
Southerners (excluding Floridians) show up at my office well-dressed, perfectly made up, and with their hair almost always neatly pulled back. They are unfailingly polite. They are trim – never skinny, and never, ever, ultrathin. Southerners want the same procedures everyone else wants, but they are extremely concerned about scars; as common as cosmetic surgery is becoming down there, they want to be discreet about it.
There are two types of Florida women: those indigenous to the state, and the transplanted New Yorkers, who are older and often retired. The retirees want face-lifts and other facial surgery, and usually it’s not their first visit. No matter how fastidious a young, native Floridian has been about her skin care, she has sun damage and wants facial work. The younger ones, especially in South Florida, are very aware of their bodies and want breast implants, usually very big ones. One woman from Miami came in wanting implants bigger than I would have recommended for her frame. But after many phone calls Tara wore me down and finally I acquiesced. “Okay,” I said. “If that’s what you really want, I’ll put in four hundred seventy-five cc’s instead of two-fifty, but please don’t come back to me complaining that they’re too big.” I did the operation in October; she failed to show up for her follow-up visit.
In February, the phone rang. It was Tara.
“Dr. Lesesne, I was in a terrible Rollerblading accident in South Beach,” she said. “I went flying right in front of all the cafés, and I have terrible injuries to my skin, my knees, my arms.” I told her I was sorry to hear that and was just waiting for her to blame it all on the size of her breasts.
“And I would have broken my ribs, too,” she said, “if not for those big, wonderful breasts!”
Sometimes, the patient knows better than the doctor what’s right for her.
Competition
I felt fortunate to have a thriving plastic surgery practice on Park Avenue. But I knew I was only as good as my last result. I knew that if I was ever anything but “on,” I’d be in trouble. I knew that I had to be aware of what my colleagues were doing, yet not lose focus on my own work.
Because as much as I wanted to succeed, lots of people out there did not want that.
The perception is that the “fraternity” of plastic surgeons, especially those who cater to a certain clientele and who themselves live richly – especially those of the Park Avenue variety – is hardly a fraternity at all, and that backstabbing is rampant.
For the most part, that’s not true – though at times it can be.
It takes immense training and sacrifice to make it here. The Gold Coast – Park, from Sixty-fourth Street to Seventy-second Street – is home to some of the most renowned plastic surgeons in the world. While once Brazil was the destination for top-of-the-line cosmetic surgery, New York has surpassed it, with Los Angeles, Miami, and Dallas not far behind. Other cities with rapidly growing demands for plastic surgery are London and Sydney, but as yet there remains no clear area in which these cities excel on an international scale.
Plastic surgeons, especially those along the Gold Coast, are my rivals, but they’re my colleagues, too. Sometimes we exchange information or opinions. I’ve shared new techniques with others. A colleague called to ask if, when doing a n
ecklift, I dissect under the platysma muscle. “Dissect under?” I said. “I go five inches under.” He asked me how, and if it was safe, and I advised him that he should make sure, when cutting, to turn his scissors vertically, not horizontally.
I’ve had colleagues generously share with me. Richard Swift, an excellent plastic surgeon, told me about a technique he’d discovered when doing a canthopexy (tightening of the lower lid) that was simpler and yielded better results than what I’d been doing, a method that also had valuable implications for reconstructive work.
As with any hypercompetitive pursuit, then, you stay on top by working hard but also by sharing with those around you who can help.
You also stay on top – or keep from getting bounced off – by assuming that your competitors every now and then crave nothing more than a little schadenfreude – that is, pleasure over your failure.
A Park Avenue address gives you enormous cachet, so of course the jockeying to plant your stake there is ferocious. You want to be the man, but so does everyone else. To begin with, not every plastic surgeon in the city has a private practice; less than half do. It’s staggeringly expensive to set one up and maintain it, easily more than $300,000 a year. Then your facility had better be accredited, and highly, by one of the three most important organizations – the Joint Commission on Hospital Accreditation (JCOH), the American Association of Ambulatory Facilities (AAA), and the American Association for Accreditation of Ambulatory Surgical Facilities (AAAA). They make sure your OR is set up for quality control, safety, and fire hazards, meaning you’ve got to implement policies and procedures and buy all kinds of equipment: crash carts, backup power supply, backup water supply, etc. My office is accredited by the JCOH – in my opinion, the most rigorous of the three ranking bodies.
Some New York plastic surgeons work at a hospital, and that’s it. Some are in private practice, but not on Park.
The ones on Park are at once the most esteemed and reviled.
So it’s no wonder that many “colleagues” gossip or even actively plot to bring each other down.
One prominent, highly skilled colleague was rumored to have attempted suicide. He did not. He recovered from the fallout of the rumor to have his practice thrive, deservedly, once more.
Another plastic surgeon was rumored to be a cross-dresser. Also not true.
Recently, the New York grapevine produced this bit of juicy gossip: One of my fellow plastic surgeons, and a role model of mine, had AIDS.
His practice took a hit. A big one.
The rumor, it turned out, was untrue. It was started by a “colleague,” a surgeon who’d been envious for years of his target’s success.
Innuendo can put you out of commission a long time. It can destroy reputations, careers, relationships. A starry-eyed patient who’d had romantic designs on her plastic surgeon circulated so many rumors about his sexual exploits – that he had slept with patients, that he was with multiple women at once – that his girlfriend finally broke up with him. But it was all fabricated. It was unclear whether the girlfriend left because she believed the charges, or because she hated that he was such an easy target for salacious rumors.
Another colleague tried to drive several competitors, including me, out of town, by exploiting a faulty complaint system. Dr. Jack (we’ll call him) repeatedly called New York State’s Office of Professional Medical Conduct with bogus or inflated claims about surgeries that other plastic surgeons had done. (New York’s OPMC is the only place in the country where, amazingly, you can make charges against a doctor anonymously.)
Dr. X shouldn’t have put in a breast implant on Patient A because she had a tram flap with compromised blood supply.
Dr. Lesesne shouldn’t have operated on Patient B because she had cancer.
In the latter case, the patient had such advanced cancer of the chest wall (which I knew about; that’s why I was performing surgery), it had eroded through her skin so that her rib was exposed. What I did not realize was that underneath the scabs were dead tissue and maggots. I cleaned the wound and did an extensive “debridement” (removing dead tissue) – but that left her lung partially exposed. I took tissue from her back (the area over the latissimus muscle), tunneled it underneath her arm, and placed it on the front part of her chest, to provide an airtight closure.
The OPMC may or may not investigate a charge – but if it does, and word gets around, it’s certainly not good news for your practice, even if you’re exonerated. When I got wind that Dr. Jack was regularly making charges against other surgeons and me, I called his bluff; I phoned the OPMC myself.
“I would like you guys to investigate me,” I said.
I could hear the man turn the phone away and call out to his officemate, “Hey, Barry! We got a doc who wants to be investigated!”
Not only was I vindicated, it prompted me to defend other innocent surgeons targeted by the OPMC. That’s not to suggest that I will defend a surgeon who I believe may hurt people in the future; unlike the popular belief that doctors protect other doctors, good surgeons subsidize bad surgeons by having to pay inflated insurance premiums. More important, though, I, like most surgeons, care about patients and our fellow man and want to protect and help them.
Bad-mouthing another surgeon reflects as badly on the bad-mouther and will come back to haunt him. If there’s a highly flawed surgical outcome walking around that he knows a colleague is responsible for, he shouldn’t talk because he doesn’t know all the facts. It might happen to him. If patients talk to you about other surgeons (as they do), then they’ll surely talk to other surgeons about you, too. Give them only good things to say.
Where once the plastic surgeons’ fraternity (if you will) valued the presentation of scientific papers that forwarded ideas, techniques, and methodologies, now the overriding value, and one “shared” with far less fraternal spirit, is the ability to market yourself. (I realize this is a common gripe made across many professions.) Big-time surgeons in New York, Dallas, and L.A. send out promotional videos to patients and print and TV outlets. A recent consult told me she had just gotten such a video from one of the surgeons featured on the reality TV show Extreme Makeover. Popular surgeons have – I kid you not – major ad budgets. Some send press kits to magazine editors. “Name recognition” becomes the predominant criterion for choosing a surgeon. Recently, I scrubbed with a young plastic surgeon at Manhattan Eye, Ear & Throat Hospital. During the breast implant operation, the second question he asked me was “Who’s your PR agent?”
“I don’t have one,” I said.
He stared at me as if I had a disease. “Are you stupid?”
The new breed of plastic surgeon thinks that media exposure – not word of mouth, not quality of work, not trust – drives your career.
Is it really necessary for a doctor to have a publicist? Maybe. I hope not. I always thought that if I worked hard, stayed current, and contributed to my profession, people would find me. But such a route is becoming as anachronistic as my father’s house-call-making doctor.
In fact, it feels as if every year I have fewer real colleagues, and more competitors – and that’s not paranoia talking, but the reality of a new age. When I started, only board-certified plastic surgeons were allowed to do cosmetic surgery. Now, certain major cosmetic procedures (face-lifts and some large liposuctions) are performed by anyone – dermatologists; ear, nose, and throat (ENT) surgeons; dentists; oral surgeons; obstetricians; and general surgeons. Different boards, with different requirements, oversee these practitioners. None of them, in my opinion, guarantee the rigor of a legitimate plastic surgery training program. So while demand for plastic surgery has gone way up, so has supply, and the people providing the new expertise are not necessarily experts. (Some are good at what they do, some aren’t.)
That’s not to say that as individuals we don’t respect and even like each other. I enjoy seeing some of my peers with whom I trained at New York Hospital. I’ll run into surgeons I know at conferences and occasionally
social functions. But I tend not to socialize with them, and that reticence is not uncommon. In fact, at times I think we avoid each other’s company. It’s just the nature of the competition. Plastic surgeons tend to be loners. (A chicken/egg question: Do loners become plastic surgeons? Or does the training and regimen of plastic surgery, and the sometimes constant barrage of patient demands, cause us to retreat into ourselves?)
I enjoy helping younger surgeons, and exchanging ideas with older ones, too, particularly discussing how we deal with complicated cases. There’s patient-sharing, too: We’ll send prospective consults to each other for second opinions. Or we’ll help in other ways. A younger colleague performed a tummy tuck and the patient developed a bad scar, possibly from clotting or a dressing that was wrapped too tightly. The doctor said it was correctable, but the patient quickly turned hostile and threatened to sue. I called the doctor, an acquaintance, to see if I could help. He sent me the chart. He asked my opinion on how he’d done the surgery technically. He hadn’t done anything actionable. He put my name in the chart. Even though the problem was fixable, the patient followed through with his threat to sue. When he saw my name on the doctor’s chart, he sued me, too.
We also compete against and along with each other, at the same time – at least implicitly, city versus city. While the majority of patients obviously use their local plastic surgeons, a large portion of our clientele is extremely wealthy, jets around easily, and seeks the best that money can buy. This means that lots of our patients come from other cities – or, alternatively, New York patients can migrate elsewhere. New York surgeons, for instance, are in constant battle with surgeons from L.A., Dallas, and Miami. Recently, the Dallas group has published more papers and courts and gets more media attention. On the other hand, a hefty portion of their local client base (Fort Worth, in particular) continues to fly to New York for cosmetic procedures rather than use the plastic surgeons twenty miles away in Dallas. L.A. doctors, as a group, are known for their body sculpting, as are Brazil’s surgeons. Dallas does lots of noses and breast implants. For a while, Kansas City had perhaps the best thighplasty person. There’s natural and constant competition for patients, and each city’s reputation can shift, too.
