by Cap Lesesne
“Hmm,” I said, trying to diagnose a cause – but before I proffered an explanation, she solved the mystery.
“We had kinky sex,” she said. “My partner couldn’t wait any longer so he flipped me over a chair. So I was in the … down position for a while there. Which I guess I shouldn’t have done.”
She smiled.
There is some information I don’t need to know.
My Method
I have tried to set myself apart in my approach to plastic surgery.
I know this approach differs from that of some of my colleagues because patients who’ve been to other top surgeons have said as much. With many plastic surgeons, the consult walks in, the surgeon looks her over, and he makes his evaluation based on what she looks like in one particular light setting. Not me. When a consult sits down, it’s just the first of multiple ways I look at her. First, I evaluate her in my exam room in which fluorescent lights have been positioned strategically so that, as I circle the patient, evaluating her face and neck, I get to see all the shadows and contours. Because it’s not just the muscles in our face that are dynamic and that need to be looked at from various angles; our physical world is dynamic, too, not static, and that also affects how the face is perceived. How deep is the shadow cast by the nasolabial fold? How much drooping of the nose is there? Does it cause more shadow in certain light? These are questions anyone might want answered about her face (it might affect what you wear, or how you apply makeup), but it’s particularly relevant to someone having surgery, who is making herself over, who is preparing to be out and about again. Are the eyebrows really too low or is the bone protruding too much? I’m looking for nuances. I’ve trained my eyes to perceive normally, in color, and then almost to switch to perceiving in black and white, to get a starker feel. I’ll look at the fine lines in the face in context of the bigger lines. Does the lower lip cast a shadow on the sublabial fold (the area just below the lip that’s almost always in slight to substantial shadow)? Does the jaw cast a shadow? Does the cheek cast a shadow? Is there a hollow in the cheek? Then I look closely at the skin – its texture and contour, because that will also affect my evaluation, and thus how I do the surgery. I’ll go from “looking” at her in 3-D to 2-D and back to 3-D: By gauging the face in different depths, I can better “see” the skin’s texture. I look carefully at the shadows and contours that have created those depressions and elevations.
I look at how shadows are cast on the neck. After age forty-five, women or men come in to talk about their face, but before the conversation is over, they’ll almost invariably say that what really bothers them most is their neck. The neck usually goes first. Typically, the pattern is this: Before you turn twenty-five (roughly), the two big vertical platysma muscles in your neck don’t sag – can’t sag – because they’re “interdigitated,” meaning the little fibers inside the muscles crisscross with each other, forming a strong, single cable, which makes for a smooth neck. After age twenty-five, those fibers start to separate, and a right and a left band form, which eventually leads to sagging.
So when, say, a forty-seven-year-old consult sits down, I know generally what’s been going on with her anatomy, because that’s what’s been going on with the anatomy of pretty much everyone her age. But I also know that I’m seeing her at just this one point in time – in the “present tense,” if you will. I need to see her in the past tense, too, so I can do a better job at creating her future tense. That’s why I ask to see old pictures of her, starting as far back as her twenties. I study the photos with her first, then by myself later. And our actual discussion of the pictures is important, too, because there are nuances to her anatomy that I might pick up on only when hearing her describe them. Were her lips fuller once? How were her breasts then – that is, they sagged less, of course, but how much fuller were they ? Maybe that doesn’t come out in the photos she’s given me, but she’ll surely mention it, with some sense of yearning.
(As other surgeons do, I’ll also ask the patient to bring in photos she likes, of the feature in question; so a rhinoplasty patient should bring in images of noses she admires, and I’ll also have an extensive set of pre- and postnosejob photos that we go through together.)
I don’t do computer imaging, for two reasons. First, I don’t think it works. It suggests to the patient that the possibilities are close to unlimited, and they aren’t; the image you’re getting onscreen is still a two-dimensional rendering masquerading as a three-dimensional representation. More often than not, then, it implies a result that’s not realistic. I get better results working from photographs, taken at different angles and over time. Second, computer imaging is time-consuming and expensive – so much that I would basically have to hire someone to do it for me.
I look at the patient’s face for asymmetry. I know I’ll never achieve a perfect symmetry, nor would I want to: Symmetrical faces are boring. Our brains and eye movements are trained not to spend lots of time on forms that are symmetrical; if you mean to catch someone’s interest, dress or decorate yourself in a slightly asymmetrical way. In fact, our affinity for asymmetry guides my decision in hiding scars. When I design incisions near the ears for face-lifts, I measure and make certain that they are as symmetrical as possible. The same is true for incisions under the chin when performing chin implants, and for bilateral incisions.
While the face and neck are the areas I most love to work on, I have also done thousands of breast augmentations. (For most surgeons, breast reductions are a smaller percentage of breast procedures performed.) Once again, my philosophy differs from that of many of my colleagues.
The normal shape of the top half of a woman’s breast is concave, the bottom half convex. I am not taking credit for this observation. But this shape, as it exists in nature, has quite literally been turned upside down – or at least the upper half has. Now, it’s all the rage to put a breast implant underneath the pectoralis muscle, which creates a convex look all the way around; it appears “puffed” because the muscles need time to relax. To me, it looks like a swollen balloon.
Great breast augmentation is best when it fits a woman’s body – that is, her chest is proportional to her hips and pelvis. That way, the implant doesn’t look obvious, but you can still have great breasts. It is beyond strange to me that several high-profile young actresses I see pictured in magazines want their implants to be visible. They go to movie premieres not just with their breasts pushed up – we expect that – but with the border of the implant visible, either in the center of the chest, when their breasts are pushed together, or on the side, when they wear a dress cut to reveal that.
When doing implants, I have to be almost as careful about cutting as I do with the face, because it’s a bad place to have a scar. Women express different preferences for where they want the scars – some want them in the armpit, some around the areola, some underneath where the breasts meet the chest. Preferences vary according to individual, background, and size of breast desired. Putting the scars around the areolas has two significant drawbacks: The accuracy of a mammogram might be compromised, and calcium can get into the scar. One disadvantage of armpit scars is that they may be visible enough to keep the patient from wearing a halter top or strapless dress. New data also indicate that armpit scars may interfere with lymph drainage, which could be especially problematic if the patient develops breast cancer; her treatment may be compromised. Scars, then, must be positioned with care.
Even my patient population for breast augmentation seems to be different from that of my colleagues. I probably see more college-educated women, who tend on average to want smaller implants. My average patient (insofar that anyone can be called an “average” patient) might want to go from a small B to a B, so the size still fits her torso. Big implants, these women often believe, make them look heavy, fat, cheap. However, some women, after coming in for a consultation, won’t schedule me because they don’t share my aesthetic.
This is where taste – and perhaps subtlety – comes in
to play.
If a woman has had a breast augmentation and returns to her surgeon, it’s almost always because she wants to get still bigger. Only once have I had a returning breast augmentation patient say that I had made her too big.
If I were to err, I would want it to be on the big side. Why? When breast augmentation is performed, a pocket for the implant is formed. This pocket is called a capsule, and it consists of collagen, which contracts around the implant. If an implant is removed altogether, the collagen will retract and the body will reabsorb it completely; if an implant is replaced by a smaller one, the capsule will contract around the new implant and no further dissection is required. However, if an implant is replaced with a bigger one, the pocket must be made larger, which requires more dissection.
After twenty years in solo surgical practice, I have also come up with other techniques that yield results that make my patients. New ways to “feather” fat when doing liposuction so it looks smoother. Cauterizing blood vessels to reduce the dried blood in the wound so that there’s less bruising and scarring. A better understanding of perforators – the little arteries that lead off of major blood vessels but which aren’t fully described in anatomy books, and whose variability you learn about from hundreds of operations (e.g., I have learned it’s better to dissect around perforators rather than to cut them – as others often do – because it allows me to maintain blood flow so that the wound heals faster). I have an understanding of the subtleties of skin, and how it heals differently in a forty-year-old versus a sixty-year-old, in a woman versus a man, and in different places on the body (e.g., the upper eyelid has the best-healing skin on the body).
I am a better surgeon now than I was five years ago, and I expect to be a better one five years from now.
Yet, while saying that a surgeon is skilled and experienced is nice, it’s not the ultimate compliment.
He’s good with his hands?
A virtue, to be sure, but not the crowning one.
Everyone knows his work?
Massages the ego, but hardly the ultimate compliment.
I trust him?
That’s it. The best thing a patient can say about her doctor. I trust him.
You have to be able to tell him exactly what’s bothering you and feel that he understands. When he tells you what he thinks you should do, and why, and how he proposes to do it, you should be comfortable with every aspect of it. You must feel he’s doing what’s best for you, and not because – as happens sometimes with the top-heavy-breast implant surgeons and the ski-jump-nosejob surgeons and the pull-the-skin-until-you-can’t-pull-it-anymore face-lift surgeons – it’s what he thinks looks good, or because it’s the only look he knows how to do well.
Trust is vital for a simpler reason: You’re having surgery. If something should happen while you’re under, and your surgeon needs to make a quick, unanticipated decision, you want that decision made by a person not only of unsurpassed competency, but whose priorities and aesthetic match yours.
I was Alma’s second surgeon. Her first, an extremely reputable surgeon in Washington, D.C., had done a breast augmentation. The implants were a little too big for her. At five feet five, with a medium frame and narrow hips, her chest was slightly out of proportion. While I agreed with her that the implants didn’t fit her frame, it was hardly egregious, and I told her so. When she said they made her look fat, I disagreed. (I would have told her otherwise had I thought so. While I don’t relish telling a patient she looks heavy, it’s my job to be as objective as she needs me to be.)
What bothered her more than what everyone could see, however, was what only she (or an intimate) could see, something that had bothered her since she was a preteen: her large areolas. There was nothing irregular about them; they were part of her normal anatomy. But when the other surgeon had put in her implants, he hadn’t proposed reducing the size of the areolas, nor had she been forceful enough to bring it up. Once the implants were in, the areolas looked even bigger, verging on misshapen.
The net result of the implants? She was more unhappy than before the surgery.
I could see what a relief it was for her to get her whole story out. She acknowledged that she liked her breasts to look big, and she almost liked the size of the new implants. But her larger, asymmetrical areolas made her feel ugly and unfeminine.
After I looked at her breasts, we decided to reduce the areolas considerably, to a diameter of three inches, down from six inches, and also to reduce the size of the implants by one size. To do the former, I would draw a circle around each areola, draw an inner circle of the desired size, then remove the encircled skin, widely undermine the normal breast skin, and close the circle by bringing the outer skin surface to the inner, or areolar, surface.
Alma was anesthetized and I began. I reduced the areolas down to a size that looked great. At three inches, they were pretty, normal, and feminine, and I was optimistic that they would make her happy … but now I realized she looked best with no implants at all. In fact, in listening carefully to her intimate monologue about how she’d felt about her breasts from puberty, I deduced that much of the image she had of herself, and much of what drove the image she wanted to present to the world, had to do with her unhappiness about what was underneath, specifically her areolas. And if she was happy with what was underneath, then it followed that she would see that her normal breast size was absolutely fine and attractive for her body type.
So reducing the implants by one size – which we’d agreed on – was not enough. I felt that if I followed that route, she wouldn’t be happy afterward – happier, yes, but not happy. Big difference. Yet I couldn’t wake her to get her approval. During the consult, I hadn’t said to her, So, Alma, if I reduce the areolas and then I realize that we need to reduce the breast volume even more than we’d thought, I’m going to do that, okay? I just went ahead and did what I knew was right, knowing all that she’d confided in me, and that she trusted my judgment, aesthetically and medically.
I removed the implants. Altogether.
Alma was asleep when I made this independent decision, but it wasn’t really made independently. While as a surgeon I make judgments about what’s best for my patient, when there’s trust and rapport, the decisions aren’t hard to make.
Alma awoke. When she was alert, I gave her a mirror to get a good look at her new implant-free, smaller-areola breasts.
In my entire career as a surgeon, I have never had a happier patient.
Or a happier significant other. Days later, Alma’s husband came by the office with Alma to express his gratitude. While husbands always – or so I’d thought – want their wives to have bigger breasts, this case was different.
“Thank you so much,” he said, shaking both of my hands and tearing up. “It’s not that she’s more beautiful to me, because that’s not possible. But now my wife knows just how beautiful is the woman I’ve been looking at for fourteen years.”
Men
George, a divorced, balding investment banker who’d worked for PaineWebber his entire adult life, retired at sixty-two, then came to see me.
“I’ve wanted to do my face and nose for twenty years,” he said. “I woke up every day thinking about it. But I was afraid to walk into work on Monday after having a face-lift.”
It was sad and it wasn’t. He confessed to thinking he was over the hill, and that life for him was finished – yet here he was in my office, obviously trying to do something about it. Plus, he said, he’d met a younger woman.
“Between her and you,” he said. “Maybe that’ll be my ticket to youth.”
I was pleased for the opportunity but I had my work cut out. Not only was George totally bald but he had low eyebrows. How was I going to pull this off without large, visible scars across the top of his head? He didn’t want to wear a toupee. I had to tell him that nothing would really return his youth. But I could make him look better, despite the apparent difficulty.
I told George about a new procedure, an endoscopic
browlift, suited for hiding scars, but I still couldn’t guarantee him a great result. The scars would be in the front part of the skull, at the top of the scalp, I told him; how visible they would be, I couldn’t say. At that point in my practice, I’d done few endoscopic browlifts, all on men with hair.
George told me to go for it.
Three weeks later, before he’d even entered the office to have the sutures removed, I was cringing. How would George look once the stitches were removed ?
I didn’t have to worry. Not only would the scars turn out to be practically invisible, but George entered my office with his new wife, the younger woman he’d been seeing. He’d married her during the first week post-op – a fairly persuasive argument that, even before the bruising is gone, the happier psychology brought about by a cosmetic surgical procedure has taken root.
While in 2005, according to the British Association of Aesthetic Plastic Surgeons, men underwent only 11 percent of total cosmetic procedures (up from 8 percent of the total in 2004), their numbers jumped by 81 percent from just the previous year. Rhinoplasty for men increased by 103 percent; blephoraplasty (the eyelids), by 95 percent; otoplasty (for the ears), by 88 percent; liposuction, by 69 percent; and face/neck lifts, 55 percent … in just one year. BAAPS do not hold statistics for minimally invasive procedures, but in the US in 2003, the American Society of Plastic Surgeons record that Botox injections for men, over the previous year, increased 152 percent; microdermabrasion, 87 percent; cellulite treatment, 71 percent; and laser treatment of leg veins, 42 percent. Part of this increase is due to the diminished stigma of plastic surgery, part is due to innovations that allow for quicker recovery time and less fussing, and part is due to the continually growing pressure to look young longer for the sake of professional advancement. But increasing numbers of men, like George, come to me simply because they want to look better, not because they’re terrified of getting passed over for promotion. (The difference between the percentage of men who get cosmetic surgery for largely professional reasons and the percentage of women who do so is narrowing, at least among my patient sample.)
