by Cap Lesesne
And more.
It was as if the cancer were flowing along a stream; the stream was the nerve. I couldn’t tell just by looking whether the samples I was sending to the pathology lab were cancerous, but the results kept coming back with the unhappy verdict of “positive margins,” meaning the cancer was still there, in every tissue sample I’d cut away so far.
I dissected farther to the back of the orbit and kept finding more cancer. Over three hours, I removed at least sixteen tissue samples. The cancer tracked over the eye, back deeper and deeper into his head.
The eye needed to be removed.
Since I’d never before taken out an eyeball, I called in an ophthalmologist to do the “enucleation” – permanent removal of the eye.
For all that I had prepared Edward – and myself – neither of us had had any idea, preoperatively, that we would be dealing with something this extensive, something that had already cost him one eye.
But the cancer wasn’t finished. The diseased nerve tunneled down to the side of the orbit; I had to saw through cheekbone to trace the meandering nerve. It was still coming up “positive margins.” I removed pieces of cheekbone but the nerve was heading back to the brain. I could not get a clear margin.
After removing much of Edward’s left cheek (the incision went from the middle of his lip to the base of his nose, around the base, then through the junction of nose and cheek, and underneath his lower eyelid, so I could peel back the skin, muscles, and blood vessels), I removed the whole cheekbone, only to see that the cancerous nerve continued toward the brain, ending at its base.
Finally, after yet another tissue sample was sent in, I got back a report of “clear margins.”
Now I had to close him – but how? The left side of his face had a huge hole in it. The flap options – latissimus, trapezius, deltoid – all had disadvantages. I decided to harvest a flap of tissue from his trapezius.
The surgery took thirteen hours.
For two weeks, Edward lay in the ICU. Finally, he was well enough to leave the hospital. He consulted an oncologist.
He was – all things considered – improving. He resumed a near normal life.
Many months later, he started getting pain in his left scalp. A CT scan revealed that the cancer had returned. It had probably infiltrated to his brain.
He came to see me, asking for my recommendation.
“I don’t know if anyone can get around it,” I said. I advised against having another operation.
Edward found a surgeon in Los Angeles who took off the front half of Edward’s skull. In the OR, Edward suffered cardiac arrest. He remained in the ICU for six months. He died.
During his remaining months, he could have lived without the surgery. No matter what, he would have been in pain at the end. Yet that would almost certainly have been a better fate than the one he suffered, and better for his family, too.
When a surgeon advises you not to operate, consider it seriously.
You Want What?
Dennis, a computer hardware salesman in his early thirties, came in for a consult. He said he wanted to change his looks.
“Okay,” I said. “What do you want?”
“Actually, I want a lot.”
“Like what?”
“I want to look like Jennifer Aniston.”
It didn’t register. Jennifer Aniston? Who’s that?
“She’s an actress,” he said. “Don’t you watch TV? She’s my absolute favorite of all time.”
“Apparently. When you say you want to look like her … how much?”
“Exactly like her,” said Dennis. He told me that for almost a year he’d been taking estrogen. He wanted me to do several procedures – cheek, chin, and breast implants. And the big, nonreversible penectomy.
Much as I was sympathetic and wanted to help Dennis, I declined his request. I could have done the smaller procedures, but I’d never done a penectomy, which involves removal of the penis, then rotation of the excess skin of the penis to create a vagina. I’d assisted in constructing vaginas while I was a resident at Stanford – a technically difficult procedure that presents such challenges as infection and scar tissue buildup in a sensitive area.
I referred Dennis to a clinic seasoned at gender-swapping surgeries and wished him well.
Everybody’s got something that bothers him or her.
It’s hard sometimes not to say outright to a patient, “No, you’re wrong. I’m right. Trust me on this and don’t have this surgery.” I don’t say that as much as I should because it sounds arrogant and the patient probably wouldn’t listen anyway. Martina, a postsurgical transsexual who’d had multiple operations (over five years, I’d done her nose, eyes, face, neck, breasts, and legs), returned to ask me to remove two lower ribs. I wouldn’t. The surgery would leave a prominent scar. Deeper structures, such as the liver, could be injured. The improvement in shapeliness was not worth the risk. Since Martina and I had a history, and since there’s always another plastic surgeon out there who will do surgery no matter how ill-advised, I tried to persuade her to reconsider.
“You’ll hate the scar,” I predicted. “It’s not worth it.”
My oratorical skills were apparently less treasured than my surgical ones, and Martina had someone else remove the ribs.
She liked the new contour all right. She hated the scar.
Obviously I’m a proponent of plastic surgery. But a successful surgery is not a given, no matter how good the doctor or how simple the procedure. There’s a continuum of human psychology, and those who exist at one end of the continuum won’t ever set foot in my office, while those at the other end I’m well-advised to rebuff. That is, if a patient doesn’t care, or is in denial, about her appearance, she’ll never consider plastic surgery. And if a patient is self-absorbed or narcissistic, she’ll never deem the surgery a success.
The best candidates for plastic surgery fall somewhere within these extremes, with a healthy enough mix of self-esteem and humility to make the chances for a successful surgery plausible.
A couple years after his initial visit, I got a call from Dennis, the man who’d wanted me to help make him look like Jennifer Aniston. He wanted to see me about some work.
When he appeared in my office, his look was considerably softer and he was (in his words) “more than halfway” toward looking like his favorite actress. He was post – psychological evaluation and still taking hormones, and he wanted me to perform four operations: breast implants, cheek implants, rhinoplasty, and eyelift. I was much more comfortable working on him now.
He was happy with the results. Afterward, he said he was off, finally, to have his dream transgender operation. I wished him well again, and again he disappeared.
It’s a huge compliment when someone entrusts you to make him or her look better. It’s an even greater compliment when they trust you to lead them to a new life – a new profession, a new way of living. Michael, a nice-looking forty-year-old electronics specialist for General Motors, wanted to be Elvis. “Before you tell me I’m crazy and order me to leave your office,” he said, though I’d made no move to do so, nor had I thought to, “I’m not crazy. If the surgery puts anything in jeopardy, I won’t do it. I’m happily married, I have two great kids, I love my family, I have a good job. But it’s my dream in life to be an Elvis impersonator. I can do everything Elvis can – sing, dance, I sound like him. You won’t believe how much I sound like him. But I don’t look like him. To get an act in Vegas or Atlantic City, I need to look like him.”
He seemed thoughtful, not a kook. Before or since, I have not encountered a more levelheaded, self-aware, inspiring justification for elective cosmetic surgery.
To make a patient look like someone else requires a different mind-set. I get about four such requests a year – sometimes to look like a celebrity (Sharon Stone’s a favorite), sometimes to get a favorite celebrity feature (Andie MacDowell’s eyes, Angelina Jolie’s lips), sometimes to look like some attractive stranger whose photo the p
atient has brought along. As a surgeon, I have to take an unusual approach. First, I have to forget my own aesthetics, since the point is not to make the patient look better but to look different. Second, I have to be sure the look we’re going for is feasible given the patient’s facial structure. Third, I need to figure out just how close I can get to the patient’s ideal.
That night, while making sketches and planning what Michael would require to look like Elvis, it struck me that we first had to make a choice. Elvis … but at what age? Young Elvis or old Elvis? The twentyish hearththrob Elvis? The thirtyish, more mature Elvis? The fortyish, paunchier, Vegas Elvis? The post office had ultimately issued two stamps, from different eras. We had no such luxury.
Not surprisingly, Michael had already given it lots of thought. In his late thirties, he knew his options were limited. Together, he and I looked through Elvis album covers. We found the perfect blueprint on one of his gospel albums, when Elvis was in his mid-to late thirties. I made a copy of the cover and placed a grid on it. Then I photographed Michael’s face, enlarged the photo to match the album, put the same grid on it, and superimposed it on the album. I measured centimeters, millimeters. I noted how to change his nose, eyes, cheeks, lips, and chin.
Six operations later, including two for the cheeks, Michael and I, between us, had re-created Elvis. Yet one thing kept gnawing at me: Despite Michael’s uncanny resemblance to the King, despite all the planning, despite two follow-ups, I never quite got the left dimple the way I wanted it.
On Michael’s final post-op visit before he and his supportive family were to move to Las Vegas, as he sat in my waiting room wearing shades, slicked hair, sideburns, and GM work clothes, a woman accompanied by her two children entered. When the girl saw Michael, her mouth hit the floor.
“Mommy!” she whispered, loud as a yell. “It’s Elvis!”
The mother did an impressive double take. Now the little boy stared, too. Michael, overflowing with delight, turned his back on them for a moment, rolled his hips, then peeked back at them over his shoulder and pointed at the girl. “Helloooo, little girl,” he said in a lowered voice.
The King lives. Michael legally changed his last name to Vegas and he now performs regularly in Las Vegas and Atlantic City.
It still bugs me that I didn’t get the dimple.
“I want Texas tits!” announced Marilyn, a big, pretty new consult from Dallas, as if she were ordering a burger.
Marilyn, single and thirty-five, was not like the bulk of my Texas patients, who tended to go for a less “bold” look than Marilyn. Then again, Dolly Parton might go for a less bold look than Marilyn.
Texas tits, to Marilyn, meant breast implants seven hundred cubic centimeters big – large by any standard. Normally, I would have told her no, outright, or that I would do an implant but not quite so large. And it was not about my aesthetic vision being different from hers. At the volume she was contemplating, breast size may become a health issue; she might have been inviting back pain.
But Marilyn wasn’t a small girl at all. Seven hundred cubic centimeters is proportional only to a tall, broad-shouldered woman, and she could handle it. It fit her physique.
More to the point, it’s what she wanted.
Still, I tried to dissuade her. But she insisted that was the look she wanted. “I know they’ll work,” she said.
“It’s going to be a 38D, at least,” I replied.
“I don’t care. That’s what I want.”
I’ve never augmented a woman that large, before or since.
A year later, while walking down Park Avenue, I noticed a tall, attractive woman approaching. She was nicely dressed and pushing a baby carriage. As she neared, she looked more familiar, but it didn’t quite click for me. As she came closer, I finally recognized her, and she me. She broke into a big smile. We stopped.
“It worked,” she said. “He’s two months old. That was the best investment I ever made.”
I smiled at her, and then at the baby.
“Dr. Lesesne?” she said.
“Yes?”
“I wonder what else I can do.”
I looked at her, confused.
“I’m sure,” she said, “that there are other procedures I need.”
I smiled at her. I didn’t know what to say.
Soon, she walked away, pushing the baby carriage up Park Avenue.
In my mail was an envelope from California, with no return address. I opened it and unfolded the single sheet inside. It was a copy of a California driver’s license. The license photo was of a woman who looked very much like Jennifer Aniston, only more angular, longer in the face.
The first name on the license? Jennifer.
Dennis, you did it.
I Don’t Do That
In the late nineties, referrals between East Coast and West Coast became more frequent, and the entertainment portion of my clientele increased. I was visited by Susan, wife of one of America’s most beloved entertainers (he started as a singer, then eventually won recognition for his acting and comic talents). I had done a face-lift on Susan’s friend that Susan had admired, and now she had come in from California for the same procedure.
She came to my office by herself. No putting on airs, I was pleased to note, though Susan certainly had the money and last name to go that route.
We talked briefly, and I told her how much I’d loved her husband’s work when I was growing up and how much I still loved it. Then I looked at her and we started to talk about what I would do, and she listened intently.
“Now I’ll need to get a couple of old photos of you so I can examine and study how you’ve aged,” I concluded.
“No, you won’t,” she said.
“Yes, I need a few photos of earlier and now. For the new photos, you can keep the negatives and send me the prints. It helps me to get the most natural look.”
“Absolutely not.”
“I need photos to study. To do the job right.”
“You can do it without photographs.”
“No, actually, I can’t. You look different lying down. Gravity pulls skin in a different fashion. I might not be able to see what’s truly fatty or not. That’s why I need to analyze photos.”
“There will be no photos,” she said.
Life is too short for certain things. And in this case, the risks of a mistake and an unsatisfied patient were great.
“I don’t think this is going to work out,” I told her, polite as could be.
She stood, turned, and walked out, mumbling under her breath, “What does he know?”
Surgeons love to do surgery. It’s worth seriously considering that fact when a surgeon says that he or she won’t operate.
There are various reasons to turn prospective patients down.
Physical: There’s just not enough there that needs fixing. (In short: If I can’t see it, I can’t fix it.)
Psychological: I sense that the patient is incapable of being made happy by any surgery, no matter how well executed. Or, as in the case of Susan, there’s a lack of rapport and trust between the patient and me.
Comfort level: I now only do procedures I’ve done hundreds or thousands of times.
Interest level: I don’t do procedures that don’t interest me. For example, I simply have no desire to do hair transplants. I don’t do hymen repairs – elevating a flap of the vagina lining and suturing it across the opening to the other side – though I’ve had numerous calls from Arabic men (from Kuwait City, Cairo, and Lebanon) asking me to do a reconstruction for a sister or female friend. In Arabic countries (among other places), they believe that having such a procedure will make the woman more desirable for marriage, as it purports to attest to her virginity.
Nor am I interested in vaginal tightening – cutting out tissue to reduce the diameter of the vaginal opening.
I also won’t do procedures that have a high dissatisfaction rate. For me, these include pectoral implants, buttock implants, and circumferential body lifts. This las
t operation – where you cut all around the stomach and lift the legs – requires working on an extremely large surface area, there’s a lot of bleeding, and the scar is disfiguring. A colleague of mine, a good surgeon, recently did a circumferential body lift and had complications. I thought, If it can happen to him, it can happen to me. (Interestingly, though, in studying the circumferential body lift, I discovered a better way to do a thighplasty, which frees me from having to go completely around the body and involves less scarring. Yet another example of why you must constantly keep up on what’s going on in the profession.)
Penile augmentation also has a high failure rate. It’s difficult to put foreign material (in this case, AlloDerm) into the shaft of the penis without a high risk of scarring and infection. This is another surgery I won’t do.
Joanna and Theresa brought in their eight-year-old daughter, Amy, whose ears were large and sticking out. Correcting the ears would not be hard; dealing with the two mothers (Theresa was the birth mom) would be.
“There must be a way you can use a holistic anesthesiologist,” Joanna kept insisting. I said, again, that for many years I’d operated side by side with one of a couple of trusted anesthesiologists, and that I much preferred to work with them.
“There’s a CD that Amy would like you to play when you’re operating,” Theresa said more than once, even though I’d told them I don’t like music or distractions in my OR.
The questions and issues kept coming. This was our fourth consultation. Poor Amy looked so nervous that I thought, if I were to do the procedure, we’d probably sedate her rather than use the local we normally give. The women asked more questions than I’d been asked by any single patient in twenty years of practice.
I didn’t have the stomach for a fifth consultation.
“I’m sorry, but I don’t think I’m your surgeon,” I said. “I don’t feel comfortable doing the surgery.”
