July 28th, 2008
This is a question frequently asked by patients during their process of screening plastic surgeons. While I appreciate anyone’s attempt to assess the experience and technical capabilities of a surgeon before deciding to use them, this question by itself is not, in my opinion, a good way to get a feel for the level of craftsmanship a surgeon puts into his or her work. Are you more likely to get a better breast augmentation from someone who does 5 breast augmentations a day or one who does 5 per week? Would you feel more comfortable being someone’s fifth case of the day or their first? Would the surgeon feel good if their loved one were someone’s fifth breast augmentation of the day?
The point I’m trying to make here is that while it is certainly important for the surgeon being considered to have adequate technical experience and practice with the type of operation you are planning, this number alone does not imply the level of craftsmanship you can expect from the surgeon.
I like to play the guitar. I have been doing this avidly since I was 12 years old (and that would be 38 years now!). As many of you who either play or know someone who plays knows, a guitarist cannot have too many instruments. They are like putters to golfers. There’s one for every occasion and sound you might want to produce. In general, experienced builders producing the finer instruments do not produce in mass quantities. Therefore, in this instance it is not correct to conclude that you’re more likely to get a better instrument from someone who builds 300 guitars per year versus a builder who produces 50. There is a different frame of mind and philosophy of business associated with these types of producers and, I would argue, you will find something similar in your search for a good surgeon.
Surgery is a physical thing like the application of any skilled handcraft and produces fatigue. Additionally, there is the pressure of the surgeon’s office schedule to attend to. If he or she is running late for office and you are the next patient on the surgery list, are you sure you’re going to get the attention and craftsmanship you are paying for in the operating room from a fatigued surgeon under this time pressure? Also, are you sure that the surgeon you enlist is doing the entire operation from start to finish or, in the interest of mass production, are they outsourcing things like closing the skin incisions to assistants? Do you get long periods of quality time with the surgeon to discuss any issues you may have before and after the surgery, or does he or she breeze in, tell you what surgery they think is best for you, breeze out and leave you in the hands of patient care coordinators to get you into and out of the assembly line? Don’t get me wrong; I don’t think that this style of practice is unethical or immoral in any way. It is just different. You should have some sense about which type of environment suits you best and the numbers don’t always reveal the truth here. The only thing the numbers reliably indicate is the surgeon’s income; not the quality of operation or treatment that you can expect. So, it’s ok to ask about the surgeon’s volume, but it is also very important to realize how volume effects quality.
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July 24th, 2008
Many patients seeing me for the first time for a cosmetic surgery consultation feel in some way guilty or ashamed for talking to me about their issue. These feelings, I am sure, arise for various reasons in different people but, whatever their origin, the end result is the production of the same feelings when they consider changing the appearance of their bodies with surgery. I start out by telling them that almost everyone has some critique of their form when they mentally compare themselves to their ideal. (I, for one, wish I had broader shoulders, but unfortunately, there is no ready solution for that problem.) I then go on to mention that concern for our appearance is thought, in general, by our culture to be a good trait. We busy ourselves for many hours during the week with activities to make ourselves physically attractive. We bathe, cut and color our hair, shave, brush our teeth, work out, choose our clothing and jewelry carefully for each occasion, decide whether or not we will get a tattoo, etc. We do this because we know that we will be judged by others, at least initially and for the largest part unconsciously, based on our appearance. This trait, like it or not, is in all of us and relates in a primitive way to basic survival instinct. We must readily ascertain if someone looks threatening or not (“friend or foe”) and the stage upon which these judgments are first formed is the stage of appearance. Very often, initial feelings of like or dislike are formed based on a subjective “sense” we get from someone’s appearance. Additionally, we have excellent statistics that show how some human features and proportions are cherished as beautiful regardless of cultural background. These would include things such as skin quality, facial symmetry and basic body shapes. Furthermore, like it or not, studies show that individuals widely regarded as attractive in our society tend to be promoted more, make higher incomes and are less likely to get laid off in the event of a down-sizing. Interestingly, it seems to be the opposite for attractive women in the legal profession who are less likely to make partner than a less attractive colleague of similar ability.
When I point out how we are always concerned with our appearance and how we frequently go about changing the way we look, we begin to see cosmetic surgery as an inevitable technological extension of this powerful innate drive to enhance our feeling of self-satisfaction by adjusting our appearance. It is not so much that we have a problem changing how we look; it is the concept of using this technology to effect more profound changes at levels heretofore unattainable by traditional means. It is important that making the step to cosmetic surgery as the next point in this continuum be safe. If it were particularly risky, then it would be unreasonable. Fortunately, the advances of modern medicine, surgery and anesthesia techniques have brought the risks of life threatening complications down to levels that are significantly lower than the mortality risk for driving your car, an activity we engage in daily with the full knowledge that many people die behind the wheel daily in our country. Driving is a very acceptable risk to us. For healthy individuals, the risk of serious or life threatening complications associated with cosmetic surgery is far below that for motor vehicle operation, bringing the risk profile to a level consistent with using surgical techniques for cosmetic enhancement.
Often, by the time I get to this point in my explanation, the patient’s initial feelings of guilt have been assuaged as they have come to understand that the use of cosmetic surgery to alter appearance (when properly and ethically employed – see “Expectations and Patient Satisfaction” and “It’s OK, give yourself permission” blog posts) is just a technological extension of something human beings naturally seek to do; maximize their feeling of confidence by putting forth a physical appearance they feel represents their true selves in the best light possible.
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July 7th, 2008
I can say unequivocally that the answer to this question is yes and no! I don’t mean to be vague or evasive, but what happens here is directly related to how we put on fat. The fat cell (lipocyte) is nothing more that a storage container. It looks a lot like a bubble and when we gain weight fat, the bubble blows up and becomes larger; we don’t make more fat cells. When we lose fat, the bubbles shrink. The fact that fat cells are essentially non-dividing is the key to understanding how your appearance might change after liposuction and how your body will behave with any gains in weight. As many of you know, there are shapes related to our bodies that, no matter how much we exercise and watch our diets, we can’t change. The example I like to use is that of the saddle bags that some women have on the outside of their thighs. No matter how much they try, they can’t get these to go away, they are just larger or smaller versions of the same shape with gains or losses in weight. You cannot spot reduce a fatty by, say, exercising the outside of the thighs more. It just doesn’t work that way. In order to change this shape, the fatty tissue must be removed. This is a great job for liposuction. The fat cells are removed, the skin shrinks in and the shape change we have made is permanent. If the patient gets heavier, she will not reproduce this same contour because we have removed the non-dividing fat cells from this area and no new ones will arise to take their places. However, since there are fewer cells for the storage of fat there, the body will just look to other places to put fat when the need arises. If this hypothetical patient were to gain a massive amount of weight, it is likely that the areas treated with liposuction would appear as indentations in the sides of the thighs because the rest of the thigh would be able to plump up normally while the treated areas would not. If large areas of the body are treated and considerable weight is gained afterward, the patient will put fatty tissue wherever fat cells are available, such as the face, arms and intra-abdominal storage sites. In addition to this, the treated areas will become lumpy and uneven in appearance as the distribution of fat cells is not completely smooth, so those areas with a slightly greater population of fat cells may gain more than the surrounding areas.
Liposuction is not for weight loss. It is for shape change. The mirror, not scale, is the place to evaluate results and all results must be maintained. Large weight gains will spoil the results, and can produce shapes that are less desirable than those for which liposuction was originally employed to remedy.
David Luethcke, MD, FACS
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