Confessions of a Park Avenue Plastic Surgeon Page 16

  Yet it distresses me when bad results happen, particularly if the physician involved doesn’t care, is untrained, or abandons the patient. And I mean real disasters, not ones where the patient and doctor have a different perception of the color of the scars. I’m distressed first, of course, for the patient who’s been hurt. Then I’m distressed because it reflects badly upon doctors and surgeons. In the last couple of years, there have been a number of high-profile plastic surgery disasters. Some of the more publicized disasters include the death of a forty-two-year-old Irish woman, following a rhinoplasty performed by an ENT surgeon who’d had his license restricted; bilateral facial paralysis, requiring ICU hospitalization, after a patient was given homemade Botox; death after lipo by an oral surgeon; cardiac arrest during a face-lift at a dentist’s office. The disasters by these physicians or dentists are all too common and not surprising, considering the training involved, or their demeanor.

  Sometimes a problem is the result of patient factors. For example, procedures involving a patient who smokes have a higher complication rate. One prominent Dallas plastic surgeon simply won’t operate on smokers. I believe that you can, but you have to tailor your operation and expectations accordingly. Smoking can lead to wounds healing badly, poor scars, and increased pigmentation. Breastlifts and face-lifts are particularly problematic for smokers because in both cases there’s a need for skin elevation. Skin is elevated to a new place and will survive only if blood reaches it. So good blood flow is vital; nicotine interferes with that.

  In some instances, the result could have been surgically prevented had the patient only done her homework and stayed away from that surgeon or practitioner.

  But how does a patient, particularly a first-timer, know what to ask and look for? To increase your chance for a good experience with plastic surgery, here are some steps to take and questions to ask – both before you pick a doctor and then once you’re sitting in his or her office.

  1. Contact the American Society of Plastic Surgeons (888–4PLASTIC; www.plasticsurgery.org), or the British Association of Plastic Surgeons (020–7405–2234; www.baaps.org.uk). Ask for a brochure on the procedure you’re considering. Even though the procedure may not address concerns specific to you (your age, genetics, goal, etc.), and the ASPS and BAAPS may slightly overplay the severity of the procedure, it’s a good place to start.

  2. Ask friends or local doctors for plastic surgeons they recommend.

  3. Once you have names, check to see if they’re board-certified. Virtually every week, I see at least one patient in my office because of a bad result from a non-board-certified plastic surgeon, and I see it from every part of the country (and often these surgeons came recommended).

  Whose board am I talking about? The American Board of Plastic Surgery (ABPS) or the British Association of Aesthetic Plastic Surgeons (BAAPS). These ones, and only these. While other boards exist, in my opinion they do not require the same rigorous training or follow-up after training. I should say here that I’m partial to plastic surgeons. I believe that when it comes to doing cosmetic surgery, they do the best job (compared with dermatologists, ear-nose-and-throat doctors, oral surgeons, dentists, ob-gyns, orthopedic surgeons, and nurses who may also perform certain cosmetic procedures). Our training is usually longer, more arduous, and the scrutiny we receive from our professional organizations, after we complete our training, is second to none.

  To check on a surgeon’s board certification, call the ABPS in Philadelphia (215–587–9322; www.abplsurg.org) or the Royal College of Surgeons in London (020–7405–3474; www.rcseng.ac.uk). They can tell you not only if surgeons are board-certified but if they’ve completed the proper course requirements, and if they’re still active members (and if they have sanctions against them).

  4. Call your local hospital, which will have board-certified plastic surgeons on staff. They won’t allow non-board-certified practitioners to do surgery because of the malpractice risk, so they represent a good clearinghouse for area surgeons.

  So now you find yourself in the office of a plastic surgeon. How do you know what’s important in helping you to choose him or not? First, at the initial consult, you may not even be talking with the surgeon – a nurse or assistant might be explaining the procedure to you. While that doesn’t mean the surgeon isn’t good, I believe that there’s a level of patient-doctor rapport that cannot be fostered if the doctor’s encounter with you is in the OR and no place else.

  Assuming you’re sitting across from the surgeon, ask these questions:

  1. Where do you have privileges?

  It’s good if it’s at a prestigious hospital. (If it’s not and the surgeon is relatively young, that shouldn’t be an automatic strike against. It takes time to get privileges.)

  If they don’t have privileges at any nearby hospital, however, you should leave. Why? Because for their office to be accredited, they must have staff privileges at a local hospital. Therefore, without such privileges, their office is not accredited (which means the quality of care, the instrumentation, and the monitoring may not be as good).

  Don’t take their word about hospital affiliation. Call the hospital to confirm that they’re on staff where they say they are. During a recent malpractice trial, it came out that a New York surgeon’s claims of hospital privileges were fabricated.

  2. How many times have you done this procedure?

  If he says he’s done two thousand face-lifts, look at him. Is he old enough for that to be true? It’s fair to assume that many surgeons, both old and young, inflate their numbers a bit, since calculating exactly requires effort.

  3. Do you do your own follow-up?

  When the operation is over, will you be seeing him or her, or an aide? Although it’s not necessary for a surgeon to see you during follow-up, it’s good medicine if we do.

  4. Who covers for you?

  Is it their clinic? The local hospital? Another plastic surgeon? Is there a specific name they can give you? I know of a plastic surgeon who had an oral surgeon cover, postoperatively for his patients’ postoperative tummy tuck. I’m not surprised that the oral surgeon didn’t recognize a significant abdominal infection.

  5. What are the pre-op and post-op regimens, the limitations and risks?

  A reputable plastic surgeon will explain all these to you. (Ask for it in writing because you’ll forget.) Does he tell you about the limitations – for example, that a thighplasty won’t remove every wrinkle but will only make your legs partially smoother? Does he explain the potential risks? Do you understand them?

  6. What kind of scars will I be left with?

  Breast reduction leaves scars. A buttock lift leaves a large scar. Virtually every operation leaves a scar. The question to have answered is, how visible is the scar? Understand where they will be, how big, and how wide they can become over time.

  (For those with darker skin: Because of your greater risk of keloid scars – elevated, thick, hard scars that result from excess formation of collagen or scar tissue – particularly around the ears, ask the surgeon how he minimizes the risk. I find it helpful to alter my incisions slightly so they’re not quite up against the ear, and to make sure there’s no tension on the closure for both face-lifts and surgery around the nose.)

  7. Is this procedure the best and only one for achieving my goal?

  To combat droopy lids, one doctor may suggest an upper-eyelid lift, where an eyebrow lift will achieve the better and longer-lasting effect. Once you’ve discussed what you want to fix, ask for the various options (if any) to achieve that effect, and the varying levels of success, risk, and price.

  8. What sort of anesthesia is used? Who gives it?

  You can’t be a surgeon and also administer unconscious anesthesia at the same time. You should have present in the OR either an anesthesiologist or a nurse-anesthetist. I’m partial to anesthesiologists because I think they have more training. But there are good nurse-anesthetists. Either way, there should be someone besides the surgeon in the OR
who monitors the patient.

  If you suffer from a chronic condition such as diabetes, heart disease, or an autoimmune disease, it’s smart to have the surgeon or anesthesiologist call your internist before your operation.

  9. Are you going away anytime soon?

  You don’t want to get surgery the day before he goes away for two weeks.

  10. How many operations do you do in a day, and what type?

  Some surgeons do lots of operations in a day – six or seven noses, or four or five face-lifts, say – and it’s tough to do a great job at that speed, and certainly impossible to put in every stitch yourself, meaning he’s leaving the room and having an assistant (resident, nurse, or physician’s assistant) close up his patients. I do every stitch myself not only because that’s what I was taught to do but because complications are more easily avoided. It also means there will always be two physicians in the OR (the surgeon and the anesthesiologist). I do an average of twelve operations a week, not including Botox treatments and other quick fixes.

  11. Do you need to see old photos of me? (This is particularly relevant for facial surgery.)

  If he doesn’t, then he’s only seeing your face at one point in time – now – and won’t have as educated a sense of your face’s innate qualities (e.g., are your heavy lids the result of aging, or have you always had heavy upper lids?). This could affect the quality of your result. You may end up looking younger but less like yourself than you want.

  The answers to the questions above, and the way in which the surgeon answers them, should go a good way in helping you to determine your comfort level. One question I recommend that patients not ask is What do you think should be fixed? What he thinks you need may not be what you think you need, and you may be offended to hear it. You need to know exactly what’s made you unhappy enough to be there in the first place, tell the doctor what it is, then ask him what he thinks he can do about it.

  Finally, during the consult, did the surgeon bad-mouth other doctors? If he did, be wary. While it’s fine and appropriate, in my opinion, for the surgeon to say something negative about another doctor if it concerns an egregious breach of medical conduct, if he is more generally and excessively critical of doctors, then he may have an inflated sense of himself. This unrealistic frame of mind can make for a doctor with serious flaws.

  A San Francisco patron of the arts had a surgeon remove a small, basal-cell skin cancer on her left upper lip. The good news? The cancer was cleared and she was cancer-free. The bad news? She neglected to choose a board-certified plastic surgeon (or didn’t bother to ask him if he was certified, or didn’t delve deeply enough to know it was even something to consider). The section of her upper lip he removed was replaced with a skin graft from her leg, which contracted within four months. (This case is now in litigation.)

  For several months after that, she walked around with a perpetual snarl – or, rather, she was so devastated that she rarely left her house. Her gums were partly exposed; they dried out, causing erosion at the base of the tooth. Largely homebound and so embarrassed that she wore a surgical mask, she sought a friend’s advice and found her way to my office. I removed the skin graft and started over, advancing her cheek skin into the upper lip. I followed a basic rule in (plastic) surgery: The best tissue match is almost always tissue immediately adjacent to the defect.

  I closed the defect and she looked fine. Eight months later she returned to my office, no longer traumatized by plastic surgeons. “Now I’d like to have some surgery for my looks,” she said. “A face-lift and a necklift.”

  “When were you thinking?” I asked.

  “How’s this afternoon?”

  If he is honest, any self-respecting plastic surgeon will say he has never done a perfect job.

  I’ve never done one, and, as a perfectionist, it haunts me. I lose sleep over work I’ve done. I run over in my mind how it could have been better. Could I have removed more skin? Could I have put more cartilage in the nose?

  But if a patient is unhappy with the work I’ve done, I ask myself even more questions. Did I make a technical error? Should I have operated in the first place? Was it the wrong procedure? Was it something about the patient?

  Sometimes you come up short for reasons beyond your control, influences such as the elasticity and pliability of skin, or the patient’s history – smoking, or cocaine exposure to the nasal septum. Yet still I reassess the operation, my technique, and our pre-op analysis.

  If you care about what you do, this taunt never goes away. It drives you to work harder, read journals, take more courses, attend more lectures, so you learn more and you improve, technically, to the point where you try slowly to innovate, coming up with better techniques than your peers’.

  Learn, learn, learn.

  Still, the result is never prefect.

  Two Frenchmen in their forties came in, friends, both lawyers. Six months earlier, they had agreed to try a new synthetic filler reputed to work wonders at eliminating lines. A surgeon injected the filler, called Artecoll (approved in Europe but not yet in the United States), into the lines in their cheeks and their forehead wrinkles. Early results of the drug’s effectiveness were encouraging, but that was from data collected over six months, hardly a long-term sample.

  The two men paid the price. By the time they came to me, their faces were streaked red, with pus oozing from the holes where they’d been injected. They had tried to style their hair and use makeup as best they could to cover up their foreheads. It didn’t matter. They looked ghoulish.

  These men, who had been looking to take only a small step to improve their appearance, sat in my office distraught.

  They’d already been through two rounds of antibiotics that hadn’t worked. So I made small incisions around the infected sites, cut out the filler, and closed it up with fine sutures to minimize the scarring. I used nylon stitches, which are less likely to cause a reaction than the equally common synthetic sutures or sutures made of sheep’s intestines. There was minor scarring.

  The lesson to be learned: Before you take any new drug or undergo any new procedure, wait at least one full year after it’s been on the market – especially if it’s elective surgery!

  It’s impossible to avert failure all the time. The best I could do was minimize its chances. To help me, I kept a list of those things that all successful plastic surgeons do.

  • Know your field but never forget what the competition is up to (through journals, conversation, conferences).

  • Listen to your patients.

  • Have an accredited office.

  • Operate smoothly, quickly, decisively, carefully.

  • Plan your surgery.

  • Anticipate what can go wrong and plan to avoid it.

  • Work nights and weekends.

  • Be patient and diplomatic.

  • Affiliate with an academic program.

  • Diversify the range of procedures you do … but not too much.

  • Stay humble. Solicit help from colleagues, former mentors, and patients.

  • Remember always: Your first wife is surgery.

  She Dies, You Die: The Royal Treatment

  She was my first European royal.

  The day before she showed up for the consultation, her security detail came to check out my office.

  Are the windows bulletproof?

  Who’s next door to your office, and what kind of access do they have?

  There’d been occasions when the bodyguards and security for other royals or members of the Forbes 400 had checked me out – doing background workups without my knowledge, even following me – to confirm that I was competent and discreet. Yet this was the first time my office had been inspected.

  Although my windows were not bulletproof, the bodyguards seemed satisfied. But now they had me worried. If the princess showed up for the consultation with two bodyguards, I wondered if we shouldn’t be meeting not in my personal office, which had a window, but deeper inside my warren of room
s, such as my exam room, which had no window. Was there really someone out there who wanted to harm this lovely woman, as one of the security agents had suggested? What about a bomb?

  The princess, blond and petite, turned out to be as gracious and easygoing as her handlers were not. It was one of the easiest preps and post-ops I’d ever had. The face-lift was a success. Everything worked out fine, despite my expecting complications and having nagging thoughts about an assassination attempt that might take me out as well.

  Come to think of it, I was kind of glad to see her go.

  For a Park Avenue plastic surgeon, socializing with successful people is a professional necessity. Not everyone I work on owns a jet, but lots of them do – usually a DeHavilland or a Gulfstream V. I want every patient on whom I perform a face-lift or chin implant or tummy tuck, etc., to love the results, and I work on everyone with an equal amount of care. But there are patients – the famous and the influential – who had really better love their results.

  When a powerful, socially prominent person recommends you, it can translate into more patients and referrals – lots of them. Conversely, a bad word from a dissatisfied, tastemaking patient can do enormous damage to your practice, even destroy it. My colleagues and I tend to lose far more sleep over a well-known news anchor or actress or Manhattanite unhappy with her eyebrow lift than we do over a malpractice suit. (For one, lawsuits are an occupational hazard and happen to us all; for another, I’ve never lost one.)

  These type-A people are more finicky, too. The ones from New York and L.A. are my most particular (more so than those from other parts of the country and from outside the United States). If I tell them they should get Botox every five months, you can be sure that, when their session is complete, they go right to Tanya and schedule an appointment for exactly five months later. And they’re more demanding: If I say I’m booked for eight weeks, they insist that that can’t be. They try to work my office manager.