Reflections on cosmetic surgery

“The high profile, high profit stuff makes it possible to do reconstructive surgery on needier patients.” Thus spoke actor Michael J. Fox as Dr. Benjamin Stone, a budding plastic surgeon, in the 1991 movie Doc Hollywood. When I began to consider pursuing the specialty of plastic surgery, after already completing a full residency in general surgery, I could not help but wonder if I was going to be wasting a great deal of my general surgery training. Although my knowledge of the specialty was embarrassingly limited, I knew enough to know that cosmetic surgery was a big part of it. The idea of spending a career doing "nips and tucks" on people who simply weren't happy with their looks, in a world filled with trauma, cancer, and congenital defects, was distinctly unappealing. I put this question, in a round about way, to Dr. Millard (I didn't want to ask directly lest it bias his decision to accept me into his training program). His answer was, "Rick, unless you can take a normal physical feature and make it better than normal, you will never be as good as you can be in taking a deformity and making it look normal". This made sense. Fast forward about 20 years. I still do cosmetic and reconstructive plastic surgery but the former pays the bills. Reimbursement for reconstruction is so low that if I did just that, I would have to totally retailor my practice, fire a number of employees, sell the office, and essentially start over with a very little overhead. Don't get me wrong, there is much to like about cosmetic work but here's the thing; it is the only area in medicine where we perform surgery which is not medically necessary. Because of what has happened in medicine over the years, now everybody and his brother wants to be a plastic surgeon. Patients tend to be healthy, surgery is elective, you can charge what you feel you are worth, and patients pay cash, in advance. What's not to like? As a result, it is the wild wild west out there when it comes to finding a plastic surgeon. Even family practitioners and other non-surgical specialists are getting in on it. As if that weren't bad enough, American ingenuity, innovativeness, and entrepeneurship, plus a sprinkling of greed, have led to a prolifieration of devices, procedures, operations, lasers, and more, some useful, some worthless, designed to make us look younger. I can't even begin to keep up with all the "new and better" stuff out there that I can add to my practice.

So, where is all this blather leading? Just this. Although it may seem a strange, indeed counterproductive, thing for a plastic surgeon to say, I truly believe that if people can make peace with their own natural features and the aging process, without resorting to plastic surgery, they are MUCH better off. Don't misunderstand. I am here to help those who can't but my role is not to sell anyone on a particular product or procedure. I also never want to find myself feeding someone's insecurities about their real or imagined issues. I know of plastic surgeons who, when you go to them, even if for a single concern, will give you a "laundry list" of the things you "need" to have done. I can't do that. Don't applaud. I'm as tempted as the next guy to cash in on someone's interest in cosmetic surgery but, as the guy in the Hebrew National commercial said, "I answer to a higher authority". One of the problems with much cosmetic surgery is that people are trying to get plastic surgeons to fix the consequences of a lifetime of bad decisions. Decisions like baking their skin in the sun, eating poorly, not getting enough rest, smoking, never exercising, drinking too much, and on and on. The ways in which we abuse and/or neglect our bodies are too discouragingly numerous to mention.

So, when you go to a plastic surgeon and ask him or her, "What do I need, doctor?", realize that the answer is, "nothing". You don't need cosmetic surgery. It is something you do for yourself because there is some physical feature or issue that you don't like and wish to fix. As long as the concern is legitimate, your expectations are realistic, you understand the risks and limitations of the procedure, and you are financially able to pay for it, I, and my plastic surgery colleagues are here to help. But, and this is an important but, we cannot undo the effects of a lifetime of neglect and abuse, nor can we stop the march of time altogether. We are, after all, surgeons, not magicians. 

Adventures in Running

 Running is undeniably the oldest and purest sport. Our earliest ancestors ran, although more likely for survival than fun. It requires no special equipment and with all due respect to manufacturers of running shoes, running apparel, and other running accessories, one can run just fine naked even though this hasn’t caught on to date except in a few naturist camps. You can do it anywhere. Marathons have been run in war zones, in deserts, and there is even an annual marathon in Antarctica. I have run on the rolling deck of a U.S. Navy ship in the middle of the Pacific Ocean.

Running is not regarded as a contact sport. True, contact with other runners is not a typical aspect of running, but there are other forms of contact. On one early morning run, I was jogging in our neighborhood. I was on the right shoulder and could hear a car coming up behind me. I could tell by the sound that it was still a good distance away and decided to cross over the left side of the street. As I angled to my left, I stepped forward with my right foot and, as I went to lift my left foot for the next step, face planted into the road. It happened so fast that I did not even have a chance to put my arms out so that when I say “face planted” I mean exactly that. I was dimly aware of the car behind me rushing past uncomfortably close and I would estimate that it missed running over me by no more than a foot or two. The driver never stopped.

Getting up, I could feel the burn of a significant “road rash” on the right side of my face, right arm, and knee. The cause of the misstep was immediately evident; my left shoe lace had come untied and I had stepped on it with my right foot. If it had happened two steps sooner, I would have been under the car. I have triple tied my shoelaces every since.

Running in Florida presents some unusual hazards to the uninitiated. A few years ago, I lived in a neighborhood that, although near town, was decidedly rural in character. Most of the houses had large, multi-acre lots. There were untouched woods and wetlands scattered throughout the area and a large lake nearby. The streets were unlit. One morning, running in the early twilight, before the sun truly was up and with no moonlight, I noticed ahead of me a dark object across the road. Thinking it was a large branch, I deviated slightly so as to go around it. As I passed it, one end of the “branch”, the one near me, opened its mouth, revealing a white maw full of teeth. It was an alligator, perhaps 6-7 feet long. They tend to travel from place to place overland during the mating season, a fact that came to mind just a little late. This one was a least a quarter mile from water. Fortunately it was a cool morning and the reptile was apparently sluggish and did not press its advantage beyond what was evidently a warning display. For that matter, it may have just been yawning. Even so, the adrenaline burst that this display released flung me through the air to a point about 10 feet away almost without apparent effort. I found myself looking back at it wondering how many places can you run where there is a real threat that you might be devoured by giant, prehistoric lizards?

Running in the tropics is one thing. The cold is another matter entirely. I was training to run a ½ marathon with my soon-to-be niece, Dawn, who was running her first. I hoped to encourage her and keep her company over the distance. Her fiancée, Nephew Brandon, and my wife, Sally, were going to cheer us on. As part of my training program, I had to schedule some long runs. One of those happened to fall on the weekend when I would be in Atlanta for a conference in January, which can get pretty cold. I planned to do a 12 mile run while there. My conference schedule was such that this had to be in the morning so, in order to get to downtown Atlanta by 8 AM for the conference, I had to get up around 4 AM, be out of my sister’s house by 4:30 to run and be back by 6:30. I ran the outward leg in the dark, in near freezing temperatures. On the return, it began to drizzle, freezing rain just shy of being cold enough for snow. Within minutes I was soaked. I ran the entire way back in a near freezing downpour and when I arrived back at the house, hurried to take a hot shower. As I undressed, I noticed something unusual for the first time: no feeling below the belt. I checked and discovered that the anatomy was about the color of a boiled cocktail frank (major shrinkage). Let’s say that the “thaw” was uncomfortable and leave it at that. Fortunately, feeling returned and all seemed to be fine after the shower. If I had run a couple more miles this story might have had a very different ending!

This next adventure also came with a life lesson, along with great embarrassment. Some background is necessary. When I ran my first marathon, at Walt Disney World in Orlando, in 1995 I learned something interesting. Some might say it should have been obvious. The marathon start was in the early, pre-dawn hours and because of the thousands of runners, we had to arrive at the staging area at least an hour before the gun went off. When you put nearly 20,000 runners in one place, all of whom have spent the past 12 hours massively hydrating with fluids, the results are predictable. The ‘porta potties’ provided were overwhelmed and the lines outside them were reminiscent of the popular attractions in the Magic Kingdom on a busy day. As I walked to the staging area, the bushes lining the path were thick with runners relieving themselves. The part that amazed me was that it was fairly evenly divided between the sexes. Women were just walking behind a bush, dropping “trou” and whizzing too. There were clearly male and female clumps of bushes. When you had to go, you had to go. It was all very business-like and discretely done with as much privacy as circumstances allowed. During the early miles, it was commonplace to see runners peeling off from the road, into the bushes, for the same purpose. This dramatically exemplified the pragmatic attitude of the long distance runner regarding the natural need to empty one’s bladder.

Fast forwarding a few years, Sally and I were staying at her sister’s condo on Fort Lauderdale Beach. One morning we set out together, she to walk/run, me to run. I sped on ahead and about 15 minutes into the run realized that I had to pee. My options were to go back to the condo, find a restroom, or go “au natural”. The former was unappealing as I did not want to retrace my steps. The second was moot as I had passed no public facilities on the way out and could see nothing ahead in the distance, which was an unbroken string of high rises on the beach on one side of the street and a wall on the other. The third presented some challenges since there was no obvious out-of-the way area out of view of the road which seemed to present itself. Passing one high rise, I noted an area of thick landscaping that appeared to have a path back into it. Following this path, I found myself in a space against the base of the building and completely out of sight of the street. Quickly relieving myself, I turned to leave and WHAM! I was staggered back by an impact to my face that left me dazed. At first I thought someone had hit me with a 2 X 4. As my vision cleared, I saw the pipe and simultaneously felt a warm trickle running down my nose that could only be blood. I had walked into a horizontal pipe precisely at face level. I had absolutely no memory of having ducked under it going in, although I had to have done so, and totally forgot it was there coming out. I walked out from behind the foliage into the sun. My glasses were irreparably bent. I straightened them as well as I could, put them back on, and ran on, dripping blood, looking for a place to check myself out, hoping to avoid being seen. A few blocks down, I found a Dunkin’ Donuts and walked in, careful to hide my face as I headed for the bathroom. The damage looked worse than it was. My nose was cut, some skin was missing, but no fracture, and, thankfully, no eye injury. My neck was sore for weeks afterwards. So, what was the lesson here? Well, if you ask my wife, it was to not pee in public. I tried to draw a little loftier conclusion. It never occurred to me that this decision to stop and pee would nearly give me a concussion. I could have been knocked cold and/or injured myself more severely. It drove home that, in life, everything can change in an instant. Despite all of our preparation and anticipation, we can be blindsided by the unexpected: lose a loved one, be diagnosed with cancer, or find that all of our plans for the future have been wiped out by the irresponsible acts of others. And, yes, I did learn to be more careful where I chose to relieve myself.