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.