by Cap Lesesne
And then there’s Liz.
A five-foot-five, seventy-three-year-old dynamo and legend in the public relations field, Liz seemed particularly pleased with my operations. She had asked me to change her breast implants three times in two years and was always happy with the way they turned out. A little smaller, a little bigger, then smaller again. C cup, now C+, now down to a B+. Although I initially balked at the second and third surgeries, Liz’s motivation seemed appropriate, and after much discussion, I believed she understood the limitations and risks (e.g., asymmetry, hardening, infection, bleeding) of each surgery.
Still, Liz looked somewhat anachronistic: youthful breasts on an aged body. But while this might tweak my aesthetic sense, Liz didn’t see it that way. She was thrilled.
I was neither flattered nor dismayed by Liz’s desire to routinely change her breast implants, but I was curious. I continued to probe for the reason behind the frequent adjustments. For more than two years, I got no satisfactory answer from her.
Six months after the third surgery, Liz comes to the office to discuss new implant set number four – and finally she cops to her motivation. “I change my breast size depending on who I’m dating,” she admits.
“Liz, I can’t do this anymore,” I tell her.
“Why do you care? It doesn’t hurt me, and it makes me feel good. Please,” she begs. “Just one more time.”
“No. Three is enough.” Each time an implant goes in, the body forms a layer, or capsule, of collagen, which can contract and distort the implant. While medically and technically there’s no reason I can’t continue to alter her breast size, I refuse, given her motivation, to do more surgery.
Liz scowls at me, not at all thrilled with my admonition.
“Can’t you put in a zipper?” she wonders.
Just because I want to help my patients doesn’t mean I always agree with their “reality.” Every now and then, I’m confronted by someone who seems to be looking in a fun-house mirror. Recently, I received this letter from Sapporo, Japan:
Dear Dr. Lesesne,
I understand you are a famous plastic surgeon.
My daughter looks like Elizabeth Taylor.
I would like her to look more Japanese.
Can you make her look more Japanese?
Thank you.
Sincerely,
It was signed by the girl’s mother.
Stapled to the letter was a photograph of a homely, very Japanese-looking fourteen-year-old girl.
Thanks to my unusual access to people seeking significant physical changes, I write this book, in part, to share what I’ve learned about what motivates us and what terrifies us.
My subjects are women and men seeking plastic surgery; my subject is the skin and tissue of aging faces and bodies. Over the course of my years in practice, I’ve seen an almost incessant burst of innovation – including lasers, Botox, collagen, Sculptra, Restylane, short-scar surgery, and endoscopic surgery – that has helped to improve results dramatically, while reducing bruising, scarring, and recovery time. Other medical innovations not specifically intended for plastic surgery have also helped the quality of the work and the patient experience. For example, the pulse oximeter, a device that measures the blood’s O2 level, allows us to monitor anesthesia continuously, thus making for safer, more accurate administration of sedation, as well as allowing for more office-based surgery. Versed, a Valium derivative, and fentanyl, a narcotic, have gained popularity because they are short-acting; when the surgery is over and we cease sedation, the aftereffects for the patient are gone within an hour, not days.
But it’s not just technical innovations and new drugs and the latest injectables that tantalize my patients. I’ve come to understand, after thousands of operations, a great deal about the anatomy of the face that isn’t found in anatomy textbooks. I’ve learned about light and shadow. About the way skin heals. About skin tension. About how much fat to remove (and whether to excise it or suction it). About where and why a surgeon should leave extra skin. About how best to disguise scars. About the false expectations of computer imaging. About why it’s crucial to examine the face over time and not just in the present. About which skin regimens work and which don’t. About a myriad of other lessons, large and small. All that knowledge has made my surgery of the face, in particular, far better today than when I did my first face-lift, in the winter of 1980, as a new surgical resident at Stanford University, assisting on a standard subcutaneous lift of a fifty-two-year-old mother of three.
I also believe that there are strategies, in contrast to those of some of my colleagues, that allow me to achieve more natural results. “Where did Greta Van Susteren go?” patients of mine wondered, along with many others, even after the Fox TV anchor admitted to eyelid procedures (she never confessed to more). “Please don’t make my mouth like Melanie Griffith’s,” patients will demand before I inject their lips with Restylane. Or they might ask me, “What happened to Leslie Ash?” (Angelina Jolie’s name is also invoked, but in her case it appears the lips are her own.) The obviously plasticized look is not the usual goal of my patients; subtlety makes them happy. “Natural” is my guiding aesthetic principle. For facial surgery, my goal is twofold: to make my patient look phenomenal, and to make no one suspect why she looks phenomenal. I want her to be able to pull her hair back without any visible scars. A patient from Texas once paid me one of my favorite compliments: “You made me look younger, intellectual, and sexy.”
On the other hand, I find it comical that so many women come in for breast augmentation thinking their husband or boyfriend won’t know. They’re shocked – “Can you believe it?” they ask me – when their partner deduces it in three nanoseconds.
Many surgeons plan their procedures as a matter of routine, without accommodating the patient’s physiognomy or individual traits. My profession is degraded, I feel, by practitioners who perform the same style of operation regardless of the subject’s nose, face, or body habitus. But there are overbooked surgeons in Los Angeles, Miami, and elsewhere who insert the nearly identical pair of oversize breast implants on a vast cross section of their patients (including office staff, wives, and even daughters), so that every woman who leaves the office sports two half-grapefruits. The result is so artificial that many of us can’t help but wonder, “What was the surgeon thinking? What was the patient thinking?” Even though I spend all my day with women, and many of my closest friends are women, there are some questions I can’t answer.
Then again, other questions that people think they have answered, I would challenge. For instance, I believe it’s a myth that Michael Jackson is a plastic surgery victim. People assume that everyone believes he’s a victim, including Mr. Jackson himself. That he must hate his face (and himself) or else why would he have gone back for more and more and more.… You know what I think? That he likes his surgery. A lot. If he’d been unhappy with what was happening to his face and wanted to reverse it, he could have, to an extent. But he never did. He had an idea of what he wanted, and he’s been following that road since. We may think it looks bad. I don’t believe he thinks so.
Here’s another myth: People who have plastic surgery have complicated feelings about it. No, they don’t – not usually. Those who haven’t had plastic surgery hyperanalyze the motivations of those who have. For most of my patients, it’s a simple decision. They want to fix something that bothers them. Period. No Freudian analysis, no overthinking. Almost every magazine article critical of plastic surgery is usually written by someone who’s never felt that urge.
Another reason I write this book is because I’ve thought deeply about the face, skin, aging, and plastic surgery, and I want to share what I know to be true and false with my patients, with those interested in plastic surgery, and with other physicians. Better education about my profession is good for me, my colleagues, and, most important, future patients. Without knowledge, how does a first-time consult know what to look for in a plastic surgeon? Or what to ask the surgeon? I’
ll include some guidelines.
I love being a plastic surgeon. I love its intellectual demand and technical artistry. Most of all, I love that I make people happy. I’m with my patients every step of the process, for every suture. Many Park Avenue plastic surgeons don’t see their patients postoperatively: The resident or post-op nurse treats them. Not me. My mentor at Duke Medical School, Dr. David Sabiston, impressed upon me that they’re my patients from the moment they enter the OR until the incisions have matured, sometimes more than a year later. As the captain of the ship, I am responsible for anything that happens to them, plastic-surgery-related, while in my care. This simple lesson in accountability has made me a better surgeon because I see changes in healing and other nuances that, were I not doing my own follow-up, I might not notice or fully understand. (Two examples: With a smoker who’s had a tummy tuck, I can tell sooner, by the shade of blue on her skin, whether she’ll have problems with her wound healing. With a face-lift patient, I can tell whether scars need to be massaged.) And because my patients always see me, not an unknown, the relationship is more gratifying.
Which brings me to the last reason I write this book: to share what it’s like to live the life of a plastic surgeon. We’ve all seen slices of it (pun intended) on hit TV series such as Nip/Tuck, a fictional drama, and Extreme Makeover and The Swan. But these programs, both fictional and “reality,” offer stylized, often sensationalized, depictions of that life. Among books on the subject, none of those written by plastic surgeons talk in detail about the life we live, its daily rigors and quirks. And books about plastic surgery by journalists, while occasionally well researched, don’t come close to capturing the essence of our sense of responsibility to each patient, the numerous details we must consider with each procedure, why we make the decisions we do, and why we make the mistakes we sometimes do. I’ll provide an insider’s view that outsiders can’t, because they don’t live it.
For example, how about this paradox to our life: Can one succeed in a profession suffused with one kind of intimacy without also sacrificing – or at least challenging – intimacy in one’s personal life? I’m usually scrubbed for surgery before the sun rises, so I have to be in bed early. The society cocktail parties, museum benefits, and charity functions to which I’m often invited – and where I regularly see former and future patients – are, for me, restricted functions. I’m expected to be a diplomat, to be cool and calm, always restrained. It’s one glass of wine, tops, and nothing after nine thirty; I’m a doctor. I have to be responsible. I must focus on my surgery.
Even my avocations can be colored by the fact that, like most plastic surgeons, I’m always “on.” When I’m at the Metropolitan Museum of Art or the Frick Museum, I wander the halls looking at spectacular paintings and sculpture, yet I can’t help but analyze them as if they were patients. The young wife in Peter Paul Rubens’ Rubens, His Wife Helena Fourment, and Their Son Peter Paul looks overweight; she could use a neck liposuction. Venus in Titian’s Venus and Adonis is often regaled as the paragon of female perfection, but, to my eye, she’s disproportionate. And whenever I see John Singer Sargent’s magnificent Madame X, which depicts a side view of her large nose with its dorsal hump and flared nostrils, I can’t help but think, What would she look like if I reduced her tip projection and rasped her dorsum?
This out-of-office PSR – Plastic Surgeon’s Radar – is not just operative while I’m strolling the halls of a museum; it’s frequently on during social functions, including when I’m having dinner with a woman. It’s not long before the more daring of my dates will ask me to comment on what she may or may not need – and sometimes they don’t like the reply. One woman, while dancing with me on our second date, challenged me to assess her breasts: “Cap” – my nickname – “what size do you think they are?”
What do I say?
That I know they’re 325 ccs? That the implant casings are “smooth” (as opposed to “textured,” whose surface features tiny ridges)? That they’re of “moderate profile” (the distance of the implants from the chest wall)? That I can even name the implant manufacturer?
“The perfect size,” I replied. “They suit you well.”
I operate on men and women. I physically and psychologically change them, yet I must remain distant. I champion their initiative and sometimes courage to transform themselves, yet I must be keenly aware of, and candid about, their weaknesses and occasionally misplaced motivations.
My professional obsession is flaws. My goal is perfection.
I agree with Aristotle: The pursuit of life is happiness. Figure out what’s important in life, then go for it. If there’s a physical attribute that can be fixed, and the procedure involves minimal risk, and your life will be improved because of the fix, then why not do it? I don’t trivialize the risk of surgery because all surgery entails risk. But I see, every week, how plastic surgery delivers physical results that change people’s lives in positive ways. I love Billy Crystal’s famous Fernando Lamas impression on Saturday Night Live – “It’s better to look good than to feel good.” It’s funny, at first, because it’s about vanity and superficiality. But for many people it isn’t far from the truth. For them, feeling good is looking good. Attractive physical appearance reinforces good body image, and good body image affects psyche. Others see you in a different light. You may be noticed and appreciated more. You’re more likely to get promoted. You get more out of life.
As one face-lift patient told me on a postoperative visit, “This changed my head.”
* * *
*I can’t – though I can tell you a few ways to tell if someone’s had plastic surgery:
1. Unevenly dimpled legs. (Liposuction)
2. Symmetrical scars. (Under the armpits: a subpectoral breast augmentation; in the same position on the hips, backs of legs, or fronts of legs: lipo)
3. Scars just in front of the ears. (Face-lift)
4. A break in the hairline. (Face-lift)
5. Facial skin different from skin on top of the hand or, more accurate (since lasers easily remove hand wrinkles and brown spots), different from skin on the lower leg. (Face-lift)
6. Cheekbones too sculpted for overall anatomy. (Cheek implants)
7. Incisions on the tops of the eyelids, sometimes only visible with the eyes closed. (Eyelid lift)
*In the long run, the forehead lift is probably cheaper.
*Six months later I spot her at The Ivy in Los Angeles. She’s having a romantic dinner with a younger man.
Youth (Without Surgery)
You aren’t born to be a surgeon. There’s no natural talent for it. No one is born with a great pair of hands for surgery – for football and piano, maybe; for surgery, no. Usually you become a surgeon (or a doctor, generally) because you want to help people, or because the aspects of the discipline – intellectual, technical, aesthetic, psychological – appeal to you, or because you’re lucky enough to have a role model. For me, all three conditions held, though early on, I was aware of only the last of these. My father, John Lesesne (luh-SAYN), was a doctor (now retired), an old-school internist who made house calls in the upper-middle-class suburbs of Detroit, where I grew up in the late sixties, the eldest of six kids. His was the kind of practice, almost obsolete now, where he treated and cared for two, often three, generations of the same family. He was an allergist, specializing in asthma. Sometimes I would go on house calls with him. While Dad paid his visit, I sat in the car, curbside, scanning the windows of the home to see if I could spot him and maybe get a glimpse of what was going on inside, but it was not out of fascination with medicine; it was the fascination of a son for what his father does, a child intrigued by the grown-up world. That’s it. At least that’s what I thought at the time. Now and then I’d bike by his office and poke in for a visit or, when I got older, stop by St. John’s Hospital on Mack Avenue. I had no idea these latter visits would benefit me years later: Because I associated hospitals with Dad’s presence, they always felt like places of warmth, even invita
tion, sanctuaries where people went to get well. For me, a hospital was never the dark, institutional warren of hallways and machines that terrifies most people. It was Dr. John Lesesne facing a wheezing little boy sitting on a table. “Now take a slow, deep breath through the mouth,” my father would urge in his Charleston accent, soft and calm, then place the cup of his stethoscope to the boy’s chest.
Proud as I was of Dad, though, as highly regarded as he was in the community, there’s another enduring image I have of him, equally unshakable.
It’s of him not there.
Because he was always working. Frequently he came home too late for dinner. He would do anything for his patients. He made a good living. I could not respect a man more. But he was anchored in one place, Grosse Pointe, Michigan, a bucolic Midwestern suburb of Detroit, and he would be there for life.