Confessions of a Park Avenue Plastic Surgeon

by Cap Lesesne

  To compete in the hypervisible, hypercompetitive world of modeling, most models now have small to major operations performed. The minor procedures include removal of moles, cauterization of blood vessels, and removal of small lipomas (benign growths of fat); these procedures we do for all models, but now it’s trending younger and younger, starting at around age twelve for adolescent models. In the late teenage years, the range of procedures widens to include cheek implants, chin implants, liposuction, and, of course, breast implants. I had a fourteen-year-old model come in, with her mother, wanting breast implants. I told her I didn’t do breast augmentation surgery on any girl under sixteen, and frequently I turn down girls for a few years after that. The breast bud is not fully developed then, so I believe it’s a mistake to do it that young. (When I turn down the chance to operate on teenage girls, roughly half the time I do it for physical reasons – there’s not enough of a defect or the trade-off clearly isn’t worth it – and half the time I do it for psychological reasons – because I sense that the girl may not be mature enough to handle it.)

  There are more esoteric procedures that models will have, too – removal of ribs, shaving of the jawbone, removal of the buccal fat (fat at the center of our cheeks) to give a more sculpted, haunted look.

  Today’s plastic surgeons are coming closer and closer to making the face you want. The question is, how far is the subject willing to go? For the model with the potential to make hundreds of thousands, if not millions, of dollars, they’ll go very far. Just about every model who comes into my office is determined. A twenty-two-year-old from the Elite agency came in for a breastlift. She was stunning but her breasts were slightly lower than normal, and she needed them lifted if she was going to get runway work. I advised her of the scarring and actually showed her a photograph of a worst-case example. She wasn’t fazed at all. She insisted on having the operation. Normally, I wouldn’t place a breastlift scar around the areola on a twenty-two-year-old, but that’s where she needed it to be, professionally. I also had to modify my technique to ensure that she could breast-feed at a later date.

  The range of possibilities in plastic surgery is expanding rapidly each year, and I expect the trend to continue. Soon, we’ll truly be able to say that we have “beauty by design.”

  Katrina, a famous Vogue model from Germany, came in at the urging of her agency. As you might expect when a current supermodel comes in for a consult, your first question as a plastic surgeon is, what the hell could this woman possibly need?

  You couldn’t tell from first glance. Blue eyes, long blond hair, five feet ten, sensational body. She wore jeans, a Nordic sweater, no makeup. Great smile. She was nervous.

  Breast implant? Lipo? I wondered. What on earth could this young woman want?

  “I have a complex,” said Katrina. “I have something that’s stopping me from getting modeling jobs.”

  “I find that hard to believe,” I said.

  “I can do runway but not magazine.” She looked down, as if ashamed. “Except if the magazine wants me in a swimsuit.”

  Then she pulled her hair back.

  Her ears were huge and tilted way forward. “I don’t know anyone who can fix them,” she said, “and my agent said you can.”

  “It’s simple,” I said.

  It took an hour, using only local.

  Removing the bandages afterward, I gently tugged the last strip off and gave her a mirror. Katrina looked and, tentatively, held her hair back. She broke into a big smile. Then she started to cry.

  A few days later, the booking agent for the modeling agency called. I thought she wanted to thank me for fixing Katrina’s ears.

  “I know you’ve worked on some of our girls, and their bodies are even more incredible,” she said. “I’m jealous. I want breast implants, too.”

  A week after the operation, she called. “You may have to take them out,” she said wearily. “I need a baseball bat to keep my husband off.”

  When I laughed, she said, “I’m serious! Can you at least recommend the best cream for backburns?”

  Sometimes, it’s almost unbelievable to me how many women want breast implants. Breast augmentation has been one of the hottest things in plastic surgery for a decade, and it’s true across social strata. Among beauty role models – actresses, swimsuit and magazine models – its prevalence is huge.

  But when the most stunning women in America are getting breast implants, it causes a thought even a cosmetic surgeon must ask: Does everybody really suffer some kind of physical insecurity? Are business demands that great? Have the altered (i.e., enhanced) standards of attractiveness in our culture pressured everyone to feel as if they’ve got something that needs changing … or else they’ve got nothing?

  Yes.

  I came to see that everyone, no matter how apparently perfect, has something that bothers him or her. Some hang-up. Something that might be trivial to you but not to them. Jowls, saddlebags, heavy lids, bags under the eyes, bump in the nose, small breasts, big breasts, uneven breasts, male breasts, the list is long. It’s true for the not so rich and the very rich, the average-looking and the drop-dead gorgeous. Everyone.

  And what those things are five or twenty years from now will almost certainly change. Once, women wanted their hair to look like Veronica Lake’s, then Jane Fonda’s, then Madonna’s, then Jennifer Aniston’s. Popular concepts of beauty change and often come from the top down. If Hollywood actresses suddenly decide that flat-chestedness is beautiful, then there likely wouldn’t be the same demand among the general public for breast implants.

  Then again, the notion of the empowered woman is not a fad but a reflection of sweeping cultural and technological change. Women (first in the West and increasingly everywhere) are more in charge than they have ever been professionally, financially, sexually, physically, psychologically. Most women pay for their own implants, as a gift to themselves. We live more and more in a world in which we’re told we can be anyone, where lives are increasingly customized to the individual. Since many women want to have the physique – at least the breasts – of a Playboy centerfold, and now they can, and easily, their philosophy is, Why not?

  While downtown New York and the modeling world were fun, my practice would live or die on my relationships with women uptown (as well as those from other parts of the country and the world). The same was true of any New York cosmetic surgeon. Gradually, I was getting more referrals through patients, and doing more types of procedures. I met people in banking, advertising, and media. I met diplomats and international lawyers – men doing what I’d long ago thought I someday wanted to do. (I had to admit, their lives seemed pretty exciting.) I continued to do the best work I could, hopeful that my patients not only felt transformed by their face-lift, browlift, tummy tuck, or hip liposuction, but also raved about it over lunch with friends.

  I got my first taste of international patients. A broadcaster from Hong Kong came in to have me Westernize her eyes, a procedure I’d learned to do at Stanford. “Don’t make me look too different,” she said. “I was beautiful when I was young. Men chased me.” Western and Asian eyes, as you might suspect, have different lid anatomies and support structures. The key to an effective “Westernizing” is to take out a little bit of skin from the epicanthic fold of the upper eyelid; this area is nearest to the nose and allows us to change the curve. The other parts of the lid are left alone. The lower lid gets altered only slightly, with fat being removed transconjunctivally – that is, the incision is made inside the lid. I’ve done far more of those procedures than I have of the reverse – undoing Westernized eyes for Asians who want their totally Asian look back. That’s much more difficult.

  A couple of weeks later, I was dining at a French restaurant when a departing patron, the wife of a wealthy Turkish businessman, caught her heel in a sidewalk grid just outside the restaurant, fell, and broke her nose. After someone rushed inside and hollered, “Is there a doctor?!” I strode outside, examined the woman – the bones had pun
ctured through the skin – and called my nurse to ready my operating room. We got the woman over there. While I sutured her, her husband playfully spun in my OR chair. The next morning, a two-foot cube of Godiva chocolate arrived for my office staff, along with an invitation for me to spend a week on their yacht in the Mediterranean.

  A wealthy and intimidating Venezuelan oil magnate came to me to shrink his waistline.

  A woman from Australia, whose husband was attached to the United Nations, came for a face-lift. She was so secretive that much of our preliminary contact was through an intermediary, and I finally stressed to her representative that I would not continue until I met the lady in person and could look at her actual face. They relented.

  One day, an eighty-year-old Italian lady came to the office. She was a recognizable figure: I would regularly see her on Madison Avenue in bright Valentino suits and stilettos. After we talked for a moment, she told me she needed “emergency breast implants.”

  “Emergency?” I asked.

  “I have a date with a hot young man in a week,” she said. “Yes, it is an emergency!”

  Just then my phone line flashed, and I excused myself to take the call. Before I even had the phone to my ear, I was being pelted by obscenities.

  “You son of a bitch! I am going to kill you you son of a bitch! You turned my penis black!”

  Who is this lunatic? I wondered.

  “Hello?” I said, turning my body away from my consult. Whatever the reason for the invective on the other end, it was unlikely to inspire confidence in the prospective patient now sitting in my office. “Who is this?” I asked, covering the phone with my hand.

  “This is Diego, you son of a bitch, you turned my penis black! My testicles are black! You gave me a black penis!”

  It was the powerful Venezuelan oil magnate on whom I’d performed waist and hip liposuction two days before.

  “May I ask you to hold for one moment?” I said into the phone, then quickly hit the HOLD button. I smiled at the lady in my office and asked her to please excuse me for just one quick little moment. I withdrew to the OR and picked up the line again.

  “Now, Diego, take it easy, everything is going to –”

  “Take it easy?! Everything is not going to be okay, asshole, especially for you! I have a black penis!”

  “Take a breath and –”

  “I’m gonna kill you you’re dead!”

  “Diego?” I could hear him breathing heavily – but pausing long enough for me to speak. “Okay, now, Diego? Everything is going to be fine. You are not going to have a black penis. Or black testicles. I promise you. The reason they turned black is that you didn’t follow my instructions after the operation. Or really you followed them too zealously. Remember I told you to wrap the elastic bandage…not too tight? How tight did you wrap it?”

  His breathing was still heavy, almost wheezing. “Tight,” he finally said quietly.

  “Very tight, I bet.”

  There was silence … and then what sounded like a deep sigh. “Very tight,” he acknowledged.

  “I told you not to do that – remember?”

  Again, a sigh. “So I’m not going to have a black penis,” he said flatly.

  “No, you’re not. Because you wrapped it too tight, you reduced the returning circulation from the groin. It’s backed-up blood. It will be gone within four days.”

  I hung up with Diego, returned to the eighty-year-old patient in my office, and we scheduled “emergency” breast augmentation for her the following Monday, so she would be ready for her date with the young man the following weekend.

  Building a reputation takes time.

  About Face, Skin Deep

  I’ve analyzed the faces of over twenty thousand women. I do it all day, week after week, year after year.

  The plastic surgeon sees the face differently from everyone else. Like most people, I look at the eyes and mouth first, then take in the face’s coloration. But within milliseconds, I break the face into individual components, then convert them into anatomy. For example, I see a large bump on the nose as if the skin were invisible; I study its cartilage component, its height, width, consistency, boniness.

  I find shapes. How does this face depart from da Vinci’s description of perfect balance, in which the face divides into three equal parts of forehead, middle third, and lower third? For example, if a patient has a weak chin, I determine if the lowest third of her face is shorter than the upper thirds because of the chin’s deficiency. Would a chin implant do the trick? Or should I do an osteotomy – a chin advancement – to increase the length of the lower third of the face, to create the pleasing facial balance the eye craves?

  I look for shadows. I look for asymmetries. Is the left side of the lower lip even with the right? To get a sense of the underlying musculature, I again look at the face as if the skin had been removed from it, and it were just muscles underneath. Which muscles are firing? Is the frontalis muscle moving the eyebrows evenly? Are the lip depressor’s (depressor anguli) moving the lips evenly?

  I look at the face from another angle – does my perception of the face change more than normally when she turns her head slightly? Now that I’m looking at it from the side, what do I see about the face that I did not see before? Is the jawline straight? Is the nose too big? Are the ears too big? My analysis of the face is multifactorial: I look to see where it is in time, what is in its future, what is its past (scars, sunlight, biopsies). I assess its appearance in light, its anatomy, its genetics (e.g., pale Irish skin heals better, say, than thicker negroid skin).

  My antennae are up the moment I walk into my office to meet a new consult. Although I know before I walk into my office what she has called about (even though many patients, particularly women, will change their minds or bring up new issues once we start talking), I like to think that if I didn’t have that information, I could still tell right away what the patient is there for, especially if it’s for something above the neck. Sir Arthur Conan Doyle, a physician more famously known as the creator of that master deducer Sherlock Holmes, taught a medical school course at the University of Edinburgh in which patients would enter the classroom and his students had to diagnose their illness merely by looking at them.

  It’s not easy for me to shut off my PSR (Plastic Surgeon’s Radar), and I don’t believe, among my professional brethren, that I’m alone. A baseball slugger sees a belt-high fastball and thinks, I can hit it; a writer overhears a memorable exchange and thinks, I can write it; I see a face and think, I can improve it. As soon as I see a face – live, in a photograph, in a painting, on a sculpture – I can’t help myself (most of the time) from assessing its symphony of features and accents, what is pleasing about it and what is not. Most importantly, as a fixer of faces, I can’t help but home in on the things that can be changed, to make it look more appealing, given what I know about medicine, anatomy, aesthetics, perception, and the psychology of seeing.

  I was trained to do this, though it’s been so long now, perhaps it’s become my nature to do it, too. It may seem overly critical and judgmental that I approach faces this way, even cruel. But I don’t volunteer to people I meet that they should do this or that, or wouldn’t it be nice if they had this done or removed some of that? I only share what I know with those who come to me, who ask me to do it, who retain me to do it.

  That doesn’t stop men and women, but especially women – sometimes dates and romantic interests – from prodding me to tell them, as if it’s some kind of game, what’s “wrong” with their face, how I would change them, what could be done that would almost certainly make them happier. It’s actually an incredibly poignant dynamic, if you think about it: people asking me to tell them what will make their lives better, asking me to guide them closer to some inner beauty by pinpointing what can be done to enhance their outer beauty. As if they didn’t have an inkling of it already.

  Because I think they already know the answer.

  The first thing to “go” in a w
oman’s face, at around age forty-two, are the upper eyelids. (This is not true of every face, of course, and various factors – sun, smoking, genetics, to name three major ones – affect the age at which this happens.) Observers can’t help registering this change because when looking at faces, we naturally look first at the eyes. If a woman has a heavy upper lid, then the eye’s apertures narrow over time. When I do an eye lift – really, an eyelid lift – it alleviates this narrowing: I remove skin and fat from the upper lid, which opens the eyes once again, and right away the subject appears younger. Roberta, a smart, pretty investment banker I once dated, asked me, after a month of our seeing each other, if I would do an upper-eyelid lift on her. (My PSR was off with her, but now that she asked me about it, I could see what she was talking about. I hesitated to do the operation, but she said she would trust no one else.) Even I was floored to see how beautiful Roberta’s blue eyes were, now that the excess skin on her lids had been removed – and I don’t mean to say what a high-quality job I had done. But that’s just the kind of difference a reversal of that “narrowing” can make.

  Facial lines first start to appear in the thirties, then increase and become really visible in the forties – and you know which ones: crow’s-feet, glabellar lines (the vertical ones between the eyebrows), and those at the corners of the mouth. The deeper, nasolabial folds, which run from the corners of the mouth to the outer edges of the nostrils, really start to appear more in the late forties and become prominent in the fifties, as do the vertical lines leading to the upper lip. (There’s a basic concept any good plastic surgeon knows: Wrinkles form perpendicular to the muscle that’s contracting.)