by Cap Lesesne
Other professional arrows, ones not aimed at us explicitly, can also wound us. “Brilliantly innovative surgeon,” for example. Sounds like a positive thing, yes? It is – except when the brilliantly innovative surgeon is less cautious than he ought to be.
First, let’s take a genuine trailblazer. In the 1980s, Dr. Carl Hartrampf, an unassuming giant in our field, pioneered using the abdominal muscle, along with its overlying skin and fat, to reconstruct the breast, postmastectomy. This provided breasts – not implants – that were natural feeling and looking.
Then there are the envelope pushers who are not quite as thoughtful as Dr. Hartrampf; in fact, they promote procedures that ultimately fail. In the early nineties, several surgeons experimented with an “advanced” technique for breast reconstruction: They harvested the latissimus (back) muscle, tunneled through the skin of the armpit, and inserted the muscle underneath the skin on the chest. The muscle was then folded to make a new breast mound. Novel idea – we’re always looking for new sources of tissue – except for one problem: When not being flexed, the latissimus muscle atrophies in sixteen to twenty months. No one knew that initially. The first papers published about the procedure talked up its benefits, reporting no problems.
Two years later, women who’d undergone the revolutionary process suffered loss of breast volume. The muscle shrank and another reconstruction had to be done.
Another example: Other “innovators,” looking to give the neck more definition, ran silicone threads underneath the neck. It looked great for the first couple of months. Then it eroded through the skin and the patient felt as if she were being choked.
Or soybean implants. This was a potentially good idea because we were looking for a breast implant filler that was more radiolucent (easily read) for mammographies than saline. Soybean implants were developed in Switzerland and initially manufactured and marketed only in Europe. Unfortunately, the soybean implants experienced some leakage, and when the soybean oil came into contact with fat, it soponified – that is, it broke down the fat in the breast, creating a liquid gel of degraded fat that looked like pus. Since almost all implants have a risk of leakage, they all had to be removed, for fear that any mishap could lead to cancer. Women who’d had soybean breast implants experienced pain, and their breasts were deformed so that they were neither round nor soft.
No innovations would happen in medicine and science without lots of mistakes and wrong paths being taken. Still, I prefer to wait at least a year before I’m willing to try someone’s new technique, no matter how promising – especially because no medical board has to ratify a new procedure.
(One surgeon on the Upper East Side may have considered himself an innovator or may just have been misguided. A patient wanted buttock implants. The surgeon decided, inexplicably, to place breast implants in her rear. After she healed, she had … well, breast implants in her rear. Whereas buttock, calf, and cheek implants are made of solid silicone, breast implants are hollow and have a fill of either saline or silicone gel. Thus, the feel of a breast implant differs substantially from a buttock implant. The patient was unhappy with the result and went to another doctor. In the exam room during the pre-op visit, the patient – not a native English speaker – told the nurse that she was there to have breast implants removed. The nurse told her, “Take off everything above the waist.” The woman replied, “Why?”)
Another nasty bit of business about our profession casts dark shadows on many of us – the one that has to do with our motives.
Why does a man become a plastic surgeon in the first place?
The first answer is that he believes in helping people. But when a plastic surgeon becomes more specialized in cosmetic surgery, it means that the vast majority of his waking life will now be spent with women. Surgeons are, by and large, a rather testosterone-charged group of men, and it surprises me that some of my colleagues refer to women in the coarsest terms. Their motivations to enter cosmetic surgery are different from most of ours. Sometimes I think that they simply dislike women, and their professional pursuit allows them the chance to mold and control them.
Did they go into cosmetic surgery with this agenda? Or did it develop after they began working so extensively with women? I don’t know. Another chicken/egg question.
A sales representative for a new laser manufacturer visited the office. Meetings like this are common for doctors – reps from pharmaceutical companies and medical technology companies promoting their products. One manufacturer after another had been boasting about how their laser was an improvement over previous versions – good for skin care and removing lines – but especially their miraculous new capability of removing scars.
I told the rep I was frankly amazed that scars could be removed since they’re the full thickness of the skin. “I have a rowing scar on my forearm,” I said, rolling up my sleeves. “Let’s get rid of it.”
His eyes widened.
“You set the parameters on the machine,” I instructed him.
Nervously, he did.
Not only did the laser burn me, it discolored my arm. I was sore for six weeks. My scar remains, and to this day, lasers don’t work well on scars.
To understand better what my patients experience – that is, to be a better doctor – I did everything possible to feel what they went through. When Botox came into fashion, I tried it on myself, injecting it into my forehead. (It hurts.) I lipoed my neck. (Painless, but I felt lumps of dried blood underneath the skin, which took a month to disappear.) I am not a salesman, looking to push new techniques and technologies and medications on my patients just because someone out there says it’s the new next best thing. And I would not be one of those doctors who upgrades his knowledge simply by taking a weekend crash course at a Las Vegas convention center.
Do I compete against the best plastic surgeons in the world, especially when it comes to faces and necks? Absolutely. That sounds arrogant, I know. But I have to think that way; I have to believe that’s true. Many other surgeons are tremendously talented, some a few doors down from me, some on Rodeo Drive in Beverly Hills, or Harley Street in London, or The Peak in Hong Kong, or Ipanema in Rio de Janeiro, or in Dallas or in Miami or in smaller cities. We see the same patients and I compare my results to what I see from them in my office.
To compete, you must be relentless.
Aging Beauties, Rediscovered Youth
Caroline, a forty-two-year-old Texan, was spunky and attractive: black leather Louboutin boots, leather skirt, light blue cashmere sweater, an ornately knotted Hermés scarf, Gucci sunglasses pushing back her light brown hair. She had brown eyes and rosy cheeks and an infectious smile – but these days she wasn’t so crazy about her smile, or her eyes, which is why she’d come to me. As a recent divorcée, she’d been too long out of the dating and mating game and had stopped exercising. She was at that stage of life when the cumulative effects of gravity manifest on a woman’s face. The upper eyelids go first with excess heavy skin. The jawline develops fat deposits and excess skin. The neck becomes loose. The mouth turns down. Caroline wanted her looks back so she could recapture companionship, sex, and a place in the social pecking order she craved as a middle-aged divorcée. That’s not to say all these good things happen the instant you wake from a face-lift, or an eye lift and a lip plumping. But Caroline was ready to start the transformation.
During the consultation in my office, I agreed that we could do something about the excess fat in her lids, and that her lips, while shaped perfectly, were small. For Caroline, a fat graft would not only make her lips fuller and sensual, but fill out the small vertical lines – called rhytides (“lines,” in Latin) – leading to the lips where lipstick smudges and bleeds. An eyelid lift, where I cut excess fat out of the upper lid, would open the aperture of her eyes and give her a youthful alertness. (You can get too carried away with this procedure, though: For those with naturally heavy upper lids – Julie Christie and Faye Dunaway come to mind – taking out lots of skin can ravage natural, sult
ry beauty.)
Given Caroline’s lively face and her effervescent personality, I was sure she’d look better, younger by three or four years. She smiled a beautiful smile – fine cracks and all – big enough to light up San Antonio’s Riverwalk at night.
Three weeks after the consult, Caroline showed up for her surgery at eight, nervous but excited. In the exam room, Caroline got ready – changed into a gown, took off her jewelry. I reviewed the operation with her, as I do with all my patients, then I wheeled her into my OR.
Just before my longtime anesthesiologist, Lisa, gave Caroline propofol to usher her into a “twilight” state (sleeping lightly but arousable), Caroline lay there, looking up at me, as I scrubbed.
“Ready?” I asked.
She nodded, and her right arm emerged from under the sheet. At first I thought she wanted to hold my hand. Lots of patients want that comfort and assurance right before they go under. Doctor, tell me I won’t die.… You know what you’re doing, right? … I’m going to look better when it’s over, right?…I’ll wake up in less than two hours, right? In fact, in the fourteen years that Lisa and I have been working together, she and I have devised our own light anesthesia cocktail partly because so many women from one particular patient cluster – breast augmentation candidates in their late thirties with young children – exhibit a mortal fear of being put under.
If anything happens to me, what will happen to the children?
Nothing’s going to happen, I reassure them –
I have to get back to my kids….
So I started doing those breastlifts and implantations, and others, with an even lighter anesthesia where, ninety seconds after the drip is turned off, the patient is close to fully awake. And can get back to the kids right away. And still have better breasts than she’s had since freshman year of college.
Caroline held out her hand – but it wasn’t hand-holding assurance she wanted. She was clutching an envelope, which she now thrust toward me. The nurse took it and put it in my scrub pocket.
“Open it after the surgery,” Caroline said in her soft, south Texas lilt. “Okay?”
I nodded. “Okay.”
The whole operation was over in fifty minutes.
In the recovery room, I waited for Caroline to awaken. I looked at her in profile. She was a pretty girl resting peacefully, eyes shut. Her eyes would soon open, and she would begin to talk – as most patients do. Within five minutes, she would be fully alert.
Then I remembered the envelope she’d given me before surgery. I pulled it out of my pocket. In it, on expensive, cream-colored stationery with an embossed red border, was a handwritten note:
Will you have dinner with me next Thursday?
Time.
It works on all of us, constantly, but sometimes it appears as if it’s more unfair to some. Too many women who’ve reached “that certain age” are made to feel undervalued, even invisible, by society, particularly by men. (This is probably more true in our youth-obsessed country than in others.) Not only is it unfortunate for those women who feel underappreciated because of their age, but also as a society we are sacrificing the considerable contributions that these women have to offer.
Fortunately, however, because of the many positive developments for women over the last ten to twenty years, more “women of a certain age” than ever are expressing optimism about the second half of their life; this period needn’t be characterized by diminishment but by opportunity, self-expression, and freedom. After divorce or tragedy, some women – as with any of us – retreat. It’s natural and important to go through grieving. But when that’s done (or at least manageable), many women resolve to live life to the fullest, often with an unprecedented determination and forthrightness. And while the majority of divorcées and widows I operate on are quite interested to meet a man, it’s not always why they’ve come to me. Lainie, sixty, had been widowed the previous year. I worked with her daughter, Lynnette, a gentle nurse at one of the New York hospitals where I’m an attending surgeon. One day Lynnette approached me shyly, to ask if her mother could come see me.
Any notion that this sweet, reticent young nurse had inherited her demeanor from her mother was gone soon after Lainie entered my office, sat down, and answered my question about what she wanted.
“Well, I want more than one procedure,” she said, reasonably enough, then paused. It was a pause I’ve experienced hundreds, even thousands, of times in my career; the moment when a patient is finally able to say – to this stranger, this man – what she thinks is most wrong with her. Not an easy moment for anyone.
That’s all right, you just tell me what you had in mind –
“I want my forehead lifted,” she said, “my upper eyes, my lower eyes, my nose, my lips, my face, my neck, my arms, my breasts, my hips, my outer legs, my inner legs, and my ankles.”
She took a breath and smiled. “And my stomach.”
I waited a moment, to see if more was coming, though she’d covered pretty much every viable square inch of corporeal real estate. Even I was taken aback by her answer. What had happened to struggling to say what’s wrong with yourself? I was apparently sitting across the desk from the world’s most unreluctant self-critic.
Satisfied that she was done, I said, “It’s going to take two operations to do it.”
She nodded, unfazed, maybe relieved it wasn’t going to take, say, twelve operations. “I’m widowed a year, and I’m ready to get back out again. I love playing tennis. But I play with a younger group and I don’t want to look like the senior one anymore. Can you get me there?”
“I can’t guarantee it,” I said, “but we’ll do everything we can.”
On the other hand, one woman of a certain age can personify, all by herself, both the unique strength and beauty of that phase of life, and its cruelty, too. I’m reminded of one of the more haunting photographs I ever saw.
When I was a boy, a woman married an heir to one of the Chicago steel fortunes. Marie was the talk of Lake Forest, as well as of every other suburb in the greater Chicago area. Everyone gossiped even though no one knew much about her – or maybe she was the talk of the town because no one knew much about her. She wasn’t from Illinois or even the United States. To us, she was, simply, “that Frenchwoman” – beautiful, blond, stylish, charming, vivacious; when she walked into a room, we heard, people noticed. She would become a famous international beauty, married to an American scion.
Years later in New York, after I had established my surgical practice and developed regular contact with the well-connected, I again encountered “that Frenchwoman.” In her seventies now, she was still beautiful, stylish, and charming. (She also had extensive sun damage to the face and hands.) She and I talked about Chicago and Illinois and mutual acquaintances.
Once, while in Paris for consults, I was invited by Marie to her apartment (one of at least eight residences she owned). As I walked toward the living room, I passed an impressive Empire-style bureau in the foyer. On it was a framed photograph from the late 1960s that I’ll never forget. Marie, maybe forty-five in the picture, is on the arm of her husband, the steel magnate, her partner of some twenty years. They are about to enter Buckingham Palace for a state dinner. She looks magnificent: smiling, slender, radiant. She wears an amethyst-colored evening gown. She looks as beautiful as any woman I’ve ever seen, an equal to Grace Kelly.
“What an incredible photograph,” I said. I knew it was taken at the pinnacle of her husband’s power and of her beauty.
“Not so bad,” she replied.
“Don’t you think you look fabulous?”
“Possibly.” She paused. “You know, Robert left me three weeks after the picture was taken for that, that, that … how do you say…?” She was too proper to finish the sentence. “And he married her!”
Marie is not alone in her bitterness. (A year later, she was in New York and invited me for cocktails at her Fifth Avenue penthouse. When I asked if it was all right for me to bring the woman I was then
dating, she said, “If you’re coming with someone, then don’t come at all!” and slammed the phone down.)
But because of improved diets, exercise regimens, and economic independence, divorcées and widows I work on are more often than not high-energy and fun. At least half of the older divorcées I know initiated the split, and the vast majority claim that their new, unattached life is more satisfying than their previous existence. They derive particular satisfaction from their work, children and grandchildren, friends, and social lives.
Indeed, while I can’t say if the sample of older women patients I see is any kind of a representative cross section, I do know that they are a particularly active and self-starting bunch. After all, they find themselves across the desk from me because they’ve finally grown so tired of some problem that any obstacle that plastic surgery once represented – it’s artificial, it’s giving in, it’s scary, it’s expensive, it’s embarrassing – is suddenly an obstacle no longer. They clearly want to take control of some problem, all these recently divorced and separated and widowed women. Yes, for some it’s a realization that they once again need to trade on their looks, and if they’re going to compete with other women for men, then they want to do so looking as good as they can. For others, it’s not about men, but just their own sense of possibility and vitality.
Perhaps the woman who best embodies all these notions rolled into one is Elizabeth, a successful beauty executive in her midseventies, who stopped by my office six days after her face-lift. I thought it was just a happy visit until she showed me the more-than-normal bruising in front of her ear and along the corner of her mouth.