Dr. Steinsapir, M.D
On Aesthetic Reconstructive and Cosmetic Surgery
Many textbooks of facial plastic surgery start with a chapter on the golden or ideal proportion: that beauty is defined by a fixed ratio that is reflected in the proportion of the face. This idea stems from the Greeks and was influential in the thinking of Renaissance scholars including Leonardo da Vinci. Ironically, Leonardo da Vinci recognized that these ratios did not accurately reflect the human faces he studied. Despite this insight, some surgeons today are still burdened with the idea that there is some ideal formula for what makes a face attractive. There is no magic formula that separates one’s features from what would be ideal. Generally, things come down to preferences and fashion.
We all recognize that fashion trends dictate whether a given skirt length is in or out. Fashion also plays a role in featuring models with bigger or smaller bust lines, waists and so forth. Recently Spain banned models from fashion advertising that did not meet a certain minimum for body mass index, a way of describing body heaviness or thinness. The standard will still permit all but the very thinnest models in advertisements. An unusual example of legislated fashion to be sure. We don’t often think of our physical appearance as being subject to fashion but what is considered desirable is very much subject to fashion. Consider how eyebrow position has changed over time. In the sixties high arched eyebrows were fashionable. Now most models in advertising feature low set eyebrows that are heavy with a fuller fold of skin below the eyebrow. Looks change, as any woman who has had permanent makeup, a tattoo placed along the eyelids, can tell you.
Reality television has shaped the public’s perception of cosmetic surgery with shows like the Swan and Dr. 90210. These programs have ridden (some would say helped to stimulate) the wave of interest in cosmetic surgery, yet they provide only a very distorted view of the practice of cosmetic surgery. The consultation becomes a sound bite and in the process minimizes the risks and appropriate concerns that must be addressed. Colleagues of mine often say they don’t watch these shows. When I come across one of these shows on television, I have a hard time looking away. The whole consultation and surgery process is made to be a spectacle. So many procedures are performed on some of these shows at one time that the surgery becomes unnecessarily life threatening. I can’t practice that way. No one should be placed in a position of choosing between their beauty and their health. Of course there are risks with any surgery and anesthesia. However, using the most appropriate anesthesia, operating in the proper setting, and limiting the amount of surgery performed at a given time these risks can be minimized.
There is much confusion about cosmetic surgery. Is it about aging or aestethics? Why would someone want to change his or her looks? Who should get cosmetic surgery? Who should perform cosmetic surgery? At the end of the day it is essential that you trust your doctor. It goes without saying that your doctor should make sense, listen to you, and treat you with respect and dignity. The office staff should also listen to your concerns and treat you with respect. Don’t be intimidated by the doctors reputation: “He or she is the best doctor in (insert the name of the town).” That reputation is meaningless if the doctor doesn’t treat you like a human being. Remember, you aren’t the forehead in room 7. Before and after pictures are also extremely important. This is generally a doctor’s best work. If you don’t like what you are seeing, it is a mistake to think your results with that particular doctor will be better than what you are being shown.
What do you do if you’ve had surgery with someone and think you made a bad choice, or are having an issue after surgery? The first thing you should do is see and talk with your surgeon. If there is an issue that is bothering you, bring it to their attention. There is no such thing as perfection following surgery. However, some issues need to be addressed and might benefit from some type of intervention. You are likely to find that your operative surgeon is highly motivated to help you with these issues. I like to tell patients to let me do the worrying and ask them to call me for any concern they might have after surgery and let me figure out if it is a small thing or a big thing. How can your surgeon address a concern if you don’t bring it to their attention? If you are still getting nowhere, then seek out a second opinion.
To get the most from a consultation, do your homework. Have a good idea of what you are trying to accomplish. Be open to an approach that is different from what you thought you needed. Remember you are seeing the doctor for their expertise. There is a tendency for patients to think that they must diagnosis their own issues and prescribe their own treatment. However, there is often more than one way to accomplish something. If you don’t like what you are being told, don’t try to convince the surgeon to do something they have just advised you to avoid. You are basically being told that they are not comfortable with that particular course of action. Be polite and decide for yourself if this is the right doctor for you. The good news is that in most cities, there are lots of options for cosmetic surgery care. No one person has all the answers. One thing I do tell my patients, though, is to be careful what you look for because someone may agree to do what you are asking for whether it is the best plan or not. If all the other doctors you have seen have recommended against a particular course, think long and hard about insisting that it be done.
Doctors take an oath to do no harm. However, doctors have an affirmative duty to the public and their patients that extends significantly beyond the standard to do no harm. The doctor has a duty to serve as an advocate for their patients. I see my role as more than just a physician and surgeon. I am actively involved in educating potential patients as well as current and future surgeons. A significant proportion of my practice is performing so-called secondary surgery: fixing eyelids and faces following unsatisfactory prior surgery. Many of these procedures were performed by well meaning, well trained, and in many cases, well known surgeons.
To get the most from surgery, it is essential that communication between the doctor and the patient be clear. The doctor needs to hear your aesthetic concerns. Equally important listen to what the doctor is telling you. Do they get it? Occasionally I am asked by a patient, presenting for consultation, after a wave of the hand about the face, what would I do or recommend? It is very difficult to address something that can’t be articulated by a potential patient. Don’t require that the surgeon also be a psychic. It is also not the surgeon’s job to undermine the confidence of a potential patient by enumerating issues that aren’t really troubling the patient. I often have patients who present a single issue; we address that issue. I might gently explore with them other issues but this must be done tactfully. However, I do expect someone to be able to tell me that they don’t like their eyes or sagging in the face or double chin. In some busy practices it has become acceptable for the patient to only deal with a so-called surgical counselor and not actually have a detailed consultation with the surgeon directly. This is a formula for misunderstanding. A detailed informed consent is also not a substitute for a detailed personal consultation with the surgeon who will be performing your surgery. In my office, it is my practice to do one or more detailed consultations prior to surgery and personally review the informed consent with the patient so I am certain they have had all their questions answered.
While we are the subject of communication, I am not a fan of digital manipulation of images to demonstrate the effects of surgery. While these images can be very compelling and persuasive in convincing patients to sign up for surgery, it is hard to avoid the implication that the surgeon is essentially guaranteeing the results of surgery. Of course you sign a waiver stating that you understand that the simulated before and after pictures are not a guarantee of how the surgery will turn out. How good are we as surgeons in delivering what is shown? The answer is that simulated pictures and reality may be close but they will never be exact. This can lead to disappointment: “I would never have had surgery if I knew that their was the slightest chance that I would not end up looking exactly like the simulated before and after picture you showed me before surgery.” It is hard to know who might experience such a disappointment. I have been doing cosmetic surgery for a long time and I have found that most people are usually quite satisfied with reviewing the before and after pictures of other patients and being shown the potential benefits of surgery with more traditional methods such as pulling the facial skin back or folding the eyelids with a lid folder. I have come to the opinion that the more reassurance someone needs before agreeing to have surgery, the more likely they are not a good candidate for surgery in the first place. No one can guarantee how you will do with surgery. I think that if you are so nervous about surgery that you need an exact guarantee of your appearance following surgery, it is very likely that no matter how brilliant your surgeon and your surgery, you will find some issue to focus on, which may become a source of disappointed. My advice in this circumstance is to listen to your feelings and avoid surgery. Try fillers and BOTOX, which are non-surgical and very powerful. Save surgery for a time and place where it is absolutely necessary.
Ultimately the Internet is not a replacement for a personal consultation with a talented, appropriately trained, experienced, and ethical surgeon who enjoys your confidence. No writing can replace the judgment and advice that you will gain from a personal consultation. I have many potential patients who travel from all over the country and in some cases from overseas to consult and have surgery with me. However, I don’t believe that you need to be my patient to benefit from the guidance provided on this webste. The better informed you are, the more likely you are to find what you are looking for, whether I am your surgeon or you choose someone else.