Published: Oct. 17, 2006
Updated: July 22, 2011
Karen, a 31-year-old woman from a middle-class family, has always been self-conscious about her profile. On a recent visit to the Duke Center for Aesthetic Services, she sat down with Michael Zenn, MD, as he “morphed” a side view of Karen’s face with computer technology to show what she would look like after surgery.
Delighted by what she saw, she decided to move ahead with plans to have a rhinoplasty (nose recontouring) and chin implant this summer. “Here’s a young woman who’s been saving up for this procedure for years,” says Zenn. “And she’s really looking forward to it.”
In many ways, Karen represents the evolution in popular attitudes toward plastic surgery over the past few decades. It’s a change that can also be neatly summed up by the titles of two popular television shows from opposite ends of that timeframe: “Lifestyles of the Rich and Famous” and “Extreme Makeover.”
Cosmetic surgeries and skin rejuvenation treatments were once considered the exclusive domain of Hollywood stars and the wealthy. But now, thanks to shows such as “Extreme Makeover,” such procedures are increasingly sought out by people from all walks of life, including those of modest means and/or over 65 years in age.
The number of cosmetic procedures performed in the U.S. has increased by 446 percent in the past ten years alone. About 1.9 million Americans had some type of cosmetic surgery in 2006; about 9.5 million more opted for a non-surgical procedure such as Botox injections or chemical peels -- for a total cost of some $12.2 billion.
Unfortunately, the money wasn’t always spent wisely. Cosmetic procedures, performed by experts after extensive, candid consultation, can dramatically improve patients’ lives. But cosmetic surgery’s boom in popularity has also been a boon for practitioners who may lack skill, scruples, or both -- with less than ideal results.
“It’s a sad fact, but some people spend more time choosing a refrigerator than they do a plastic surgeon,” says Zenn.
Even when surgeries are completed without complications, patients can be disappointed if results don’t match expectations. “Patients come in with a vision of what they want,” says Gregory Georgiade, MD.
“The surgeon needs to translate that into what’s feasible, and make sure the patient’s expectations are realistic and that they’ll be comfortable with the likely results. That’s why we put in a lot of time with patients up front. As a result, there are occasions when the patient will change his/her mind about the procedures they originally came to discuss.”
Sometimes, the most responsible thing a plastic surgeon can do for a prospective patient is to explain gently why what they want to have done won’t give them the results they seek. That’s especially true, Georgiade says, when it’s clear that a person isn’t trying to repair a physical feature so much as a troubled relationship or a tenuous self-image -- something no procedure, no matter how well done, can guarantee.
It’s a delicate line to walk. On one recent day, Zenn says he saw 15 new patients -- and turned away three of them. “I tell them, ‘I don’t think you’re a candidate for this procedure. I only get paid if I actually do these procedures, yet I’m telling you that you shouldn’t have it done.’ I add that if they keep looking, they’ll find someone who will do it, but they won’t be happy with the result.”
One of those patients was a woman of about 70 pounds overweight requesting liposuction, Zenn says: “I had to tell her that liposuction is not a substitute for weight loss -- it’s a contouring procedure for people whose weight is stable.” (The woman decided to lose some weight, then come see Zenn again.)
For people who have achieved dramatic weight loss -- often as a result of bariatric surgery -- body contouring is often the crucial final step to a positive self-image. “Body contouring is a new field with increasing numbers due to high demand,” says Detlev Erdmann, MD, who specializes in body contouring.
While insurance carriers usually cover weight loss surgery, most don't cover contouring. “After bariatric surgery, patients often experience massive skin redundancy, and they are left alone. We try to provide these patients acceptable quotes to have these procedures performed.”
Surgeons disagree whether shows like “Extreme Makeover” have been good for their specialty. They say viewers sometimes get the impression that the whole process can go a lot more quickly than ethical practice (and real-world physics) allow.
In general, however, Drs. Georgiade and Zenn believe that -- thanks to resources such as television programs that actually show plastic surgeries and the wealth of information available on the Internet -- patients are much more informed than they used to be, and are usually quite realistic about what they’re hoping to achieve.
“Most people don’t really want extreme makeovers,” says Zenn. “They want to look younger to match the youthful way they feel, for example. And even though subtle things like a reshaped nose or slimmer thighs may seem like no big deal to you and me, they’re often all our patients need to feel better about themselves and to have the confidence to make big changes in their lives.”
What’s important to remember, the Duke physicians caution, is that even seemingly minor procedures demand significant expertise. “Here at Duke, we’re all highly trained plastic surgeons who are qualified in every cosmetic procedure,” says Georgiade. “We work in a fully equipped, state-of-the-art surgical facility that has been accredited by JCAHO (Joint Commission on Accreditation of Hospitals -- the same entity that scrutinizes and certifies hospitals).”
And because the facility is housed in a freestanding building on the leafy Center for Living campus, patients don’t have to choose between the comforting expertise of Duke specialists and the comfortable, private setting that plastic surgery patients understandably seek.
An important issue that should be (but isn’t always) considered when choosing a plastic surgeon is how anesthesia will be administered. “Many people who call themselves plastic surgeons do all their procedures in an office without an anesthesiologist, using only an oral sedative and a few numbing shots,” says Erdmann.
“To put it mildly, that can make for a very bad experience on the part of the patient. Here at Duke, we have a dedicated cosmetic anesthesiologist (Dianne Scott, MD) whose exclusive focus is on keeping the patient comfortable and safe, allowing the surgeon to concentrate on the procedure.”
“People often come to Duke after bad experiences elsewhere,” says Erdmann. “They went to people who weren’t really qualified to do those procedures in the first place, and who -- when they got into trouble -- had no depth of experience to get out. We have the expertise to help these patients, but we can’t help wishing they had just come to us first.
“Even worse than the negative outcome for a lot of patients is a sense of abandonment, a feeling that the aftermath wasn’t dealt with appropriately,” Erdmann adds. “Their concerns have been dismissed with a ‘you look fine’ kind of attitude. Any practitioner can encounter a complication, but you have to own that. It’s important to be honest with your patients and to take responsibility for your work. That’s the way we do things here at Duke.”
It’s an approach that gets high marks from scores of patients. “We have files bulging with thank-you letters from patients,” says Zenn. “The beauty and challenge of this specialty is that there’s no hiding your work. It’s right out there in the open for everyone to see.
“The fact that our patients are so happy is our best possible advertising.”
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Thinking about a cosmetic procedure? Keep the following points in mind when choosing a practitioner.