The ABCs of plastic surgery

Let’s say, for the sake of argument, you want to turn back the hands of the clock a wee bit. As it happens, a friend had a lift or a tuck and he or she looks so good you’ve decided to have a few wrinkles removed, too. Where do you begin? And what do you need to know? If you’re considering plastic surgery — and thousands more people are every year — you need to know what it is, who does it, what it entails, and a host of other things.

What it is then: Plastic surgery is a surgical specialty that employs a variety of techniques to remodel body structures, with the intention of improving their function and/or appearance. It consists of two overlapping areas, reconstructive surgery and esthetic, or cosmetic, surgery.

Reconstructive surgery is chiefly concerned with the correction of facial deformities; the re-implantation of limbs (such as a severed thumb); surgery of the hand; maxillofacial (the jaw and base of the skull) and craniofacial (the face and the upper part of the skull) surgery; and the surgical treatment of burns, congenital malformations, and tissue loss from trauma or cancer surgery.

For example, a woman who undergoes a mastectomy to root out a cancer may he surgery to “reconstruct” the lost tissue; a child born with a cleft palate may be transformed by correcting the congenital defect; or — thanks again to a plastic surgeon’s skills — someone may regain the use of a hand crippled by arthritis.

The aim of cosmetic surgery is to improve the form and/or appearance of areas of the body a person considers unpleasing in size or shape. That might mean smoothing out a few wrinkles, or contouring someone’s body by removing excess fat; reducing, enlarging, or merely “lifting” a patient’s breasts; or remodelling another’s nose.

Obviously, there’s a good deal of overlap between the two forms of surgery. The woman who has a breast reconstruction after a mastectomy, for example, will benefit from some of the techniques used in cosmetic breast enhancement surgery, and the child who has a cleft palate repaired will have a more normal look if treated with the skills of a surgeon versed in cosmetic work as well.

So, who performs these miracles of transformation? A good number of healthcare professionals, including general practitioners, dermatologists (skin specialists), ophthalmologists (eye specialists) and others, though in Canada only a medical doctor (M.D.) with four years of further training in plastic surgery has the right to call him- or herself a plastic surgeon.

That doesn’t mean only plastic surgeons are capable of performing good cosmetic procedures. It depends on the individual.

Dr. John R. Taylor, a plastic surgeon in Etobicoke, Ont., agrees, with certain stipulations. Taylor is the author of A Patient’s Guide to Cosmetic Surgery (Summerhill Press, 1989) and associate editor of The Canadian Journal of Plastic Surgery: “It isn’t what your specialty is called,” he says, “it’s who has the interest, who has the extra training, and who does it well. I don’t think that’s true for non-surgeons, but amongst surgeons I don’t think it matters just who does what. Because a lot of our specialties have histories of growing up in other specialties.”

Taylor draws the line at surgery: “I don’t think surgery is something anyone should dabble in, because I don’t think it’s good for the patient.” He also worries that “dabblers” — non-plastic surgeons who learn a particular technique — may be competent but limited. Some otolaryngologists (ear, nose and throat specialists), for example, do partial facelifts; some dermatologists do facial peels and dermabrasion (two forms of skin resurfacing); and some ophthalmologists do eyelid surgery, sometimes at rates lower than plastic surgeons. But, Taylor says, “if you only have a hammer, the whole world looks like a nail. You see that in people who only know how to do liposuction, and don’t know the other alternatives.”

There’s another consideration to ponder: There are plastic surgeons — especially in the States, where some Canadians go for surgery — who do only one form of surgery, reconstructive or cosmetic. Should that matter to you?

In Canada, most plastic surgeons do both; in the U. S., surgeons more often specialize. There’s an argument to be made for both approaches: By focusing on specific operations or techniques (breast enhancement, say, or liposuction), a surgeon has special skills and understanding of the procedures he or she does. But there are limits to those skills.

Taylor does a full range of cosmetic surgery, as well as reconstructive work, including hand surgery, trauma, injuries, and skin cancer. “Those who only do one operation are missing the point,” he says. “Plastic surgery is the application of an idea to many different problems to solve surgical dilemmas. The broader you understand and practise that, the easier it is to see all the potential solutions to problems. In other words, doing one operation only, you tend to miss other ways and other methods of solving a problem.”

Dr. Timothy Sproule, a plastic surgeon in Scarborough, Ont., and past director of the (now closed) burn unit at Scarborough General Hospital, also does a full spectrum of cosmetic and reconstructive work, including reconstructive surgery in Third World countries. He agrees it’s important for plastic surgeons to have a broad base of experience for cosmetic surgery: “You should have had reconstructive experience at some point in your training. That makes a big difference in terms of how good you are.”

The same skill set is utilized in almost every aspect of plastic surgery, Sproule says: “You cannot do as good a cleft lip repair using only reconstructive philosophy as you can with the combination. A perfect scar is essential in a cosmetic operation, but it’s also darned important in a cleft lip repair or in many reconstruction operations.”

Sproule recently collaborated with an otolaryngologist in a complicated head and neck operation that called for a unique reconstruction technique using microsurgery on the floor of the patient’s mouth. Doing that kind of operation “gives you a very different perspective when you’re doing facelifts,” Sproule says. “You understand the anatomy much more completely than if you did nothing but facelifts and never did any other, more involved surgery. You know where the important structures are, where they need to be preserved, where your risks are, that kind of thing. I think being able to do everything and experiencing everything makes you superior in all of the different areas.”

Performing facelifts and tummy tucks and “various other kinds of skin-shifting operations,” Sproule says, can teach a surgeon methods of hiding burn scars in unique ways. “Every case is unique, and cosmetic patients are not less important. They’re in fact more challenging because the communication is so unique and important.

“Someone comes in with a cleft lip, it’s straightforward. They need to have their lip improved, and they’ll probably be happy with any improvement. If someone comes in who’s already attractive, and maybe a little bit depressed about their situation in life, that’s a very different situation, and you have to have a higher level of interchange so you don’t end up on different wavelengths. Technically, the surgery itself is usually relatively straightforward. It’s just a question of making sure you’re providing what the patient wants — and making sure the patient’s expectations are appropriate.”

hat are your expectations? Are they realistic? If you’re looking for a modest improvement in your appearance, that’s realistic, but if you’re hoping plastic surgery will change your life, you may be expecting too much.

A problem surgeons often encounter is a patient whose expectations about what plastic surgery will do for him or her are way out of proportion. It’s essential the surgeon be sensitive to a patient’s psychological makeup — both before and after the operation, because cosmetic surgery can deliver an unexpected psychological wallop, even after a successful procedure. “Some of this is normal. Some is temporary,” says Montreal plastic surgeon Dr. Gerard Rheault. “Usually it is temporary.”

Thus, Rheault listens carefully to patients when they first come in, to establish a rapport, but also to make a preliminary assessment of the patient’s motivation and psychological makeup. He also wants to assure himself the patient is having a procedure done because they want to do it, not because they’re under outside pressure — from a spouse, say, who’s pressing them to change.

Dr. Harold Silver, a veteran plastic surgeon who runs a private clinic at Toronto’s Royal York Hotel, always asks, “What does the patient want? Can you give it to them? Are the patient’s expectations realistic? If I can’t give a patient what they want, I tell them I can’t help them.” And if that means turning them away, “yes,” says Silver, “I do. That’s the proper practice of medicine.”

It’s vital that you and your surgeon communicate fully. You may have done a lot of research before your consultation and think you know exactly what you want, but there may be alternatives to the procedure you’re considering that are less invasive, less costly or simply better at achieving the desired result. Make sure you discuss all possible alternatives — including doing nothing — before going ahead.

Take your time. Sproule often sees patients several times pre-operatively; he actually encourages it, telling patients to go home and think about it if they have doubts: “Sometimes I’ll see a patient five or six times before they make a decision.

“I have a reputation for scaring patients away, and I’m comfortable with that. I like to tell them, always, what the worst things are that can happen, and what the common things are that can happen, and at the end of all that sometimes they’re scared away, and that’s OK.”

What scares them? The possibility of complications, for one thing. A good plastic surgeon will be “quite exhaustive,” Rheault says, in his explanations of what can happen, however rarely: “Bleeding, infection, bad scarring, loss of tissue. Patients will often ask whether they can die on the table. They can. It’s never happened to me [nor to any other plastic surgeon in Canada in recent memory], but it could happen. In the States, some 60 people died last year from complications following liposuction procedures.”

To a degree, complications are inevitable in any surgeon’s practice, Sproule argues, “no matter how much experience you have and how good you are. No one is perfect, and when we’re dealing with vagaries like tissue and wound healing and different characteristics of patients, there are so many things that can go wrong.”

Sproule considers it his responsibility to look after patients as best he can, for as long as necessary. Not every surgeon is willing to make that commitment, sometimes simply because they maintain too large a caseload to deal with complications. Find out where your surgeon stands on the issue: Will he or she be available to deal with complications that occur?

Another consideration is whether your surgeon has an affiliation with an active treatment hospital. “There are [surgeons] that are just magic with their hands,” Sproule says. “They can do all kinds of great things, but what’s important is what they’re going to do for you if you have a problem.”

Sproule chose the location of his own clinic specifically because it’s connected to “a big, active treatment hospital, so if one of my patients has a problem in the middle in the night, I can have them in the emergency department in a matter of minutes. That gives them a higher level of safety.”

The trade-off is in decor: Sproule’s clinic is pleasant but unextraordinary: “I’m not interested in providing ornateness — giving my patients flowers afterwards, things like that,” he says. “I’m interested in giving them clinically high standards of care.”

By contrast, Silver’s clinic — befitting its setting in Toronto’s most storied hotel — is a model of interior design– a flatteringly restrained palette of deep colour and muted lighting. Silver doesn’t believe the hotel environment compromises his patients’ safety, it’s simply a different approach that offers a special degree of comfort and reassurance to clients who prefer a discreet ambiance and private care.

Silver can also offer clients the benefit of his experience in plastic surgery. In England, where he got his early training and practice, he was one of only two plastic surgeons serving several hospitals, doing every sort of reconstructive and cosmetic surgery over a huge geographical area. Shortly after coming to Canada, he joined the staff at Toronto’s Women’s College Hospital, with which he’s maintained an affiliation for the last 30 years.

Since opening his clinic at the Royal York in 1974 Silver’s patients have come to the hotel for surgery. After the operation, he has a nurse take them to private rooms in a wheelchair. “The nurse puts them to bed and makes sure they’re comfortable. They give them instructions. They have a telephone. If they want a nurse, they can have one. They come down the next morning and we change the bandage or remove their bandage altogether and send them on their way. For people who live on the periphery of the city, or outside the city, it’s a much more convenient way of doing things.”

ne of the safety measures all surgeons employ is a pre-operative assessment, to ensure a prospective patient is actually healthy enough to undergo a surgical procedure. Grossly overweight people will likely be turned down, as will anyone with an obvious psychological disturbance, but some conditions one might think exclusionary, such as a heart problem, can often be accommodated. Indeed, Silver has “lots of patients who have heart problems. It depends how stable they are. It’s a question of how functional you are. Do you walk every day? Do you get tired? Do you have pain, and so on. Are they physically able to have it done?”

Even the most exhaustive preparations, however, can’t guarantee every surgical procedure will achieve the hoped-for result. Even without complications, a second procedure — a revision — may be necessary. No two people’s tissue have exactly the same texture, elasticity, shrinkage and scarring characteristics, healing response and so on, which is why the same procedure given to different people may produce different results. Make sure your surgeon is going to be there for you if revisions are necessary, and find out whether or not they’ll entail additional costs. In fact, make sure you fully understand all the costs involved in a procedure, Rheault says. “That should include the surgical fees, anesthesia fees, operating room fees, implant fees, etc. That should all be fully explained.”

Don’t be afraid to ask questions — lots of questions, if necessary. The best patient is an informed patient. Knowing as much as possible can help to mentally prepare you for surgery, and help you to form valid expectations about what the procedure you’re considering is likely to achieve.

It’s important to understand what your responsibilities are. Depending on the procedure, you may be asked to abstain from using any of the many medications that contain ASA (acetylsalicylic acid), such as Aspirin, Anacin, Midol, Alka Seltzer, Dristan and a host of others. Similarly, you must inform your surgeon about any medications you’re taking. Some people don’t, for fear they won’t be allowed to have the procedure. That could cost them their lives, or make recovery a far more difficult business.

If you’re a smoker, you’re probably going to have to butt out, at least for a couple of weeks before and after surgery (and that includes abstaining from nicotine substitutes). Tobacco can cause constriction of microvascular blood vessels, which can lead to loss of skin, increased scar formation and a poorer healing response.

Be prepared for post-operative complications: Ask your doctor what you should be alert for, and what you should do if any complications occur. Forewarned is forearmed.

One last thing: How do you actually choose a surgeon? Very carefully — you’re going to have to live with the results of his or her work for some time. It’s difficult Sproule admits. “A lot of different specialists are capable of treating people safely with various techniques, including lasers. A couple of things, though, I think are important to keep in mind. One is, does the person you’re seeing have access to or the ability to do a large spectrum, if not the full spectrum of things, that are possible to do? And does he have a hospital affiliation?”

Taylor urges people to “go and listen — and participate. Ask questions. No one is ever forced into surgery — ever. And they don’t have to make up their mind immediately, unless it’s life-threatening.

“Another factor is: Do I like this person? In other words, do I think this surgeon, this person, is honest, ethical? Is he giving me the bad with the good? Because he should, even though I have this drive not to want to hear it.

“This is a really tough question, an emotional question. In the end, you just decide, but first you do some homework. You ask people, patients, your friends. It doesn’t really do you any good to say, ‘Can you give references, and can I talk to three patients who’ve had surgery?’ An unethical physician, will simply say, ‘Here are three of my best patients.’ So, this is an imperfect human experience, and it can’t become perfect. This isn’t mathematics.”

What you can do is verify that your doctor is a qualified plastic surgeon by contacting an appropriate governing body — the Canadian Society of Plastic Surgeons, the Association of Plastic Surgeons of Québec (in Montréal), the Canadian Society for Aesthetic (Cosmetic) Plastic Surgery (in Woodbridge, Ont.) or the Royal College of Physicians and Surgeons of Canada (in Ottawa), as well as any of the provincial colleges of physicians and surgeons.