Full Text from Dr. Berman's Book

Chapter 1


Cosmetic vs. Plastic Surgery

Words can be used incorrectly by so many people so often that they become accepted for their incorrect usage. Most people use the term plastic and cosmetic interchangeably when referring to cosmetic or aesthetic surgery. The word plastic is actually derived from the Greek and Latin roots, meaning to mold, shape or to form. Indeed, plastic surgical techniques have been around long before man developed petroleum based products commonly known as plastics. Even so, many people assume plastic surgery is so named because it employs the use of "plastic" materials.

Plastic surgery is the field of surgery devoted to the reshaping or restructuring of various body parts in order to improve or restore appearance or function. Actually, many surgical fields involve plastic surgery as parts of their discipline. It's not unusual that there is a lot of overlap among surgical specialties and plastic surgery.

When plastic surgical techniques are employed to enhance or improve appearance this is referred to as cosmetic (or aesthetic) surgery. On the other hand, reconstructive surgery is generally concerned with putting parts back together or restoring function. And indeed, these two areas frequently overlap. For example, in performing a cosmetic rhinoplasty, if there is airway obstruction, then reconstructive surgery is also performed to improve the airway, i.e., the function.

Somehow over the years, perhaps because of the public's fascination with various cosmetic procedures and because most of these procedures were most often done by plastic surgeons, the words cosmetic and plastic have been used almost interchangeably. Even plastic surgeons and plastic surgical societies have improperly used the word. If one realizes, then, that through plastic surgical techniques you perform reconstructive and/or cosmetic procedures, it is clearly redundant to refer to oneself as a "Plastic and Reconstructive Surgeon." Clearly, this is an illogical use of the words. It would make more sense to say "Cosmetic and Reconstructive Surgery," "Plastic Surgery", or as in my case, simply "Cosmetic Surgery". Although some of the procedures I do are reconstructive in nature, I use my plastic surgical skills primarily to effect cosmetic improvements. Today, there are several surgical disciplines that perform cosmetic procedures besides plastic surgeons. Otolaryngologists are trained in facial cosmetic surgery. Ophthalmologists can perform cosmetic eyelid surgery. Dermatologists are performing cosmetic laser surgery, liposuction, and hair restoration. Maxillo-Facial surgeons perform cosmetic procedures to enhance their reconstructive work. Many other surgical disciplines can perform various cosmetic procedures. Indeed, the specialty of Cosmetic Surgery has grown as a marriage of the aesthetic interests of the different surgical disciplines.

This leads us to our next consideration. Why do we perform cosmetic surgery? To answer that question, I'd like to start with the meaning of life. I doubt many (any) people picked up this book thinking that the meaning of life would be discussed before page 10, or 310 for that matter. Sit down folks.

Maybe I'm rather simple minded, but there's no need for a trek to Tibet to discover the meaning of life. I will agree to stipulate that should you have particularly profound religious or super spiritual beliefs, life's meaning might take a higher, or at least different, course for you.

But for me, the meaning of life is to exist and be happy (in other words, survive and have fun). This applies to the individual and society as a whole. We get up each day and go to work in order to continue our survival. We continue to survive because of the happiness we experience along our journey through life. Unfortunately, many of us forget to actively appreciate our moments of happiness. Whatever it is that strikes a cord with our sense of happiness are precisely the reasons for which we live. It is only the profoundly depressed who are completely unaware of their happy moments. Also, it seems that many people are concerned about making a difference, making their mark and leaving a lasting contribution to be remembered. If one does what they really love to do, it occasionally happens. Most of us would be quite fortunate to leave a lasting impression on our family or friends. If en route to the big bang, we miss sight of the fun we experienced along the way, then we've cheated ourselves of the daily joys of living. Clearly, there are moments of happiness which are greater than others, but it is the ability to appreciate even the simplest of joys that defines our existence.

Mozart is certainly well remembered as one of the great composers, but I can't help but believe that he performed his craft because of the happiness he derived (not to mention the economic compensation he received which helped him survive). I doubt he derived much happiness from becoming a legend after his death. He probably would have preferred to have enjoyed his life into a few more decades.

As I mentioned, this meaning applies to the individual and the society in conjunction. They can not be separated. For instance, if some character survived and had fun by robbing other people, this would be intolerable to the happiness and survival of the other individuals of the society as it would infringe on there ability to live peaceful, fun lives. In other words, you should not have fun at someone else's unconsented expense.

I've spent many an evening debating this topic among friends (well, at least, former friends). Nonetheless, I have yet to find a more basic meaning. It may be that one feels they have to experience something greater from life in order for their life to be "meaningful", but that would imply there is a greater meaning to life. This I highly doubt. For example, the person who says the meaning of life is to bring peace and kindness to all he or she meets, is still doing this because they believe these are the things that will make them and their society happy and better able to exist. As another example, I remember a discussion initiated by my father. He told me that he has come to understand the meaning of life. He was content to know that life's meaning was to take your abilities and use them to their fullest extent in order to achieve the most success possible. I pointed out to him that this was his "method" to living his life. It was what made him happy and helped him to survive.

So, why elaborate on the meaning of life in a cosmetic surgery book? Well, for one thing, it helped me understand why it was okay to use lessons I learned in medical school, to save lives and relieve suffering, and instead, apply them to improving the quality of otherwise healthy lives. For the most part, I perform surgery to make people happier. Not infrequently, there are benefits that enable my patients to survive much better too (e.g. better jobs, better nasal airway, etc.).

Isn't it vanity that causes people to submit themselves to cosmetic surgery? Often it is argued that we should like ourselves the way we are and that it is unnatural and particularly vain to want to alter our appearance through surgery. Vanity is generally defined as "the inconsequential concern about one's appearance." If an attractive woman excuses herself from the dinner table, retreats to the ladies room, touches up her make-up which was fine to begin with, places a curl more to one side or another, and then returns to the table not particularly happier, one could easily say that is vanity. However, if someone buys a new suit, puts it on and enjoys how it looks, to the point that it makes them happy, I doubt most people would consider that vain. In fact, buying new furniture, or getting usable furniture reupholstered, or buying a fancy new car could all be signs of vanity. However, most people understand that we are cheered by such attractiveness which surrounds us. The net result of our happiness does not make it vain. Where do you draw the line then? Because if you have some negative physical aspect which when surgically altered removes your displeasure, thus making you happy, then this can not be considered vain. In practice, there are many gray zones we have to deal with. A woman with attractive "C" cup breasts who desires to make them larger may indeed define vanity, though may possibly reflect her independent view. The doctor and the patient need to work out these issues together so they're both comfortable with the proposed operation.

Now, if you've decided that cosmetic surgery can actually make you happier (or at least relieve some sort of psychological pain), how does this measure with one's self esteem? Do people undergoing surgery feel better about themselves, or even worse? Well, it depends. Let's look at some basic situations to understand the concept of self esteem and how physical appearance affects it. As an issue of the 90's, self esteem has become the politically correct gift to choose for your kids. Unfortunately, self esteem is tied to self worth. Its an empty proposition to promote your kid's self esteem if he or she isn't doing anything to merit it. We try as parents to reinforce positive attributes we see in our kids so they can take a positive road in life. By developing a positive sense of self esteem, we help develop strong, independent survivors who can be honestly happy. When we are young, much of our self worth is based upon our physical appearance. True, other abilities, intellectual, artistic, athletic, etc. are important parts of the foundation of self worth, but physical appearance seems to occupy a large percentage of the whole during our youth. In the obvious case where a teen is very uncomfortable because of a disharmonious nose, corrective surgery may go a long way toward opening the door to improved self worth and self esteem. Not infrequently, personalities are completely freed from their self imposed prisons by such remedies.

As we mature, and we have the opportunity to add more credits to our character, we have more attributes which improve our self worth. Hopefully, as we emerge into young adulthood, we bring with us a good sense of self. Self esteem may be nothing more than a selfish belief in one's self. Maybe it is genetic, but I believe it can be developed. It just gets harder to develop as too much time passes and you allow yourself to continually doubt your worth. Nonetheless, a person with a good sense of self is usually the ideal candidate for cosmetic surgery. This is a person who objectively recognizes that they have a physical flaw which bothers them. They, however, like themselves for the person they are and simply want to correct a problem. If you had a car you really liked and the paint faded, you wouldn't like the car any less, you would simply get the car repainted. A thirty-five year old mother of three, happily married, happy with herself, but not with the resulting sagging breasts of motherhood doesn't necessarily improve her self esteem with a breast augmentation. She simply improves the appearance of her breasts and is happier for it.

Long ago, I used to lecture that if we lived in an ideal world, we wouldn't care about appearance. Several years later, I realized that wasn't true. If we lived in an ideal world, everyone would be attractive looking. Let's face it, we like looking at attractive scenery. A beautiful sunset, mountains capped with snow on a clear day, a fancy old restored car driving down the street, downtown skyscrapers, or the smile on your child's face (if you have a child) are all but a few examples of things we like to look at. It makes us happy. There must be some release of neuro-chemicals, the happy hormone, that tells us we enjoy these sights. Included in this list are people. The advertising and movie people certainly know this. We like to look at physically attractive people. And, more than that, we are pleased when our own appearance is a positive one.

No one cares about your appearance as much as you do. If you are happy with your appearance, congratulations, cosmetic surgery is not in your immediate future. However, physical appearance is not the only thing that makes us attractive. Once you are comfortable with your (or your friend's) appearance, then there are other things that make people attractive as well. One's accomplishments, sense of humor, kindness, personality, ability to articulate and communicate, etc. are all attributes which make people attractive. Cosmetic surgery will become infinitely advanced the day we learn how to perform charisma transplants, until then we must be satisfied with simply enhancing physical attractiveness.

So then, who are reasonable candidates for cosmetic surgery and what are the limits? Basically, anyone who will benefit from the surgical enhancement of their appearance is a potential candidate for cosmetic surgery. Several years ago, I developed a simple formula for predicting success in cosmetic surgery. It is: "The benefits should be greater than or equal to the expectations which should be greater than the risks, expense and inconvenience of the operation."

The "benefits" are simply being happier with your appearance or at least not being unhappy with your present condition. This should ideally correspond to your reasonable, realistic "expectations." If your expectations are met or exceeded you're more likely to be happy. Disappointment is inevitable when your expectations are not achieved. This is the variable in the equation often most difficult to comprehend and it is critical for the surgeon to help you understand realistic expectations. If anything, the smart surgeon will lean more toward minimizing your expectations, it gives a little more room for success. Merely telling you that you'll "look great", may be setting you up for disappointment.

Communication with your surgeon is the key to understanding your potential results. To this end, many surgeons employ computer imaging. Some surgeons still consider the computer as a sales gimmick and a potential for future litigation among patients who do not achieve the viewed results. However, if used responsibly, the computer provides a wealth of information not achieved by traditional methods. Basically, by taking a picture of your image, and then making the realistically achievable changes, you get an idea of what your face or body would look like with the predicted alterations.

I favor using the computer mainly for changes in facial contour, such as the nose, the cheeks or the chin. Many other conditions are easily discussed and understood without having to use the computer. However, patients often think that when they change some characteristic of their face, particularly their nose, their entire face will change. I'm reminded of several of my male patients who have desired rhinoplasty. They may not be terribly attractive, and fixing their nose might help some, but it won't approximate the bubble image over their head where Cary Grant resides. The computer may burst the bubble, but if the surgery is done, the patient is less

Example of a young woman who desired cosmetic nose surgery. However, with the computer, we can demonstrate the weak chin and the need for correction as well.

Example of a patient before surgery, after computer imaging for nasal reconstruction and cheek augmentation, and then an actual picture ten days after surgery. Although there's some swelling, it demonstrates that computer imaging is generally fairly accurate.

likely to be disappointed. By the way, no responsible or even semi-talented surgeon would put a computer image on the screen that he or she was not capable of achieving. Though the exact result might not be achieved, it should be in the ball park. At the very least, the patient and the doctor will know what they are trying to achieve.

Once a reasonable expectation is understood, this must be balanced against the risk, the expense and the inconvenience. The risks of elective cosmetic surgery vary from procedure to procedure. First, the general health of the patient must be considered. Since these are elective procedures (they do not have to be done) it would be unwise to put an unhealthy patient at undue risk. By conducting a thorough discussion of your health history, your doctor and you can determine the appropriateness of the operation, what alternatives are available, and how to proceed in your best interest. Nonetheless, today procedures are safer than ever. Anesthesia techniques have greatly improved. Although many doctors prefer general anesthesia for their patients, most cosmetic procedures can be safely and comfortably performed with intravenous sedation and local anesthesia. With improved monitoring devices and improved techniques all methods of anesthesia have been improved. Nonetheless, it is anesthesia that generally results in the most considerate risk.

Bleeding is rarely a risk with cosmetic procedures. The formation of a hematoma (collection of blood under the skin or tissues) is a rare problem most frequently related to inadvertent aspirin use.

Infections rarely occur. Generally, cosmetic procedures are covered with prophylactic antibiotics. Because of it's great blood supply, facial procedures most rarely develop infections in spite of the inability to completely sterilize the operative field. Body procedures, particularly breast augmentation where a prosthesis is used, are done under the strictest sterile technique.

Scarring from surgery is usually minimal and well hidden. Occasionally, patients may react to suture material or for various reasons develop thicker, unattractive scars. Keloid type scars is a rare phenomenon in typical cosmetic surgery even in very dark skinned individuals. Nerve damage may occur in various procedures. During the healing phase of all procedures there will be temporary changes in the way tissues feel. Permanent numbness or loss of motor function is rarely seen in face-lift procedures and occasionally (less than 5% incidence) in breast augmentation. Most cosmetic procedures are not painful. Finally, the most common risk of performing a procedure is getting less than the desired result. When that occurs, it is most often a minor condition which can usually be corrected. Unfortunately, most corrections require a waiting period, generally around six months, prior to attempting the correction.

Death from elective cosmetic surgery is still reported in isolated cases. Fortunately, this is an extremely rare occurrence. Put in proper perspective, there is a lot more risk in simply traveling the road to the operating room than there actually is during the operation.

The expense of the operation figures into the equation. Generally, most cosmetic procedures are meant to be a single event or at least give long lasting results. Procedures are not cheap, although with increased competition there have been some downward trends among many surgeons. Procedures are considerably more affordable than in the past when fewer surgeons were doing the work in expensive hospital settings. Nonetheless, the patient is spending a lot of money for a long lasting condition. Based on the amount of money Americans spend on their cosmetics, surgical expenses hardly compete. Most doctors will accept various forms of payment, including credit cards or some type of financing. There are a few procedures where insurance may cover all or part of the expense. Generally, insurance does not cover "cosmetic" procedures.

Finally, the inconvenience tolerated by possibly missing work or your normal activities for a period of time is probably the biggest problem to most patients. Some procedures can be done with less than a day or two of home bound recovery. Some patients don't want to go back to work until they look really good - that might take two weeks or longer in certain cases.

One can only handle so much daytime television before they decompensate. Also, since there's not much discomfort from cosmetic surgery, you don't generally feel "sick." This can make it all the more difficult for generally active patients to hide out during their recuperation. Nonetheless, many things have been done to promote the convenience of surgery for prospective patients. Not too long ago, cosmetic surgery was performed in hospital operating rooms and the patient was kept for several days in a hospital room for post-operative care. Now, most procedures are performed in office surgical suites on an out-patient basis with the patient either returning to home the same day or to a special post-op care facility. The post-op care facilities are usually a comfortable and convenient hide-away that will provide transportation to the doctors office, nursing care and food services. Generally, most offices will find ways to accommodate the patient in a convenient manner. In my ideal world, patients would be comfortable to go back to work in spite of their bruises and swelling. This would help others see how the process works. Somehow I doubt most people will buy into that line of reasoning and I suspect patients will still tend to lay low, often maintaining strict secrecy about their procedures.

Like any other area, cosmetic surgery continues to make strides toward improving the specialty. There will always be latest trends developing. To some extent the "industry" has been stifled, as every other industry, by an onslaught of bureaucratic regulations. Between the lawyers and the government I often wonder how any progress is achieved. It is however, and generally the cost is passed on to the consumer. There are better answers to these problems, but that is a topic for another book. Suffice it to say that we are seeing changes and improvements within the area of cosmetic surgery. From the computer to the laser, there have been a number of technologic additions. There have been continued improvements made in nearly every aspect of cosmetic surgery. In general, the trend is to improve appearance with natural changes. Ironically, most people are unaware of people who have undergone cosmetic surgical procedures. While they may say they can spot them, in reality all they are identifying are the few patients who may have had sub-optimal results. Nonetheless, it is important to remember, that the key to the results is improvement and not perfection. An old adage of cosmetic surgery is simply "The enemy of good is perfection." And though we strive for perfection it is tantamount that we must be willing to accept improvement.

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