Confessions of a Park Avenue Plastic Surgeon

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I nodded.

“Then I’m happy,” she said. “And if I’m not happy, nothing else matters.”

Introduction (#ulink_1874445d-cc53-548a-9202-61d8ae1f98b8)

We plastic surgeons are perhaps second only to psychiatrists when it comes to being privy to patients’ intimate secrets. As a doctor, though, I’m committed to strict confidentiality. Divulging anything is not just unethical, it’s illegal: I could lose my license. Indeed, a proper plastic surgeon doesn’t even acknowledge his patients when he sees them at events, unless they’ve been explicitly open about their operation. At a Los Angeles charity function crammed with A-list actors and industry players, several patients of mine roamed the mansion’s grounds while I strolled with one of the town’s most powerful female executives.

“You’re lethal to walk around this party with,” she said, taking me by the arm. “I’d love you to comment on who here has done what.”

“I can’t do that,” I said.

She looked at me sternly, as if that might do the trick.

“I can’t,” I said.

Now she practically batted her eyelashes.

“I can’t,” I said.

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So why would a doctor like me write an exposé about what goes on behind the scenes in my profession?

The last decade, especially the last three to five years, has witnessed a revolution in my profession and its public perception. There’s less stigma now to having cosmetic surgery. There are more public expressions of pride by patients. Once upon a time, the only celebrities who confessed to going under the knife were Joan Rivers and Phyllis Diller. It’s long been rumored in our circles that the legendary L.A.-based plastic surgeon Dr. Frank Ashley did face-lifts on John Wayne and Gary Cooper (among other Hollywood legends). There was Ann-Margret’s obvious facial reconstructive work following her terrible fall in 1972, while rehearsing for a show in Las Vegas. Aside from that, though, there was mostly silence about who’d had work done – and the silence wasn’t only from famous folks whose appearance was critical to their livelihood, but the not so famous, too. The high schooler who returned in the fall for her senior year with a suddenly smaller, usually upturned, nose – likely an idealized Caucasian variation modeled on Grace Kelly or Barbie – did not necessarily explain, much less advertise, how the change had come about.

Today, much has changed. Far more people talk openly about the procedures they’ve had (though many still won’t, and some, like Sharon Stone, who sued a plastic surgeon for implying that she might have had work, shudder at the very suggestion). My patients rarely feel the need to disappear for weeks, so they can return to their hometown looking refreshed. In 2004, according to the American Society of Plastic Surgeons, 9.2 million cosmetic surgery procedures were performed in the US, a 24 percent jump from the year 2000. During the same period, the British Association of Aesthetic Plastic Surgeons (whose figures only cover their own members and not nationwide figures), over 16,000 procedures were carried out, an 18 percent jump since 2000. 22,000 were carried out the following year, marking a 37 percent jump between 2004 and 2005. Comparing 2005 to just one year before, almost all major cosmetic surgeries in the UK increased markedly: breast augmentation was up 51 per cent; surgery on the eyelids, 50 percent; face/neck lifts, 42 percent; rhinoplasties, 35 percent; brow lifts, 35 percent; otoplasty (for the ears), 28 percent; liposuction (major), 25 percent; abdominoplasty, 24 percent; liposuction (minor), 10 percent; and breast reductions, 9 percent. And because of recent technical and medical developments, which have led to the popularity of nonsurgical, outpatient procedures such as “injectibles” (unfortunately not recorded in the UK, but in the US in 2003, such minimally invasive procedures jumped 43 percent over the previous year, a clear indication of UK trends), the decreased cost of beautifying and enlivening one’s looks, particularly in the face, is increasingly attracting the non-wealthy. Those who might once have chosen a forehead lift (average US fee, $2,800; average UK fee, £3,000) are opting instead to get a Botox injection ($375 every five months in the US; £350 in the UK).

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Yet despite the more accepting attitude toward cosmetic surgery, and despite the booming business my profession is enjoying, the surgeon – the good one, anyway – remains behind the scenes. For most patients, the goal is subtlety, and the doctor who delivers subtle results is greatly appreciated – discreetly.

To repeat, then: Why would a doctor like me write an exposé?

Because of my experience as a plastic surgeon and my particular skill – to reposition the skin and tissue of the face, to sculpt fat, to reverse the residuals of pregnancy, and to undo some of the other changes wrought by time – I have come to see, hear, and understand an extraordinary amount about the range of our dreams and disappointments, our motivations and fears. Two decades of solo plastic surgical practice have exposed me to the yearnings of the human heart. While I’m a technician who transforms his patients physically, I also bear witness to their psychological transformation, which frequently starts before the bruising has resolved. For instance, a woman having breast augmentation often sees such a radical upswing in confidence and body image, she makes another dramatic change: new boyfriend, new job. Why? Often, her man becomes more interested in her – way more. Indeed, a husband may become so infatuated with his wife’s new breasts that she may perceive his lust as weakness. She may lose respect for him. I can’t count how many times I’ve seen it happen.

On the other hand, couples that come in together for cosmetic surgery – a small but not insignificant part of my practice – almost always display some of the healthiest relationships and long-term intimacy I’ve ever encountered.

Like it or not, I’m exposed to my patients’ lives before, during, and after surgery. You know many of them from magazine covers, movies, and TV. Some of them walk the fashion runway. Some run for office. Some are royalty. Some are rock stars. Some are socialites. Some are international tycoons. You’ve seen their boldfaced names, or those of their spouses, in the gossip columns and the business pages. My practice is located in the epicenter of the plastic surgery world – an eight-block stretch along Park Avenue between Sixty-fourth and Seventy-second streets where the major players have discreet offices that cater to (among others) the wealthy, the famous, and the beautiful.

And the often unhappy.

I am not a psychiatrist, nor do I have Oprah’s gift for empathy. I am not overly warm and fuzzy – an occupational necessity rather than a character flaw. But I have sat and listened and tried my best not to judge as prospective patients have come into my office and shared with me their aspirations, the physical attributes that haunt them, and other insecurities. They tell me their stories, proving that even the most successful, attractive, and seemingly aloof people suffer many of the problems that haunt all of us, regardless of status. We all share the identical fears about appearance, age, and time. We worry that our looks or aging will lose us love, security, desire, or sexual attractiveness. He can’t get the movie role he wants. She can’t get a date. He’s been working out for six months and still has an abdominal roll. She comes to me after a divorce or on the eve of menopause. He comes to me not long before he’s up for a promotion, or right after he doesn’t get it. She’s about to cheat on her husband, though he doesn’t know it; in fact, she doesn’t yet know it. (What else am I to make of a comely young woman, half-French, half-English, who repeatedly complains to me about her investment banker husband, and who describes her intensive spinning class and free-weights regimen – her first serious exercise since giving birth five years before – and yet insists that the face and breast surgery she desires are “only for herself”?)

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Many of my patients are between forty and sixty, with the rest divided evenly between those older and younger. Women are particularly vulnerable during these decades. Their childbearing years are nearly over. Their kids are getting older. Their parents may be dying. They’ve become the elders, the generation in charge. Patients sit in my consult room and tell me things not even their husbands or girlfriends or best friends know. Essentially, they want me to restore a lost youth, back to when they were nineteen, or twenty-six, or thirty-five, or forty-seven. Their determination to rediscover happiness and self-assurance supersedes all else. “If I don’t look good after this face-lift,” said Lee, the seventy-year-old who shrugged off the heart attack she’d had immediately following her operation, “then nothing matters.”

I maintain a familiarity with my patients for brief periods or for much longer. Frequently, I get to know them well – maybe too well. I become friendly with many, travel with them, attend their weddings and even those of their children. Sometimes I’m invited to their post-divorce parties. It’s no wonder such a bond should form between patient and doctor. In doing something so intense and personal, and which can palpably improve lives, I can’t help but achieve a closeness unusual for doctor and patient. For my patients’ part, they can’t help but reveal themselves candidly to me. Part of this intimacy stems from the fundamental difference between elective and nonelective surgery. By the time prospective patients have chosen to appear in my office, they’ve thought deeply about personal and often painful subjects – their self-perception, how others regard them, and their goals.

During our introductory consultation, the patient and I will share pleasantries, then she’ll switch gears. For example, Renee, forty-two, suddenly tells me, “I’m meeting my old high school boyfriend next week, and I don’t look as good as I want to. Can you do a liposuction of my abdomen and legs and fat grafts for my lips in time?” (I can.) Or Frank, a New York TV anchorman, orders me to make him look younger by removing the fat bags in his lower eyelids, after his production manager comments on Frank’s late-night carousing – a particularly deflating comment since Frank spends his nights at home, prepping for work. (On-air TV personalities require a different surgical and aesthetic approach – more on that later – so I remove the fat by making incisions inside the eyelids. After surgery, Frank looks five years younger, with no visible scars, and misses only one weekend of work.) Or Danielle, a once beautiful, newly widowed social force in Palm Beach, complains that because of a disastrous surgery performed on her by a non-board-certified plastic surgeon, her face has deteriorated into a distorted, unnatural mask, with sweeping lines across her cheeks. “I’m desperate,” she says. “You have to help me.” (When I cut the multiple suspension sutures that distort her smile, her cheeks release and resume a more natural position; the results are apparent before the surgery is even done.)

And then there’s Liz.

A five-foot-five, seventy-three-year-old dynamo and legend in the public relations field, Liz seemed particularly pleased with my operations. She had asked me to change her breast implants three times in two years and was always happy with the way they turned out. A little smaller, a little bigger, then smaller again. C cup, now C+, now down to a B+. Although I initially balked at the second and third surgeries, Liz’s motivation seemed appropriate, and after much discussion, I believed she understood the limitations and risks (e.g., asymmetry, hardening, infection, bleeding) of each surgery.

Still, Liz looked somewhat anachronistic: youthful breasts on an aged body. But while this might tweak my aesthetic sense, Liz didn’t see it that way. She was thrilled.

I was neither flattered nor dismayed by Liz’s desire to routinely change her breast implants, but I was curious. I continued to probe for the reason behind the frequent adjustments. For more than two years, I got no satisfactory answer from her.

Six months after the third surgery, Liz comes to the office to discuss new implant set number four – and finally she cops to her motivation. “I change my breast size depending on who I’m dating,” she admits.

“Liz, I can’t do this anymore,” I tell her.

“Why do you care? It doesn’t hurt me, and it makes me feel good. Please,” she begs. “Just one more time.”

“No. Three is enough.” Each time an implant goes in, the body forms a layer, or capsule, of collagen, which can contract and distort the implant. While medically and technically there’s no reason I can’t continue to alter her breast size, I refuse, given her motivation, to do more surgery.

Liz scowls at me, not at all thrilled with my admonition.

“Can’t you put in a zipper?” she wonders.

Just because I want to help my patients doesn’t mean I always agree with their “reality.” Every now and then, I’m confronted by someone who seems to be looking in a fun-house mirror. Recently, I received this letter from Sapporo, Japan:

Dear Dr. Lesesne,

I understand you are a famous plastic surgeon.

My daughter looks like Elizabeth Taylor.

I would like her to look more Japanese.

Can you make her look more Japanese?

Thank you.

Sincerely,

It was signed by the girl’s mother.

Stapled to the letter was a photograph of a homely, very Japanese-looking fourteen-year-old girl.

Thanks to my unusual access to people seeking significant physical changes, I write this book, in part, to share what I’ve learned about what motivates us and what terrifies us.

My subjects are women and men seeking plastic surgery; my subject is the skin and tissue of aging faces and bodies. Over the course of my years in practice, I’ve seen an almost incessant burst of innovation – including lasers, Botox, collagen, Sculptra, Restylane, short-scar surgery, and endoscopic surgery – that has helped to improve results dramatically, while reducing bruising, scarring, and recovery time. Other medical innovations not specifically intended for plastic surgery have also helped the quality of the work and the patient experience. For example, the pulse oximeter, a device that measures the blood’s O

level, allows us to monitor anesthesia continuously, thus making for safer, more accurate administration of sedation, as well as allowing for more office-based surgery. Versed, a Valium derivative, and fentanyl, a narcotic, have gained popularity because they are short-acting; when the surgery is over and we cease sedation, the aftereffects for the patient are gone within an hour, not days.

But it’s not just technical innovations and new drugs and the latest injectables that tantalize my patients. I’ve come to understand, after thousands of operations, a great deal about the anatomy of the face that isn’t found in anatomy textbooks. I’ve learned about light and shadow. About the way skin heals. About skin tension. About how much fat to remove (and whether to excise it or suction it). About where and why a surgeon should leave extra skin. About how best to disguise scars. About the false expectations of computer imaging. About why it’s crucial to examine the face over time and not just in the present. About which skin regimens work and which don’t. About a myriad of other lessons, large and small. All that knowledge has made my surgery of the face, in particular, far better today than when I did my first face-lift, in the winter of 1980, as a new surgical resident at Stanford University, assisting on a standard subcutaneous lift of a fifty-two-year-old mother of three.

I also believe that there are strategies, in contrast to those of some of my colleagues, that allow me to achieve more natural results. “Where did Greta Van Susteren go?” patients of mine wondered, along with many others, even after the Fox TV anchor admitted to eyelid procedures (she never confessed to more). “Please don’t make my mouth like Melanie Griffith’s,” patients will demand before I inject their lips with Restylane. Or they might ask me, “What happened to Leslie Ash?” (Angelina Jolie’s name is also invoked, but in her case it appears the lips are her own.) The obviously plasticized look is not the usual goal of my patients; subtlety makes them happy. “Natural” is my guiding aesthetic principle. For facial surgery, my goal is twofold: to make my patient look phenomenal, and to make no one suspect why she looks phenomenal. I want her to be able to pull her hair back without any visible scars. A patient from Texas once paid me one of my favorite compliments: “You made me look younger, intellectual, and sexy.”

On the other hand, I find it comical that so many women come in for breast augmentation thinking their husband or boyfriend won’t know. They’re shocked – “Can you believe it?” they ask me – when their partner deduces it in three nanoseconds.

Many surgeons plan their procedures as a matter of routine, without accommodating the patient’s physiognomy or individual traits. My profession is degraded, I feel, by practitioners who perform the same style of operation regardless of the subject’s nose, face, or body habitus. But there are overbooked surgeons in Los Angeles, Miami, and elsewhere who insert the nearly identical pair of oversize breast implants on a vast cross section of their patients (including office staff, wives, and even daughters), so that every woman who leaves the office sports two half-grapefruits. The result is so artificial that many of us can’t help but wonder, “What was the surgeon thinking? What was the patient thinking?” Even though I spend all my day with women, and many of my closest friends are women, there are some questions I can’t answer.

Then again, other questions that people think they have answered, I would challenge. For instance, I believe it’s a myth that Michael Jackson is a plastic surgery victim. People assume that everyone believes he’s a victim, including Mr. Jackson himself. That he must hate his face (and himself) or else why would he have gone back for more and more and more.… You know what I think? That he likes his surgery. A lot. If he’d been unhappy with what was happening to his face and wanted to reverse it, he could have, to an extent. But he never did. He had an idea of what he wanted, and he’s been following that road since. We may think it looks bad. I don’t believe he thinks so.

Here’s another myth: People who have plastic surgery have complicated feelings about it. No, they don’t – not usually. Those who haven’t had plastic surgery hyperanalyze the motivations of those who have. For most of my patients, it’s a simple decision. They want to fix something that bothers them. Period. No Freudian analysis, no overthinking. Almost every magazine article critical of plastic surgery is usually written by someone who’s never felt that urge.

Another reason I write this book is because I’ve thought deeply about the face, skin, aging, and plastic surgery, and I want to share what I know to be true and false with my patients, with those interested in plastic surgery, and with other physicians. Better education about my profession is good for me, my colleagues, and, most important, future patients. Without knowledge, how does a first-time consult know what to look for in a plastic surgeon? Or what to ask the surgeon? I’ll include some guidelines.

I love being a plastic surgeon. I love its intellectual demand and technical artistry. Most of all, I love that I make people happy. I’m with my patients every step of the process, for every suture. Many Park Avenue plastic surgeons don’t see their patients postoperatively: The resident or post-op nurse treats them. Not me. My mentor at Duke Medical School, Dr. David Sabiston, impressed upon me that they’re my patients from the moment they enter the OR until the incisions have matured, sometimes more than a year later. As the captain of the ship, I am responsible for anything that happens to them, plastic-surgery-related, while in my care. This simple lesson in accountability has made me a better surgeon because I see changes in healing and other nuances that, were I not doing my own follow-up, I might not notice or fully understand. (Two examples: With a smoker who’s had a tummy tuck, I can tell sooner, by the shade of blue on her skin, whether she’ll have problems with her wound healing. With a face-lift patient, I can tell whether scars need to be massaged.) And because my patients always see me, not an unknown, the relationship is more gratifying.

Which brings me to the last reason I write this book: to share what it’s like to live the life of a plastic surgeon. We’ve all seen slices of it (pun intended) on hit TV series such as Nip/Tuck, a fictional drama, and Extreme Makeover and The Swan. But these programs, both fictional and “reality,” offer stylized, often sensationalized, depictions of that life. Among books on the subject, none of those written by plastic surgeons talk in detail about the life we live, its daily rigors and quirks. And books about plastic surgery by journalists, while occasionally well researched, don’t come close to capturing the essence of our sense of responsibility to each patient, the numerous details we must consider with each procedure, why we make the decisions we do, and why we make the mistakes we sometimes do. I’ll provide an insider’s view that outsiders can’t, because they don’t live it.

For example, how about this paradox to our life: Can one succeed in a profession suffused with one kind of intimacy without also sacrificing – or at least challenging – intimacy in one’s personal life? I’m usually scrubbed for surgery before the sun rises, so I have to be in bed early. The society cocktail parties, museum benefits, and charity functions to which I’m often invited – and where I regularly see former and future patients – are, for me, restricted functions. I’m expected to be a diplomat, to be cool and calm, always restrained. It’s one glass of wine, tops, and nothing after nine thirty; I’m a doctor. I have to be responsible. I must focus on my surgery.

Even my avocations can be colored by the fact that, like most plastic surgeons, I’m always “on.” When I’m at the Metropolitan Museum of Art or the Frick Museum, I wander the halls looking at spectacular paintings and sculpture, yet I can’t help but analyze them as if they were patients. The young wife in Peter Paul Rubens’ Rubens, His Wife Helena Fourment, and Their Son Peter Paul looks overweight; she could use a neck liposuction. Venus in Titian’s Venus and Adonis is often regaled as the paragon of female perfection, but, to my eye, she’s disproportionate. And whenever I see John Singer Sargent’s magnificent Madame X, which depicts a side view of her large nose with its dorsal hump and flared nostrils, I can’t help but think, What would she look like if I reduced her tip projection and rasped her dorsum?

This out-of-office PSR – Plastic Surgeon’s Radar – is not just operative while I’m strolling the halls of a museum; it’s frequently on during social functions, including when I’m having dinner with a woman. It’s not long before the more daring of my dates will ask me to comment on what she may or may not need – and sometimes they don’t like the reply. One woman, while dancing with me on our second date, challenged me to assess her breasts: “Cap” – my nickname – “what size do you think they are?”

What do I say?

That I know they’re 325 ccs? That the implant casings are “smooth” (as opposed to “textured,” whose surface features tiny ridges)? That they’re of “moderate profile” (the distance of the implants from the chest wall)? That I can even name the implant manufacturer?

“The perfect size,” I replied. “They suit you well.”

I operate on men and women. I physically and psychologically change them, yet I must remain distant. I champion their initiative and sometimes courage to transform themselves, yet I must be keenly aware of, and candid about, their weaknesses and occasionally misplaced motivations.

My professional obsession is flaws. My goal is perfection.

I agree with Aristotle: The pursuit of life is happiness. Figure out what’s important in life, then go for it. If there’s a physical attribute that can be fixed, and the procedure involves minimal risk, and your life will be improved because of the fix, then why not do it? I don’t trivialize the risk of surgery because all surgery entails risk. But I see, every week, how plastic surgery delivers physical results that change people’s lives in positive ways. I love Billy Crystal’s famous Fernando Lamas impression on Saturday Night Live – “It’s better to look good than to feel good.” It’s funny, at first, because it’s about vanity and superficiality. But for many people it isn’t far from the truth. For them, feeling good is looking good. Attractive physical appearance reinforces good body image, and good body image affects psyche. Others see you in a different light. You may be noticed and appreciated more. You’re more likely to get promoted. You get more out of life.

As one face-lift patient told me on a postoperative visit, “This changed my head.”

(#ulink_f7df576c-b2b7-50ee-96d7-8bba6fdb9bf2)I can’t – though I can tell you a few ways to tell if someone’s had plastic surgery:

1. Unevenly dimpled legs. (Liposuction)

2. Symmetrical scars. (Under the armpits: a subpectoral breast augmentation; in the same position on the hips, backs of legs, or fronts of legs: lipo)

3. Scars just in front of the ears. (Face-lift)

4. A break in the hairline. (Face-lift)

5. Facial skin different from skin on top of the hand or, more accurate (since lasers easily remove hand wrinkles and brown spots), different from skin on the lower leg. (Face-lift)

6. Cheekbones too sculpted for overall anatomy. (Cheek implants)

7. Incisions on the tops of the eyelids, sometimes only visible with the eyes closed. (Eyelid lift)

(#ulink_30efdb7a-40a1-59ff-a2a6-0293d1935c1d)In the long run, the forehead lift is probably cheaper.

(#ulink_f4a413aa-6a3e-5f7f-8371-ed6b299c6cc5)Six months later I spot her at The Ivy in Los Angeles. She’s having a romantic dinner with a younger man.