I just got back from an intensive five day conference in San Francisco entitled The Art of Rhinoplasty.  This course has been in existence for 47 years, all under the watch of Dr. Leslie Bernstein.  Dr. Bernstein is in his eighties and his enthusiasm for teaching his accumulated knowledge involving the nose to his pupils is electric.  I feel as though I was lucky to meet someone whose found his life’s passion.  Dr. Bernstein had our conference begin everyday between 6 and 6:30 am, and jammed the day full of lectures by his proteges.  We quickly advanced to discussing the most complicated cosmetic rhinoplasties possible.

As the name of the course implies much emphasis was placed on the artistic nature of cosmetic surgery.  I’ve long thought about this subject and felt that after the years it takes to accumulate the knowledge and techniques necessary to perform cosmetic surgery there’s another dimension to embark on.  I feel that this is where artistry comes in.  A Plastic Surgeon that I trained under used to say,”Plastic Surgery isn’t Art, it’s a craft.  One needs to have predictable outcomes which fall into the range of the ideal human figure, such as a master craftsman builds furniture or weaves a fine fabric to certain standards.”  That statement never felt right to me.  I believe that Surgeon was correct in describing the middle stage of a cosmetic surgeon’s career, after the technical skills are achieved, but I think that in some ways that’s just the beginning.  Most people would agree that fine art such as the Mona Lisa wasn’t done by a craftsman, Leonardo breathed life into those paint strokes.  By seeking perfection Leonardo became known for his work because it stood out from the other painters.  This is exactly the same pursuit for the cosmetic surgeon.  However it’s a little more difficult because the science of healing, aging, and patient selection all comes into play.

One of the week’s highlights for me was to perform nose dissections on human cadavers at the UCSF Medical School.  For a Surgeon the cadaver lab is a sacred place.  It’s where another human being has died and given you permission to take a look inside to educate yourself to help the living.  It’s a powerful experience that always has mixed feelings of humility and excitement for me.  In the lab I was reminded of Irving Stone’s description of the young Michelangelo dissecting corpses in the catacombs to a single candle’s light in The Agony and the Ecstasy. That’s where the famous Artist learned his anatomy in the middle of the night.  During Medical School we had 24 hour access to our lab and I would often go late in the evening to try to emulate the artist.  Needless to say I found the experience at UCSF immensely helpful in furthering my understanding of the human body.

Dr Bernstein repeatedly urged those in the audience to follow his example and take adult education courses in drawing and sculpture.  He told us that in his earlier career he did this and it made a huge impact on his cosmetic results.  One of our many talented lecturers was a former student of Dr Bernstein’s who took his teacher’s advice and found that he was gifted in sculpture.  His name is Dr. Steven Neal from Oregon.  Dr Neal is the most accomplished Surgeon/Artist that I’ve met.  Dr Neal’s talks revolved around bridging that gap between Art and Science, he backed up his talks with examples of his patients as well as photos of monumental bronze sculptures that he was commissioned to create by his home city.  Dr Neal brought 50 clay human faces to the conference.  He asked us to sculpt noses where he had left a void.  I found it interesting that so many rhinoplasty surgeons in the room couldn’t do it.  It’s not as though they didn’t try but the proportions were off or the anatomic structures that we had been discussing at the conference were all ignored.  I found this exercise really gratifying, I quickly made a well proportioned nose with some subtle details that I was happy with.  More importantly while I was sculpting I quickly entered a zone where I wasn’t thinking about the 10 hours we had already spent listening that day.  The Japanese have a word for the mind and body becoming one during an activity, Satori.  This is where time stands still and you become engrossed in an activity such a tea ceremony, flower arranging, calligraphy or in this case sculpture.  I find the act of surgery to be exactly the same way.  A surgeon needs to have his/her judgement and skills perfectly in tune so that the differences in patients anatomy can be seen and thereby a surgery can work with the patient, not against them.  I’m more aware of these relationships now than I was 10 years ago and I try to incorporate them into my OR cases.

As I was sculpting that night I keep thinking that this could encourage areas of my brain to grow in ways that could benefit my patient’s results.   I’ve decided to take Dr. Bernstein’s advice, so I’ve enrolled in a continuing education sculpting class starting in January.

I’ll let you know how it goes.

Throughout a woman’s life her breasts change.  That can mean a lot of different things to those of you reading this.  Small breasts may become large during pregnancy and stay that way, large breasts can deflate and droop later in life, and breast development can seem to never have taken place at all.  As luck, and Plastic Surgeons, would have it there’s a solution to each of these dilemmas.

Breast surgery should center around the three S’s

Size, Shape, and Scars

A woman’s breast size needs to be compared to her body’s size.  This means that the same sized breast placed on a large woman and a small woman will have completely different proportions to each individual.  Looking attractive vs. abnormal is all about proportions; whether it’s breasts, noses, or waist size.   A medium C cup tends to be the size that mimics a good pair of shoes, these can be most easily dressed up, or down.  This means that a mid-C can be accentuated with push up bras and low necklines to look even larger when desired, or easily concealed beneath a flowing blouse when a more conservative appearance is necessary.

Shape concerns tend to do with droopiness (ptosis-Doctors have a different name for everything).  If we all lived long enough gravity would turn us all into puddles on the ground.  Add to this effect that a woman’s firm breast tissue gets replaced by less firm fat over the course of time and that the skin enveloping the breasts losses much of it snap.  It’s no wonder that many women are seeking out surgical options to correct ptosis after they’re done having kids.  These surgical procedures focus around moving the nipple-areola complex up, and creating upper breast fullness.

In some ways scarring is the most important of the three S’s, because what’s the use of changing the size and/or shape if you can’t fathom having scars on your breasts.  It’s a little like robbing Peter to pay Paul, you have to give a little to get something, you don’t get something for…….I can go on and on.  Basically it’s not magic.  After hearing what your concerns are about your size and shape and then examining you I can present the different options that are possible to give you the look you desire.  This is done with the underlying premise to create the least amount of, and best quality, scarring possible.

There you have it, an introduction to breast surgery.  Look for future entries targeting more specific breast issues and their surgical management.  I hope to give you a glimpse into the way I think about these types of cases and about how gratifying this type of work can be.

I think most people would agree that there are few areas on the human body that have a deeper connection to who an individual is then the eyes.  I suppose this is because of the eye’s ability to convey emotion and to hint at what an individual may be feeling as in, “a window into the soul”.  When someone is considering cosmetic eye surgery usually their biggest fear is that they don’t want to drastically change their appearance.  Generally what they are saying is that they don’t want to change their identity that they feel they convey with their eyes.  What most of these patients do want is to just discard their  tired look that brought them into the Doctor’s office in the first place.  Fortunately for the Plastic Surgeon only the later of these is possible.

The eye area is one of the first problem areas that cause patients to seek the help of a Plastic Surgeon.  This is because eyelids comprise the thinnest skin on the human body.  Thousands of times a day we move this skin while blinking and conversing.  All this movement paired with a greater amount of sun exposure than other body parts causes the skin to wrinkle at an earlier age than the rest of our face in most people.  The protective fat around our eyeballs begins to herniate out causing those unattractive bags.

Like all new prospective patients, the first consultation starts off with a detailed interview about the overall health status of the patient.  Then the conversation turns to focus more on the specific complaints relating to the appearance of the eyes and any associated problems or issues pertaining to this area.  The eyes are then examined with the patient in front of a mirror so she/he and I are looking at the same thing as I discuss what can be done and how.

Cosmetic eye surgery centers around removing or relocating the fat bags, as well as tightening the skin.  Patients generally state that the surgery is less painful than they anticipated and all sutures are removed by the sixth post operative day.  Results start to show by one week and continue to improve over the first few months.  For those not ready, or willing, to undergo a surgical procedure great gains can be made with Botox.  This agent can reduce crow’s feet and change the shape of the brow to minimize the extra upper eyelid skin.

Wherever you draw your line in the sand options to improve those windows into your soul exist.

Dr Roland