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.

As the last ten years of my practice have quickly passed bye I’ve begun to make a conscious effort to write about the process of becoming, and being, a Plastic Surgeon.  I hope you enjoy what follows.

As physicians we go through many stages during our education and training.  Eventually when those years are behind us, we’re set free and for the first time able to begin shaping the kind of practice we had only dreamed about before.

More so than many of the other surgical specialties Plastic Surgery has two sides.  These are easily split into Cosmetic and Reconstructive surgeries.  However after a closer look, and many years of experience, it becomes clear that these two have more in common than first meets the eye.

Modern reconstructive surgery really took off during and immediately after  World War I,  where trench warfare and mass casualty triage first met in modern military medicine.  Triage separated wounded soldiers into three categories.  Those that would survive their injuries until more help arrived,  those that were beyond saving in the field, and those that needed immediate attention to hopefully be saved.  Focus on this last group of critically injured soldiers led to a large increase in the survivability of wartime injuries.  More soldiers started showing up at military hospitals with previously uncommon facial disfigurements due to more of them surviving their initial injury in the field.  This led to Plastic Surgery giants such as Sir Harold Gillies to open specialized centers near the front lines and to invent many new methods of reconstruction to help with these disfigurements.  In many ways the creativity of Plastic Surgery really blossomed during that time.  Much of the ground work that has gone into today’s cosmetic and reconstructive means was laid during that post war episode (1914 to 1939).

Cosmetic surgery witnessed a large boom during the 1960’s and 1970’s.  Prior to this period elective cosmetic cases were often thought of as only for the well to do.  Many times these types of surgeries were being performed on patients well past their sixties as large overhaul procedures.  Today the increased life expectancy of the World War II  baby boomers combined with an overall increase in the American standard of living and numerous surgery financing companies has made cosmetic enhancement surgery more prevalent than ever before.

For me these two sides of Cosmetic and Reconstructive surgery are easiest to think about as the Yin and Yang symbol, neither one is truly complete without the other.  These two elements are intimately intertwined while appearing to be opposite.  Each side propels the opposite to achieve a higher quality in patient outcome and satisfaction.  For example, reconstructive microsurgery has now advanced to the point where a woman’s tissues can be removed from one area of her body and microscopically reattached on the chest to be sculpted into a reconstructed breast.  However it’s not enough to just get the tissue there and for it to survive.  This new reconstruction has got to look better and more natural than the older techniques it’s replacing; or else what’s the point?  This is how the whole of Plastic Surgery benefits from it’s two halves.

I also see this Yin and Yang element in my own practice.  Starting right out of your Plastic Surgery residency training there usually isn’t a long line of people falling over themselves to get a face lift by you.  What’s more typical is that you perform those cases when they come along and instead set your mind on getting as much reconstructive experience as possible.  If you’re as fortunate as I was you land a dream job as a staff Plastic Surgeon at a large inner city trauma hospital.  This was Jacobi Hospital in the Bronx for me.  At Jacobi I felt a lot like how those wartime surgeons must have felt, never knowing what you were going to see next, or if you had ever seen it before.  The fast pace and high complexity of reconstructive cases at a city hospital is a young Plastic Surgeon’s proving grounds.  It was there, usually in the middle of the night, that cases would come along that would force me to think outside the box, where conventional reconstructive solutions wouldn’t always suffice.  Over the course of a decade much experience was gained and all the “rules” of Plastic Surgery which took so long to learn were now being bent to solve some seemingly unsolvable problems.

This trauma work experience slowly began to weave it’s way into my cosmetic practice.  As time went on and people began seeing my work they began referring their friends and relatives.  Soon I was using all the reconstructive lessons I had gained at Jacobi to solve cosmetic surgery issues which compelled me to try to get the absolute best results possible.  I began to see my cosmetic surgeries more as events than as workdays.  I find it very motivating to think of these surgeries as an athlete or musician would think of their performances.  This level of total focus is difficult to manage with the busy nights associated with Plastic Surgery trauma. Therefore in August of 2008 I gave up my regular position at Jacobi to focus my energy towards my cosmetic surgery practice.  This has been extremely rewarding for me professionally, but at the same time lacking in a certain way.  Remember the Yin isn’t whole without the Yang.

I’ve now entered a new stage of my career where because of the good fortune I’ve had in cosmetic surgery I can now perform reconstructive surgery pro bono.  In December of this year I’ll be traveling down to the Dominican Republic on a medical mission with the Devino Nino charity to perform Reconstructive Surgery on their needy population.  It’s my hope that trips like this will aid me in making the crucial connections necessary for my personal charity, Vanity 4 Humanity, to aid women with breast cancer deformities in underprivileged countries around the world.

There you have it, Cosmetic surgery in Manhattan making Reconstructive surgery possible in third world countries; the Yin and Yang of Cosmetic and Reconstructive Surgery, neither one whole without the other.