Of This Fair Proportion

by Dr. Dennis Nigro MD, FACS, FICS

Beholding beauty with the eye of the mind he will be enabled to bring forth, not images of beauty, but realities (for he has hold not of an image but of a reality), and bringing forth and nourishing true virtue he may become the friend of God... -Plato

Plastic surgery is no longer a luxury of just the idle-wealthy languishing in fits of their own vanity. It has become a part of the modern scene. Corporate executives, judges, politicians, men and women in all walks of life are having plastic surgery in precipitously increasing numbers.

Board Certified plastic surgeons have responded to the challenge, both ingeniously and intensely to provide ever improving materials and methods.

Plastic surgeons have been singularly unselfish in the dissemination of their ideas, collegial interaction and the honest evaluation of their results. The commingling of these individual talents toward a common goal has been very successful and has, like many other pursuits, opened new doors fathering ideas that some day will be reality. These surgeons have also posed questions and challenges for an exciting future. I often wonder if industry or national government worked with such camaraderie what would be accomplished.

Concepts initially brought forth to reconstruct the injured or congenitally deformed have made substantial contributions to the areas of cosmetic surgery. Knowledge gleaned from the ghoulishly deformed has been collated and interpolated to treat the more subtle variations. lntrinsic facial relationships peculiar to each face can be determined. Plastic surgeons have admired and profited from centuries of the great creative masters of painting and sculpture to study and compare societal norms and definition of beauty, clarity, symmetry, and their almost rhythmic interaction. It has often been said that art imitates life, but in cosmetic surgery, the reverse may very well be the rule.

The observant eye tempered by years of experience is an invaluable tool to the experienced practitioner, but now computer generated analyses, sophisticated three dimensional x-ray techniques, and the use of magnetic resonance imaging are commonplace. (Magnetic resonance imaging, or MRI, produces a highly accurate diagnostic picture from the magnetic field of the anatomic structure and charge.) Once, what may have been the exclusive realm of Jules Verne, Isaac Asimov and Gene Roddenberry is no more.

Missing or defective parts can be analyzed without surgical invasion. Utilizing the information obtained in these diagnostic studies, a three dimensional replacement or mold can be made before the procedure is even scheduled.

Surgeons have long preferred to use tissue that came from the patient at some other site or region, as it is the most "bio-compatible." It has little chance of rejection or infection and has the best chance to grow and behave normally. A time proven example is the split thickness skin graft applied to the burn victim. With this procedure however, comes the obvious tax of the donor site (area where the skin is split or shaved and removed) and the quantity of material available. In the case of our burn victim, it does not take a rocket scientist to realize the numbers aren't good in a 60% total body surface burn. In the late 1980s several investigators have successfully been able to culture cells and literally grow skin, sheets of it - a truly monumental breakthrough. It has been used clinically and has met with reasonable success. The doors that beckon offer entry to a theatre of culturing the patient's stem cells to grow bone, skin, muscle and other organs. It may sound ludicrous or farfetched, but it is real, it is here and the men and women who are knocking at these doors are diligent and determined. Officially, the medical community is exercising its customary, careful, cautious optimism, but at a sub rosa level, it is children on Christmas morning.

The age of the bio-active implant is upon us. An implant of any type should live in supportive symbiosis with its host, most mimicking the "original equipment." Rather than being an inert substance which merely occupies space, newer implant technology is seeking and finding material that will be incorporated and will add to the overall regional well being. Massive amounts of privately funded laboratory research have begun to work out these problems.

Derivatives of a basic structure very similar to sea coral have been successfully implanted as a bone substitute in various areas of the facial skeleton. Researchers, like Dr. Ralph Holmes of the University of California, San Diego, Division of Plastic and Reconstructive Surgery have made great strides in working out the cellular events associated with bone growth. They have identified certain physiologic clues which have been key revelations in this most ambitious world to find a process to manufacture a substance when placed in the correct human environment will produce new strong viable bone. As these mysteries are tediously unraveled, this process once as airy as the smoke curling above as a holographic pipe dream is now real life physiologic masonry.

Breast augmentation with implants over the years has probably received the most notoriety in this area. Some good, some not so good. The American Society of Plastic and Reconstructive Surgeons is carefully and critically looking for the ideal implant. Texturing the surface of these implants either with polyurethane or scoring the silicone shell in some way has been producing consistently improved results with a constantly increasing percentage of success. New radiographic techniques have allowed safe implantation without the fear these implants will hide the signs of breast cancer. Earlier reports of the silicone causing cancer in rat muscle, and extrapolating this fallacious notion that it is therefore dangerous to humans, was a multi-dimensional error. It is a tragic error in animal model choice, scientific interpretation and deduction and a monumental error in rhetoric. The shock wave that pulsed through my patients who had breast implants was unfortunate. To date, not one single case of cancer similar to those found in the rats has been found in humans. This is in over three million, five hundred thousand patients having breast augmentation over thirty years. The ideal breast implant will be easy to insert, will never harden and will be radio lucent, i.e., x-rays can be taken through it. Researchers are pressing on. Breast augmentation continues to produce high levels of patient satisfaction and as any reader can see, the curvy but toned muscular female form is the fashion.

In the area of technical advances, the thin suction cannula with its varying shapes and sizes of orifices has become a major force in cosmetic surgery. There have been literally tens of thousands of these procedures performed over the last several years. Before the 1980s, "BODY CONTOURING" usually involved large incisions, high risks of complications and some, but limited success. While it was really never meant to replace good surgical technique or proper nutrition and exercise, suction assisted lipolysis has brought happiness and satisfaction to many patients over the past several years. These patients; however, need to be well selected as candidates, for not all fat is the correct target. (Obesity, cellulite and eating disorders are not meant to be treated with suction, but rather areas refractory to good exercise and nutritional regimens in patients whose contour problem is mostly the result of a dysmorphic deposition of subcutaneous fat.) Suction assisted lipolysis (S.A.L.) is an excellent solution to a distressing problem, but it has been badly abused. It has been over-advertised, misused, and misrepresented by surgeons and some non-surgeons who do not have the panorama of technical experience and options to apply to the spectrum of body contouring problems presented by their prospective patients. Since the only tool they possess is the suction cannula, the response is sadly unilateral. Indeed, as one board certified plastic surgeon so incisively observed "when all they have is a hammer, all the world looks like a nail."

Not only is the "with what" and "how" changing but also the "where." Most procedures can he done as an outpatient. This means no overnight hospital stays with the astronomical costs that may well be higher than the surgical fee in some instances. Well equipped, safe in-office operatories or free-standing outpatient units provide efficient, lower cost and personable answers to the question of how to avoid these inflated costs while maintaining a high safety quotient. Hospitals are now caring for much more severely ill patients than 20 years ago and their operating costs reflect this change.

The late 1980s produced the embryonic emergence of "after care'' facilities. These are free standing units, sometimes comfortably appointed homes or hotels that offer mid-level nursing care and shuttle service to the doctor's office. This burgeoning industry will find a substantial niche as the baby boomers turn forty.

Providing a discrete, comfortable low-key retreat to recuperate at slightly above hotel rates, make them an appealing commodity to both surgeon and patient.

Lastly, in our discussion of the progress and new notions that have been introduced in Plastic Surgery, looms a specter which dampens the glow and allure of the future.

No physician, insofar as he is a physician, considers his own good in what he prescribes but the good of his patient; for the true Physician is also a ruler having the body as the subject and not as a mere moneymaker. -Plato

Since this has become a big business, cosmetic surgery has attracted appalling yet sometimes cleverly disguised carpet-baggers. They are creatively adept at the shell game of misrepresenting their qualifications while never overtly lying. Huddled behind the billboards of their conjured titles and experiences, they wait to mug the patients that have been enticed down their avenues directed by spurious and misleading advertising. Self serving "Boards" have been created to give themselves "print credibility."

A common and unsavory practice is to list "Board Certified." Make no matter that this board has no residency, marginal qualifications for entry other than the applicant's ability to fog a mirror and pay the fee. However, as they confer degrees on each other, employ public relations firms and generally attempt to muddy the water, these avaricious practitioners turn their cross hairs and focus to bag their "market share." Due to the American restraint of trade laws, well qualified surgeons have had to work within a system that makes it difficult to expose these charlatans.

The perception that the "open market" will allow for higher quality and lower prices while not carefully qualifying the doctor is a misdirected one. The notion that the patients who will suffer as a result of this practice are like casualties of war (a necessary but practical evil) is the devil child product of the marriage of free enterprise and sociopathy.

But hope springs eternal and even as this goes to press alert and compassionate law makers and consumers are attempting to rectify these inadequacies and inequities.

These flotsam and jetsam of medical practice needs some garbage collection.

What are we to make of all this? Are we sacrilegiously now more empowered to abreact the great plan of the Creator through the improved diagnosis, techniques and materials of this art? Or have we elevated our thinking to the place that truly lets our physical presentation be a more accurate reflection of our spiritual being?