Confessions of a Park Avenue Plastic Surgeon

Dedication

This book is dedicated to

JOHN M. LESESNE, M.D.,

and

DAVID C. SABISTON, M.D.,

physicians worthy of emulation

Contents

Cover

Title Page

Dedication

Epigraph

Preface: On the Table

Introduction

Youth (Without Surgery)

First Cut

I Don’t Have What It Takes

Love Affair

Blood Everywhere

Nasty Surgeons, Not Enough Sleep, and Other Myths

New York Practice

You Can’t Go Home Again

Model Behavior

About Face, Skin Deep

Women of the World

Competition

Aging Beauties, Rediscovered Youth

My Method

Men

I’m Ready for My Close-up Now

Failures (and What to Ask a Surgeon)

She Dies, You Die: The Royal Treatment

A Little Romance

The Royal Treatment, Part II

Reconstruction

You Want What?

I Don’t Do That

America’s Sweetheart

Raising Eyebrows

Sounds of Music

In a Zone

No One to Heal

The Limitations of Plastic Surgery

The Politician and the First Lady

We’re All Alike

The World Is My Museum

Acknowledgments

About the Author

Praise

Copyright

About the Publisher

Epigraph

I believe in strict patient confidentiality. To honor this principle, names and circumstances have been altered, and the identities of patients are known only to me. In those cases where patients have permitted their names to be used, I have done so.

The names of institutions, teachers, colleagues, staff, and friends are real. The same is true for celebrities – except, again, where they have also been patients.

Preface: On the Table

The nightmare every surgeon dreads is coming true, before my eyes. My patient is dying.

And I don’t know why.

Lee McKenzie, a seventy-year-old Manhattanite and former literary agent, lies sedated on the table in my operating room. Maybe she’s dreaming about the face-lift she’s undergoing, and for which she’s saved up over many years. She couldn’t have been more certain that the operation would recharge her. She’d said so months before, when she’d visited my office at the urging of a friend on whom I’d done an eyelid lift. “Feeling ugly and rejected is no way to go through life,” said Lee. I wouldn’t have been shocked had she dumped a lifetime of accumulated coins and bills on my desk right there.

Lee had an unusually heavy neck, baggy eyelids, and lots of jowl, and very much looked her age. Observing her both in person and in photographs at age forty and forty-five, I determined we’d get the best outcome – a defined neck, with chin and jawline clearly separate from the neck – by removing fat from the platysma muscle between her clavicle and jaw, pulling the largely functionless muscle backward, and removing extra fat along the jawline. It’s an operation I’ve performed maybe three thousand times. Barring complications, she would be off the table and in the recovery room within three and a half hours from the moment she was wheeled into my OR. Bruising and swelling would be gone within two weeks, and she would look as if she’d bought seven to ten years.

Before I could operate, though, we had to confirm she was up to it. Her health, generally, was excellent. She had never smoked. Never had a heart problem. The preoperative tests – EKG, blood studies, stress test – all turned up normal. The morning of the operation, she was so excited she practically wheeled herself into the OR.

Now, a couple hours later, I am also experiencing a rush, but it’s because Lee is lying on my table just beneath me, her face opened from ear to mouth, and something is going very wrong.

The operation is still an hour from completion. I have finished removing fat and elevating the skin on her right side, and I am doing the same on the left when Lisa, my trusted anesthesiologist of fourteen years, says, “I have a problem.”

“What is it?” I ask.

“Her blood pressure’s dropping, her oxygen’s dropping, and I can’t reverse it.”

“What do you mean you can’t reverse it?”

“I’ve reduced the anesthetic, I’ve increased her fluid, I’ve given her medicine to bring the BP up, and it won’t go above ninety over fifty.”

“Let’s put her on one hundred percent oxygen,” I say.

Lisa does – to no avail. Two minutes later, Lee’s O2 level is still low and her blood pressure is down to 80/50.

My hands are moving as fast as possible. It’s not abnormal for patients to have brief episodes of low oxygen or blood pressure, but this one is persisting. I can’t simply stop operating. I have to close her up. And before I can do that, I have to stop the bleeding.

“I’m getting worried,” Lisa says. “Hurry up.” Like most anesthesiologists, Lisa is paid to be, among other things, cool. We’ve been through a lot and we trust each other; I’ve done face-lifts and other procedures on friends she’s referred to me. But the mix of symptoms manifesting in Lee is new to both of us. My mind runs through the possible explanations.

Heart attack? Maybe, but her EKG hasn’t changed.

Aspiration? Doesn’t jibe with the drop in BP.

Vasovagal syncope? Her O2 would be normal.

Could this be Lee’s normal blood pressure? Still doesn’t explain the oxygen drop.

Something going on in her head or nervous system? She has no history of neurological problems.

Pulmonary embolism? She’s too physically active for a blood clot.

Even though Lee’s EKG hasn’t changed, I go with the most reasonable possibility: heart attack. After twenty-plus years in training and private practice, this is, remarkably, the first time a patient of mine is suffering a heart attack midsurgery.

“Reverse all the anesthetic,” I tell Lisa. She shuts down the standard cocktail of fentanyl, propofol, and Versed that had ushered Lee into a “twilight” sleep, while I speedily continue closing incisions, tying fine nylon sutures, and inserting nickel clips in the scalp. Finally, Lee’s blood pressure begins to rise. Same with her O2. Good. The sedation has worn off and it’s only local now. As Lee awakens – the still-opened side of her face resembling a cut watermelon – she asks groggily, “Are we done?”

“We have a little problem,” I say.

“What problem ?”

“Do you have chest pains?”

“No.”

Huh. Another indicator she did not have a heart attack.

“Shortness of breath?” I ask.

“No. What problem?”

“We didn’t like some of the readings,” I say.

Lee looks at me as if I were dense, as if I were from Neptune – as if I’ve forgotten why we are all gathered there and why I have gone into this profession to begin with. As if I’ve forgotten why she has spent every last discretionary penny to be lying here.

“I don’t care if I die,” she says. “I waited my whole life to look good. I’m not going one more day looking the way I do.”

Her eyes are piercing; there are no remnants of the effects of anesthesia. “Just do a good job,” she coaches me.

Despite her aberrant readings, I accede to Lee’s wish and complete the face-lift. This time, her signs remain stable. After I finish and suture her, we call for an ambulance to transfer her to the hospital, to make sure she’s monitored.

The moment the EMS technicians place Lee on a stretcher – the face-lift dressing cradling her head – her eyes roll back and she turns blue.

Oh, God, I think. She’s gonna go.

She is having a heart attack.

Fortunately, Lee responded to another drug-reversing agent. She came to; she did not code. That night, in a crowded emergency room, with an IV in her arm, she asked me, “Did you do a good job?” It’s a question she would ask me every day for the week it took her to recover in the hospital’s cardiac care unit.

I nodded.

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

Introduction

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.*

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).*

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”?)*

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 O2 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.