Behind the scenes in a plastic surgery practice

While we hope that we make it look easy, there’s a lot that goes on behind the scenes to make a plastic surgery practice tick. It does simplify matters that I don’t do as much reconstructive surgery as I used to, so my day doesn’t typically start with hospital rounds anymore (I use the time to get to the gym instead.) We do surgery most days here in our accredited facility, which is a great convenience but also a lot of work to keep up to speed and comply with safety standards. Practices that do surgery in an offsite facility often have surgery days and clinic days, so some patients have to wait until the afternoon to start, all the while hungry and thirsty because no oral intake is allowed for anesthesia reasons. But maintaining all of the standards of accreditation for a surgery facility is time consuming work, including such things as regular inspection of all equipment, Advanced Cardiac Life Support certification by all clinical staff, quality assurance reviews, drills for emergency situations, and the like. And every case begins with a “time out” checklist, similar to what an airline pilot does before takeoff. I also serve as an inspector for AAAASF, the accrediting agency for our surgery facility ( http://www.aaaasf.org/consumers.php ), though our own inspections are of course done by an independent examiner.


There’s another aspect to my practice that isn’t typical, in that I use the same nursing staff in surgery as for patient consults, pre-op visits, and post-op care. The advantage of this is that the patient sees the same people before, during, and after surgery, which is a comfort and helps assure consistency. When the surgery is done at a facility separate from the practice, the surgeon has less control over the patient’s experience. The challenge is that my nurses have to possess the technical skills to assist in surgery as well as the people skills to work on the clinic side, and that is a special combination.

Of course before you ever get to the operating room, or the consultation room for that matter, you will have met the front office staff. Their challenge is finding time for all of the administrative chores involved in medical recordkeeping while still devoting 100% of their attention to you.

When it all works as planned, I find time for interesting clinical research projects, blogging, teaching, and learning. There’s not a lot of “down time” around here, and we (or at least I) wouldn’t have it any other way.

innovating the future of plastic surgery

I am off to Hawaii in a couple of days for the annual scientific meeting of the Northwest Society of Plastic Surgeons. I know you feel sorry for me, but you have to give credit to the society for including the state of Hawaii as a member, giving us an excuse to go there from chillier parts of the Northwest in February. As it turns out, I will be working, and I am just now putting the finishing touches on two talks I will be delivering. The first has the high-falutin’ title “Integrating the Future of Plastic Surgery.” If you are a regular reader here you will know that I am interested in trends, new technologies and techniques, and how we can best bring these to our patients for their benefit.


What I am going to talk about is an approach to problem-solving called integrative thinking, defined as the ability to reconcile opposing concepts by creating a solution that has elements of both but is something new and unique. I look at it as involving both sides of the brain, uniting the rational, verbal, linear left with the artistic, holistic, creative right. Einstein described it well: “Invention is not the product of logical thought, even though the final product is tied to a logical structure.”

So what does this have to do with plastic surgery? Plastic surgeons are after all inherently creative people, the word “plastic” implying a flexible approach. No two cases are alike, and so plastic surgery is often more improvisation than cookbook recipe. But as techniques have evolved, certain standard approaches have become the norm, and once this “source code’ is out, any surgeon can learn how to do it. Plastic surgeons now compete with a variety of doctors from other specialties moving into plastic surgery for economic reasons. A related phenomenon is similar to outsourcing; just as your tech support person is likely to be in India, thousands of Americans travel overseas for discount plastic surgery. All of this is based on left-brain thinking and it has been tremendously successful. But because it is based on standards that can be taught and copied, it becomes difficult to contain, and some plastic surgeons feel that we are losing ownership of our own specialty.

I believe the key to continuing success in plastic surgery is innovation. Patients want (and deserve) less invasive procedures delivering more natural results with faster recovery. Creating the innovations that fulfill these goals requires tapping into the artistic right brain, and as Einstein said, tying it to a logical structure. Besides, it’s fun.

Is your avatar having more fun than you?

No, this isn’t about the movie Avatar but it isn’t about the original meaning either (in Hinduism avatars are incarnations of deities.) In modern times, computer games have brought a broader definition to the term, for an assumed identity with whatever characteristics are selected. In other words a sort of alter ego, a double identity.


What does this have to do with plastic surgery? I got to thinking about it reading the book Connected by Nicholas Christakis and James Fowler, about the way social networks impact our lives in unexpected ways. In the book they note that our appearance affects the way people treat us, a topic I have covered here before. Whether we like it or not, attractive people tend to earn more for the same work, attract more friends, and have opportunities presented to them that similarly qualified but less good-looking people do. What’s interesting is the research finding that avatars in online games tend to take on personality characteristics and behaviors matching their appearance, rather than the player’s real-life persona, and other players in the games react to the avatar's appearance in predictable ways too. If like me you don’t play online games, you may still have noticed this sort of thing at Halloween costume parties.

I think there is an element of this phenomenon in plastic surgery. Young people born with a large or crooked nose, for example, who have a rhinoplasty before going off to college often blossom from wallflowers into happy, socially active adults. Women often feel more confident after breast implants, and men after some lipo. Sure, it may be noble to learn to live with one’s genetic inheritance, but keep in mind that appearance affects others’ behavior toward us as much as our own.

What I have observed over the years is that most patients aren’t trying to become a glamour icon and start behaving like celebrities, they are just looking for an improved version of themselves. Plastic surgery for them really does help them fulfill their dreams and improve their lives, and there are scientific studies to prove it. Of course it is possible to have a happy and fulfilling life without either having plastic surgery or winning the genetic lottery for natural good looks, but dismissing the whole notion as vanity doesn’t acknowledge how powerful even a minor transformation can be for some. In the meantime, I will keep working on my techniques to make people 10-feet tall, blue skinned and capable of riding flying dinosaurs. Come to think of it, avatars of Vishnu are often portrayed with blue skin …

Lessons from the world's first plastic surgeon

Judging from some of the ads I see, you would have to conclude that plastic surgery was a recent invention, with any number of people taking full credit. But while it may be true that plastic surgery as we know it is less than a century old, its roots go back more than two millennia. While I was in India last week, I noticed that there was an exhibit at the National Science Center Museum highlighting an Indian physician and surgeon from the 5th century B.C. named Susruta, who preceded Hippocrates by hundreds of years. He was a teacher, healer, inventor of many surgical instruments, and developed a cheek flap procedure for nose reconstruction, without a doubt the world’s first plastic surgery. A variation of that is still used today.
So what does this mean for plastic surgeons today? For one, it is humbling to think of the long heritage of innovation and service that we inherit. It reminds us that we should try to create a lasting contribution to the specialty, and treasure the opportunity to make a lasting difference in our patients’ lives. Particularly during the holiday season, we need to remember that our talents are a gift. So while the poverty in India is indeed overwhelming, I am richer for the experience of having gone.

Bollywood Masala: My India Report

Inspired, perspired, impressed, depressed: like India itself, the operative word for my experience there this past week is “contrast.” No question India is worth seeing, not just because with 5 times the U.S. population it is by far the world’s largest democracy, but because despite all of its challenges it is doing a lot of good things. As it turns out, I was there on the one-year anniversary of 26/11 (November 26th), the terrorist attacks on Mumbai and other sites. India has comported itself well in the aftermath of that tragedy, and the commemorative observances were moving.
I was there to give a paper at the IPRAS meeting (International Confederation for Reconstructive, Plastic, and Aesthetic Surgery) in New Delhi. It was interesting to be on a panel with plastic surgeons from Brazil, Columbia, Iran, the U.K., and Portugal. The IPRAS meeting was more than just a meeting of the minds though, it was a source of inspiration in itself. Plastic surgeons around the world have long been able to put aside political differences between governments and work together in the interest of service. Through partnerships with organizations such as Doctors without Borders, and a new effort called Women to Women, IPRAS has fostered efforts to care for burn victims (mostly women) and children with birth defects, where access is limited either by cultural customs, lack of funding, or both. The challenge remains a large one, but encouraging progress is being made.
Of course there was some fun to be had, and seeing the Taj Majal is a worth the effort. We just missed seeing Ben Kingsley (Academy Award-winning actor who played Ghandi) there by a day. He is doing a movie based on the life of Mumtaz Mahal, the wife whose love inspired the Taj.

"Paint by Numbers" Plastic Surgery?

Lately I have been thinking more about the relationship of art and plastic surgery. What usually sets me off on this train of thought is an article or lecture by some expert who has developed an elaborate mathematical analysis of the approach to a particular operation. While there are circumstances where numbers are important (for example matching the base diameter of a breast implant to the dimensions of the patient) but they can be misleading just as often. Take the example of rhinoplasty (nose reshaping): there are standards that can be referenced for every angle of every part of the nose, so that an “ideal” result can be achieved. So what is wrong with this “cookie cutter” approach?

The answer is that there is no such thing as an ideal set of proportions that works on every face, or every body. Consider for example the actress Penelope Cruz: a mathematical analysis of her nose would likely show that it is too long, the angle from the nose to the lip is too acute, and so forth; but she is widely regarded (and I agree) to be one of the most beautiful women in Hollywood.

There have been some intriguing articles written where people are surveyed as to which celebrities have the best features; who has the nicest nose, the most luscious lips, etc. A computer program is then used to cut and paste all of these favorites into a composite face, which usually ends up looking fairly bizarre. This is why these canons of beautiful proportion have been routinely debunked, but they reappear on a regular basis nonetheless. I call it “paint by numbers” surgery, like the kits that help you reproduce a “masterpiece” by just painting in the designated color onto the numbered spaces. The thing is, they never quite look like the real deal either.

How does art inform plastic surgery?

I was at my regular life drawing group yesterday, and reflecting on how drawing relates to my "day job” of aesthetic plastic surgery. Plastic surgeons love to talk about artistry in their work, but it is actually a tricky thing to pull off. Surgery is partly a manual skill, but one that is fundamentally based on science. Art on the other hand is a "right brain” thing: more intuitive. At least that is according to Betty Edwards, author of the now classic work “Drawing on the Right Side of the Brain.” I had some interesting correspondence with her last year, as she had been invited to participate in a drawing course for plastic surgeons at our annual meeting and she was trying to figure out how plastic surgeons think. “Right brain” plastic surgeons tend to be less verbal during the surgery, as the verbal domain is on the left side.
In my view, the key is to be able to integrate both sides, truly blending the rational scientific side with the spatial, artistic side. It’s more difficult to do than it sounds, and it is something that I have consciously worked on over the years. But the artistic side needs to be freed up sometimes, just for its own sake. That is where the drawing groups come in. A little Mozart music, the model strikes the pose, and everyone just draws, saving the conversation for the breaks.
This right brain-left brain thing works both ways of course. Just as a surgeon needs to acquire a substantial base of knowledge in order to employ the best judgment about how to manage a case, artists need to study the techniques of the masters. And in both instances, the ability to envision the final result in the mind’s eye before starting is hugely beneficial. As my technical proficiency has increased with experience in performing surgery, my drawings have become more anatomically precise but perhaps less artistic. So it is a constant effort to keep the artistic side engaged in concert with the logical left brain. It helps me as a plastic surgeon and as an artist.
Check out a sample of my sketches here: http://www.baxterplasticsurgery.com/art_main.htm.