Approximately half of my job is cosmetic plastic surgery of the face, breast, and body. Unlike reconstructive plastic surgery where the goals are more straightforward ( build a breast, close a wound ), aesthetic surgery does not necessarily have clear pathways or endpoints. Thus the question: What are we, as plastic surgeon and patient, really trying to accomplish with all of the potential operations and treatments out there?
First of all, we have to admit that no one actually needs aesthetic treatments, we merely want them. That want, however, is an important and justifiable one. For better or worse, our society has decided that youth and attractiveness are desirable. In one of my favorite books, Survival of the Prettiest, Harvard sociologist Nancy Etkoff documents what we find attractive and the competitive advantages attractive people have. So, in a rich society such as ours, that want becomes a relative need.
Okay, so these treatments can justified. Since they are elective, though, there is no excuse for lack of a clear goal undertaken with optimal conditions. What should that goal be, then? It is surprising how confusing that question can become for both patient and surgeon. The goal is not just getting injected with Botox, fitting in the largest breast implant manageable, or removing every bit of extra skin on the face or body. If we want the benefits of being more attractive, then that should be the goal of the treatment.. looking more attractive – not smoother, bigger, tighter, or whatever.
When I consult with a patient who is dissatisfied with a feature or body part, I try to determine what she would find more attractive, assess if this is realistic and aesthetically appropriate, and then decide how to get there. The path should minimize cost and risk while maximizing effect and longevity. Sometimes, my recommendations may run counter to what the patient was originally considering. I am not trying to lose a patient. With the understanding that I have the perspective of training and experience, I am just trying maximize the probability of having a happy patient who is satisfied with her improved attractiveness while minimizing risk of failure.
When considering facial rejuvenation, for example, treatment starts with good skin care and product choices with guidance from an esthetician. The next step may be Botox, fillers such as Juvederm or Fat, and laser treatments for skin tightening or uneven skin tone. The final step might be surgery, often starting with eyelids and ending with brow and facelifts. Occasionally, it may even be appropriate to redo a facelift. Always, the goal is not how much can you do, but how naturally attractive do you look when you are done. Sometimes, the answer is wait until you would optimally benefit from a treatment, do what may seem a more aggressive treatment earlier, or even do no treatment at all.
The thought process of what is attractive in the long term is also applicable to breast augmentation size ( Goldy Locks Theory- not too big, not too small, just right ) and large weight loss patients ( scars are an acceptable trade off for improved contour – but don’t expect to be “shrink wrapped” ) as well as just about every aesthetic need out there. My role as a Board Certified Plastic Surgeon is ultimately to help the cosmetic patient achieve maximal attractiveness while balancing risk and expectations.