Questions From Readers

1. What is it like working in Cambodia?

I first came here twelve years ago to start a charity dedicated to repairing burn-injured children free of charge. I did form this charity and we have performed over 200 such operations. Fortunately, the volume at OPERATION KIDS has dropped off significantly due to a reduction in acid attacks.

 Along the way, I was asked, by ladies mostly at first, to perform cosmetic procedures for them. A few film stars here and singers there and soon my office had a modest but steady flow of patients from Cambodia and other countries in the region including Australia, Singapore, Hong Kong and France. Soon thereafter, U.S. citizens heard about me and started coming over for an amazing vacation and surgery at about one third the price.

Our patient population is about 40% locals and 60% foreigners.

As for the Cambodians, they are wonderful people. There are exceptions of course but the overwhelming majority are gentle, happy, polite, friendly, loving souls. As far as plastic surgery is concerned, I was pleasantly surprised to discover the extent to which female beauty is valued in the Khmer ethos. Again, this is present in all cultures but it is particularly pronounced in this part of the world where mostly Cambodians, Vietnamese and Chinese reside.

One small drawback of living here has been that it is not a particularly salubrious place to live. There is a lot of air and water pollution and if you’re not lucky, you can get some very nasty infectious diseases that you’ve never heard of in the west except for those of you who like to read obscure medical textbooks. This is merely an expression of the third world status of this nation and will improve with time.

Since the volume of OPERATION KIDS has decreased, however, I do plan to establish a presence in The United States soon; perhaps Florida or California.

 

2. Do you put the implants above or below the muscle?

This depends on the patient; in particular, how much soft tissue (i.e breast tissue) coverage they have.

Placement above the muscle generally results in a better cleavage because I can get the pockets very close together in the midline. With placement below the muscle, you are restricted by the medial insertion of the pectoralis muscle onto the sternum. Above the muscle placement results in breasts which are softer and easier to massage as well and there is far less post-op discomfort and a quicker recovery when the implants are placed above the muscle.

The one published drawback is that the incidence of a late complication called capsular contracture is greater with above the muscle placement. I have found this to be the case in my practice but not overwhelmingly so.

All of these issues are discussed in great detail when you come in for a consultation. You have the opportunity to look at hundreds of before and after photos before you decide on implant size, incision (infra-mammary, peri-areolar, or trans-axillary) and whether you want your implants placed above or below your pectoralis muscles and I will make recommendations for you if you wish. (Articles posted in this section go into these decisions in greater detail).

 

3. Please explain the “What” vs. “How” you referred to in an earlier post.

I’m glad you asked this because if my explanation of this most important issue was anything but lucid, I need to clarify it for you and any other reader who was confused.

Perhaps, I will explain by giving a few examples.

Suppose you are a film student. During the course of earning your degree, you will learn how to shoot a conversation between two characters. You will learn how to light your subjects with a simple three light system composed of a key light, a back light and a fill light. You will learn that the “master and two pops” as we refer to it, is the starting point to getting the scene in the can under severe time restraints and if you are afforded the luxury of more time (i.e. budget), you can get some close-ups and don’t forget those all-important reaction shots which can save you from that embarrassing 2 a.m. call from your editor.

If you were paying attention that day, you learned that a face-larger-than-screen composition can connote something about the characters thoughts. You learned how to most effectively compose the frame; what it means to shoot one actor from below the eye line and one actor from above it. You also learned that you should never shoot the two over-the-shoulder pops with lenses of very different focal lengths (30 mm and 100 mm for example). You learned what the 180 degree rule is and that you should almost never violate it. Maybe you learned something more about composition- in particular, the rule of thirds and nines- or maybe you knew this already (but you didn’t know what it was called) because of your superior aesthetic sense.  On other days, you learned about establishment shots, film speed, the three act format, breakdowns, treatments, tracking shots, tilts, and how to pick a young Jimmy Stewart out of a hundred kids who show up for a casting call.

Certainly, by the end of film school, you will know how to make a movie. Unfortunately, you will not necessarily know what to do.

If they could teach you what to do, every graduate of the AFI, or of UCLA or USC or any other film school would be as famous as  Speilberg or Truffaut but alas, very few are.

Knowing what to do is both a more rare and a more valuable asset than knowing how to do it.

 

 

Seeing the “what” and using the “how” to get to it…

 

Suppose you were not innately gifted in the arts but you want to be a sculptor and you go to school to learn how. At this school, you learn all about the equipment you will use when you graduate; the various hammers, their weights and designs, the different types of chisels, etc. You also take field trips to the quarry and become an expert at recognizing quality marble. You learn how to chip off the right size piece of stone by placing your chisel just so and hitting it with the appropriate force. In your first year, when the teachers asked you to produce a marble cube of a certain size, you were able to do it. As a senior student you were able to produce a near-perfect sphere.  At the end of your training, you certainly know how to sculpt.

 As your first commission, a family wants you to produce a pair of marble horses to adorn the gate at the entrance to their castle. Do you know what to do?

“Yes” you answer. “I know what to do. I will produce a pair of  magnificent horses rearing up on their hind legs”.

 

Now suppose a modern-day Leonardo Da Vinci comes strolling along. He didn’t go to sculpting school but he overhears the conversation you are having with the family and knows deep down inside him that he can do it. And so he somehow convinces them to give him a chance at the commission.  The owner of the manor agrees to award the fee to the man who can produce the most magnificent set of horses. Now who do you suppose will sculpt the most magnificent set? Leonardo may not know how to knock the right size piece of marble off the inferior block he chose, at least initially. But he’s smart and he’ll learn the “how” fairly quickly. The recent graduate on the other hand, already knows how. And he chose a better piece of marble. But if he does not possess the same degree of innate aesthetic sense, he is in serious trouble as regards being awarded this commission.

I guess what I’m saying is, Leonardo “sees the what” in his block of marble and will easily learn the “how” in getting to it. The recent graduate can’t see the “what” so it does him no good to know “how” to get to it.

As for plastic surgeons, find one who has a heightened aesthetic sense, who knows what to do, not merely how to do it.  Never forget that doing the right thing is more important than doing it right. For example, if the patient with upper eyelid sag really and truly needs a forehead lift, an average forehead lift will look better than a perfectly performed upper lid blepharoplasty.

Let me explain this last one briefly because I will probably get some e mails asking me to.

I wrote a book recently which was, essentially, a collection of essays. It’s called PHYSICS AND THE GOLF OF MATH MEDICINE. Here’s an excerpt which explains this concept:

Principle Number 2: Doing the Right Thing is More Important than Doing it Right

 In golf, choosing the right shot around the green is a more effective way to get the ball close to the hole (even if you don’t execute it perfectly) than trying to skillfully pull off a poorly-conceived shot. For the better player, choosing the right club from the fairway is more important than how solidly he hits it. 

It’s the same with plastic surgery. I don’t care how skillful you are, if you choose the wrong operation, you’re in serious trouble.   In reconstructive surgery, but particularly in cosmetic surgery, deciding what to do is the most important part of the entire process. If the patient needs an abdominoplasty and you do liposuction- even if you do it perfectly- its not going to look as good as a mediocre abdominoplasty job.  If you do an upper lid blepharoplasty when the patient needs a coronal brow lift- a very common error- you have done them a disservice. Never do a breast augmentation alone if the patient is in need of an accompanying breast lift.

Let’s say you play poker for a living. You walk into the “P” room at one of the huge casinos in Las Vegas.  Games are underway.  The place is bustling with excitement. You recognize some regulars, some fellow pros, some fresh-off-the-plane neophytes doing their best not to look like tourists…

What do you think is the skill or element most vital to your success in making money that night? Is it how well you bluff? Is it the cards you are dealt? Will it be the decision you make on that critical big-money hand; the decision to fold or hang in there?

It is none of those.

The most important decision you will make all night by far is simply deciding what table to sit at.

I didn’t know this when I was younger but I do now. I learned this principle by observing life, liberty and the pursuit of happiness over the last fifty years.

To a great degree, what you decide to go into as a career is more important than how well you perform at that career. This is not an absolute truth but, generally, it is true.

An average, run-of-the-mill hedge fund manager is worth tens of millions of dollars, far more than a one-in-a-thousand chemical engineer even though the level of intelligence is about the same.

Its even true in medicine. An average neurosurgeon will do much, much better than an individual who is in the top one percent of general surgeons. In other words, if you’re talking about money, what you decide to do is more important than how well you do it.

If you think that neurosurgery is technically more demanding and therefore deserves higher compensation, you are mistaken. Give me a skull saw, some cottonoids, some gel-foam, a suction apparatus and some aneurysm clips and I can do it all. Not really, but what makes one operation more difficult than another has nothing to do with its location on the body.  It depends on three things.

1. exposure; how easy it is to comfortably “get at” what you’re working on
2. the friability of the tissue; how fragile and difficult it is to work with and occasionally,
3. particularly in plastic surgery, artistic or design challenges that must be conquered spot on.

 

Some of the big general surgery operations such as an esophagogastrectomy are extremely difficult; much harder than any neurosurgery procedure. Even at The Massachusetts General, 40% of them leak. Heart surgeons will admit that some of the general surgery procedures they performed as residents were far more technically demanding than the coronary artery bypass grafts they perform after they switched specialties.

Neurosurgery is not difficult from an intellectual standpoint either especially after recent neuro-radiological advances; the various modern scanners and so forth. While general surgery is not particularly difficult to understand nor are orthopedic surgery or plastic surgery for that matter, I can assure you, you don’t have to be a brainsurgeon to be a brainsurgeon.

Now that I’ve offended everyone, allow me to take as a final example, one from everyday life that we have all experienced. 

Have you ever done something wrong to someone or hurt their feelings? If so, perhaps you were torn over whether or not to call them up and apologize. It’s understandable. Admitting you were wrong is not always easy. Maybe it’s best to forget it… But something inside you says: “No. Call that person up and apologize.”  And so you muster up the courage to do it. I submit that your clumsy delivery while apologizing to that person is of little importance.

If I had children I would teach them that “Doing the right thing is more important than doing it right” applies to everything in life, particularly as it pertains to issues of common decency.

 

So there you have it; my feeble attempt to answer the first three e mails I have received from this new website. If you keep sending them, I promise to keep answering.