Why plastic surgery?

I often get asked this question when people find out what I do.

A lot of impressions of plastic surgery have been formed thanks to the popular media: you know which TV shows, magazines, and websites I'm talking about. People can't imagine why anyone would choose such a vapid life of handing out gigantic breast implants and wild nose jobs, dealing with superficial, looks-obsessed people, and feeding into unhealthy "addictions." And it surprises me when people are surprised to find out that life at Duet Plastic Surgery isn't exactly like what goes on at Nip/Tuck (yes, we are plastic surgeons; yes, there are two of us; yes, we do see patients together; NO, that is where any similarities end). . .

Plastic surgery is an incredible field, and it is a privilege to be a part of it. Neither Dr. Weintraub nor I can imagine doing anything else.

There is such breadth and depth to plastic surgery, which challenges your technical skill and artistic creativity every day. One day in the operating room can offer a remarkable range of stories: a small child who fell off his bike and needs his nose set back in the right place; a young woman who has saved money from all her summers as a nanny so that she can have breast surgery; a mom of two active boys who has lost 40 pounds through sheer willpower and can't wait to fit into "regular" jeans again.

Every day we are inspired by our patients, from the present and the past. Vivid memories of taking care of the tiny Guatemalan baby whose mother shed tears upon seeing her cleft lip repaired, the heartbreakingly charming 6 year old who survived the house fire started by his family's Christmas tree, the stoic young man who needed his fingers reattached after a shop class accident, the ecstatic silver-maned lady whose only regret was that she didn't have her breast reduction sooner.

It is amazing to meet these patients, to get to know them as people, to participate in their lives for a sliver of a moment, but to carry their stories in your heart forever.

The new year begins, for some of us

Every summer in any academic teaching hospital is punctuated with a little bang on July 1st. The traditional start date for nervous interns, tired residents, and anxious fellows, the first of July is when hordes of well-educated, hard-working physicians descend upon hospitals for a period of their lives marked by intense learning, teaching, and taking care of patients.

It's a very interesting time in the hospital: those last few weeks of June and the early part of July. Because interns, residents, and fellows turn over relatively quickly (due to the length of their programs, usually between 1 and 7 years), many of the hospital staff (who often sport pins rewarding decades of service on their scrub uniforms) turn a jaundiced eye toward the flurry of activity before the Independence Day holiday.

At the end of the "academic" hospital year, trainees feel good about their knowledge and skills; they've finally discovered their comfort zone and how to get into it quickly. They know their own duties and the expectations of their attendings ("attendings" = the veteran doctors who supervise, instruct, and mentor - all while doing their own jobs as physicians) so well by June 30th that it becomes a little disheartening to see the calendar tick over to July 1, because that means starting over.

But it's also exciting, to move on, to finish, to start something new. For some, that just means another year out of many checked off on the torturous route to the finish line. For others, it means a new life of freedom and (hopefully) a salary that lingers above the minimum wage for once.

Often, around this time of year, the media turn their attentions to this transition time in the hospitals. The pendulum of public opinion swings back and forth regarding trainees and patient care. There are some who would never think to have their care anywhere but a "name brand" Ivy League-type hospital; others look distrustfully at the thought of being "practiced upon".

Even the so-called experts disagree. Some think that community hospitals (where there are only attendings, no trainees) provide better care for patients, while others think that academic institutions are safer or more effective.

As someone who has been in both worlds, I would be hard-pressed to issue a sweeping opinion. I know so many excellent physicians - and they're not all in academic institutions or all in community hospitals. If it were a matter of making a medical decision for my loved one, I would want them to have the absolute best care, of course. But the "best" depends on so many variables: the patient, the problem, the specialists, the procedures, the location, the aftercare...

Honestly, I think that all else being equal, this is a situation to go with your gut. Seriously. Perhaps the most important thing for patients is to be able to trust their doctors - and you can't do that unless you feel comfortable with them, their staff, their hospital - academic or not.

A rare day

Last week, my husband and I found ourselves with some rare free time. Somewhat bittersweetly, we decided to head north to enjoy our state parks while we can. Above is a view of Tomales Bay from Pebble Beach at low tide. We discovered it was low tide when we had finished picnicking on the shores, and there wasn't much shore left to get us back on the trail...


We then avoided the crowds at Hearts Desire (what a fantastic name for a beach) and set out for Point Reyes. Since it's a national seashore, it's in no immediate danger of closure... but you never know. The drive there was in a word, bucolic.


Along the trail to Chimney Rock.


An incredibly beautiful, perfectly misty day.


We wrapped up the day with a great meal at Stellina in Point Reyes Station. We licked our appetizer and pasta plates clean. Their kale and salted tomato sauce pizza was one of the better pizzas I've tasted in the Bay Area, and the much lauded gingersnap-meyer lemon ice cream sandwich deserves the attention.

A little healthy competition

The day the aesthetic community has been waiting for with bated breath: finally, a competitor for Botox has entered the field. The "new" kid on the block is named Dysport (also known as Reloxin).

With the same active molecule as Botox (Botulinum Toxin Type A), Dysport has actually been used outside of the U.S. for years - for both neurological applications and cosmetic use. The FDA approved Dysport for cosmetic use in the U.S. in April 2009, and Dysport's distribution company, Medicis (the same folks who bring you Restylane and Perlane), began shipping product to physicians' offices a few days ago. And like Botox, Dysport was approved only for cosmetic use on glabellar lines (those pesky wrinkles between the brows), and with the same "blackbox" warning.

By all accounts in the medical literature, the efficacy of Dysport is similar to Botox; some anecdotal reports claim that the Dysport seems to "kick in" more quickly than Botox and that it lasts a few weeks longer on average. Close reading of the tiny print of the FDA medication guide, however, is more vague - no claims here about being any faster or longer.

Bottom line for patients? Hopefully competition will be good - Botox has long maintained a stranglehold on the effective treatment of glabellar lines, which left doctors and patients with no choice when Botox's parent company, Allergan, steadily raised prices every year. Broken down per treatment, it looks like Dysport might be up to 25% cheaper than Botox. We'll have to wait and see how Allergan responds to that...

A solution for "this"

A lot of people have been asking lately about how to do "this". What is "this"? You can visualize it pretty easily for yourself: in front of a mirror, take your fingertips, place them just beside your cheekbones, push in gently, and lift up.

Back in the day, there was only one answer: a facelift. All too often, that resulted in people not quite looking like themselves, and not exactly in a good way. The discriminating observer could easily pick out from a crowd who had been to which plastic surgeon, based on the "after" qualities of the face. The first generation of facelifts were often characterized by a tight, drawn look - as if features had been shaped by a surprise stop in a magically transformative wind tunnel. These facelifts were strangely popular, until they weren't.

Plastic surgeons, ever the perfectionists, weren't satisfied with the old way of doing a facelift. The old technique didn't really address the main culprit, gravity. Rather than pulling skin to the sides of the face (which was convenient in terms of hiding scars), surgeons developed new methods that more directly counteracted gravity's downward pull and addressed the soft tissues beneath the skin. That's what we use these days - a combination of techniques that minimize scarring, return volume to its rightful place, and smooth out the skin - without leaving you looking like a plastic surgery victim. But it is real, full-out surgery.

A lot of attempts have been made to capitalize on the public's hunger for quick, easy, cheap, painless, scar-free solutions for an aging face; sadly, the flashy new techniques (often with catchy brand names) haven't really panned out. I've advised family and friends, patients and new acquaintainces, over and over to be cautious - if it sounds too good to be true, it probably is.

There are, of course, a number of great "minimally invasive" procedures that can make small but significant improvements (e.g. Botox for certain types of wrinkles, or dermal fillers like Juvederm or Evolence to smooth out deep folds and creases - more details on these solutions in a future post). And never underestimate the power of a great skin treatment to take years off your face. But in the end, a lot of cases of "this" can only be properly addressed with good, not-old-fashioned surgery; there is no magical solution - yet.

Flying kites

There is a kite flying area at Shoreline in Mountain View. My husband and I discovered this after futile attempts to launch his homemade box kite in the fairly windless vacant lot near our home.

The wind, as you can see, was a bit more friendly at Shoreline yesterday.

We saw everything from wild dual-lined stunt kites to simpler cartoon-charactered delta kites, even an airborne pirate ship.


I've seen a remarkable number of rainbows since I moved to the Bay Area, but I wasn't expecting to see this one, on such a beautifully dry and sunny May afternoon.











Our elegant little box kite. The spool had 500 feet of string, and at one point, we had let it nearly all the way out.

The perils of climate change

As we lay the groundwork for opening Duet Plastic Surgery in 2008, we definitely felt the rumblings of change in the cosmetic surgery sphere. What may have been a very open and inviting climate just a few years prior was now being aggressively defended by overcrowded veteran practices. And if the rumors were to be believed, even those practices were looking for a way to get their hands back in the reconstructive, insurance-backed pot.

It was a little bewildering for us. While we were in school and training, we had observed a certain "circle of life" with regards to plastic surgery practices. Fresh, hungry graduates would hang up their shingle, take call at the local emergency rooms to sew up cuts on faces and fix broken fingers, hang around the established practices in hopes of snagging any "small" cases that the veteran surgeons were "too busy" to take, all the while building up a foundation for a cosmetic-focused practice. Once you developed that loyal client base, you were then able to shed the call and insurance cases for the next batch of up-and-coming surgeons. After a respectable career arc, you settled into the pleasures of retirement, allowing room for those young practices to flourish. This seemed to be the reassuringly predictable pattern for decades.

But as we were beginning to make our entrance into the real world, that once stable pattern had turned all topsy-turvy. Everyone - not just the expected competition from derm and ENT - we're talking about pathologists, emergency room physicians, pediatricians - was trying to make a "quick buck" by doing "cosmetic surgery". That hard-earned but dependable stream of income from taking plastic surgical call? Dried up, because veteran plastic surgeons suddenly wanted back in after decades of private practice. And the space cleared by the graceful exit of retirement-age physicians? It didn't happen, because 401k's and pension plans shriveled with the plunge of the stock market, and doctors were forced to stay in the job market.

This has certainly hit the Bay Area plastic surgery community pretty hard; and I can imagine that a lot of major metropolitan areas around the country are seeing the same thing, as this article in New York Magazine describes.

As you may have deduced, we weren't intimidated out of the fray. It may be a little tougher and it may take a little longer than if we had gotten started even two years earlier... But we honestly believe that Duet is different enough to distinguish ourselves from the rest of the crowd (hello out there - two female plastic surgeons, right here!), sturdy enough to outlast this rough economic time, and strong enough to succeed. I'll keep you posted.