Traveling for a smile

Some of my favorite moments in plastic surgery have been on medical mission trips. In previous posts, I've talked about the breadth and depth of plastic surgery, and I think that these trips have added sparkle to those dimensions. Most of the time, the focus is on repairing cleft lips and palates, but we always try to take on anything that comes our way.

Above is a scene from my 2007 trip to a tiny little town in Guatemala called Nuevo Progreso. A long flight to Guatemala City, followed by a long bus ride into the southwestern corner of Guatemala, up a narrow winding road to the Hospital de la Familia. The colorful crowd in the photo is an energetic yet serene assortment of patients and their families, waiting to be seen in the busy surgical clinics.


The photo above is from my 2007 trip to Guanajuato, Mexico. These little ones were enjoying a reception the staff throws for their honored patient-guests every year. The babies are always incredibly sweet and inevitably end up stealing your heart.

Partially sponsored by Smile Train, two intense days of cleft lip and palate surgeries were tempered by our gallant host, Dr. Abel de la Pena, who organized a fun international crew of surgeons.

A few satisfied customers in Mexico. It is such a privilege to be a plastic surgeon, and you never feel it more intensely than on these trips. For more photos, including some of Dr. Weintraub's trip, you can click here.

I am very excited to be going on another cleft trip soon, this time to China: two weeks at a hospital in Hunan province, with a team of almost forty American medical providers and about twenty more local Chinese staff. There were rumors of internet access, so I'll keep my fingers crossed on being able to blog from the trip.

Some of you might wonder, How is there time for me to spend two weeks in China? I would be tempted to respond, How is there not time?

I am very grateful to Dr. Weintraub and to our shared philosophy of giving back at Duet Plastic Surgery. We fiercely believe in the good that these mission trips achieve, and we have chosen to incorporate its spirit into our practice.

Why private practice?

Another popular follow up question is, "Why private practice?"

There is a long answer to that question. Here's a somewhat condensed version:

Jennifer and I had been talking about the idea of "Duet Plastic Surgery" for years. We met when we were medical students, interviewing for plastic surgery residency positions. Luck (and frankly, a lot of hard work) brought us together at Stanford, and we developed an amazing friendship through the trials and travails of residency.

Our training created a hard edge that neither one of us liked, and we both were afraid that it would become permanent if we continued our careers in an institutional behemoth of a hospital. We were also dying for some modicum of freedom, which simply was not an option during surgical residency.

But those difficult days also brought us hope - I can't tell you the number of times female patients have sighed in relief when they saw a woman surgeon come through the door. We female plastic surgeons are still a rarity, even though the vast majority of plastic surgery patients are women.

We felt that there was a definite need - many women are curious about plastic surgery but are not comfortable discussing such private and personal matters with the stereotypical older male plastic surgeon. We embodied a different perspective - and aesthetic - as women; there is something to be said for truly understanding a woman's psyche and physical being, inside and out. We also strongly believe in finding flexibility and balance, not just in our work lives - by giving back through medical missions and volunteerism, but also in our personal lives.

And so, flying in the face of the conventional wisdom and advice offered by those very same older male plastic surgeons, Duet Plastic Surgery was born.

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.