Here’s a blog by our own Dr. Shenker, where he explores his early perceptions and the truth he knows now about plastic surgeons.
Once upon a time, a long, long time ago as a medical student contemplating my future career, I thought plastic surgeons were the happiest of all the different subtypes of surgeons.
Why did I think that? Through the eyes of an aspiring medical student, plastic surgeons seemed to me to have a great thing going on: they didn’t have to operate in the middle of the night on stinky perforated bowels like the general surgeons. They didn’t have to spend every weekend in the winter fixing hip and wrist fractures like the orthopedic surgeons. They didn’t do the same operation over and over and over and over again, like ophthalmologists removing cataracts all day. And they didn’t have to sadly say to patients “there’s nothing we can do” like the neurosurgeons have to do all too often.
Dr. Shenker on one of his first days in the OR at TCSC.
Plastic surgeons also seemed to have fewer on-call requirements. And the emergencies they did have to treat were rarely the “drop everything and race to the hospital” types of emergencies. Plastic surgery patients rarely, if ever died. And the surgery plastic surgeons did was just so super cool! As a medical student, there were so many reasons to think plastic surgeons were happy.
Was I ever wrong.
A month ago in late September, I attended the annual meeting of the Canadian Society for Aesthetic Plastic Surgery (CSAPS), in Toronto. I have been a proud member of CSAPS for many years, and the CSAPS annual meeting is always one of my favourite meetings of the year. This year I even had the privilege of moderating the breast surgery panel discussion with my brilliant colleague from Kelowna, Dr. Brian Peterson.
As I sat through this year’s meeting next to my surgical scrub nurse Patti, it occurred to me that I have never heard such a bunch of self-critical and frustrated surgeons in one place at one time as at that meeting! I realized that I hear the same self-deprecating, miserable pattern of complaining at every plastic surgery conference I attend. Plastic surgeons aren’t happy at all! It was eye opening and… it made me fall in love with plastic surgery all over again.
Let me explain what I mean.
At the CSAPS meeting, like at every plastic surgery meeting, I heard expert, experienced and world-renowned surgeons say that they were unhappy with many of their results, and, despite decades as busy surgeons, still had no idea how to do with perfection the operations that they do every single day.
I heard these surgeons say, with what I would swear was a tear in their eye, that the incredible results they showed could have and should have been just a little better, higher or tighter or perkier or bigger or smaller or longer-lasting or more natural appearing or easier to recover from.
I heard these surgeons say that they did a particular operation one way for years, then completely abandoned their favourite technique for a very different way of doing it because they realized that it could just possibly be improved.
I heard them say that despite being an expert in their field, most of the time they still don’t get their operations to be perfect. They stood at the podium in front of their peers from around the world and criticized themselves.
I never hear non-plastic surgeons doing that.
Plastic surgery, and especially aesthetic plastic surgery, is a field of never-ending frustration. There is an infinite search for tiny, incremental and yet meaningful improvements in surgical planning and technique. There is a never-ending search for new instruments and technologies that yield ever better results for patients.
I may be wrong, but I don’t hear about general surgeons saying that they should have removed that last appendix just a little bit better. In fact, the incision site for an appendectomy has not changed since Dr. McBurney described it in 1889. I don’t hear urologists saying, if only the scar from the kidney transplant operation was 3 mm shorter, the patient would have done better. And the orthopaedic surgeons just want someone to invent a better hammer.
But plastic surgeons are constantly engaged in a near-existential struggle to improve every single minute detail of every single part of every single operation every single time we do it. There is no end to the details we sweat over. We twist ourselves inside out over every aspect, starting even before we get to the operating room, with our choice of skin marker when we draw our preoperative markings. Should we use a black or red marker? Fine point or medium? Which ink will hold up better as the skin prep solution is applied? Should we use pattern templates and rulers for the markings, or draw our surgical plans free hand? Should the new areola on the breast be 36mm wide? Maybe 38mm is better? Or maybe 40mm? Or maybe 40.25mm? Should the belly button we make in a tummy tuck be oriented vertically, or horizontally, and if vertical then, how vertical??
Then we engage in a debate worthy of Aristotle over the exact location of our incisions. Should the face lift incision be in front of the tragus of the ear, or behind it? Should it extend to the hairline behind the ear? Should the breast implant go in through a 3 cm incision centered on the inframammary fold under the breast, or just slightly to the outside part of the fold? Or the inside part of it? Or somewhere just in between the in between part? And don’t get me started on the competition over who can get the best results with the shortest possible incision. We beat ourselves up when any of our incisions are even one millimetre longer than it needed to be.
During our procedures, the struggle continues: Are the soft tissues better held with permanent or dissolving sutures? Should the dissection be done with the scalpel or the electrocautery? In my operating room, we even debate the best type of forceps to use to handle the skin!
Our collective agony does not end when our patients leave the operating room. The postoperative follow up visit brings new levels of self-recrimination, even when our patients are ecstatically happy with the results. Maybe I should have used more fat graft in that mastopexy procedure? Would a full projecting implant have been better than the moderate projecting one I chose? Did I leave too much skin on the right upper eyelid compared to the left? Maybe thirty seven more millilitres of liposuction fat removal in the left hip area would have made the result just that much better. Did I lift the eyebrow high enough to allow for the inevitable tissue relaxation inherent to the patient’s skin, which I should somehow have been able to predict when I saw the patient preoperatively? HOW DID I EVEN PASS MY PLASTIC SURGERY EXAMS ALL THOSE YEARS AGO??? AAAARRRGHHHH!!!
And on and on it goes.
Over the course of my career so far, I spent a great deal of time reflecting on the brilliant but seemingly unsatisfied plastic surgeons who speak at CSAPS and the other international conferences I attend. Like all plastic surgeons who struggle for the best possible cosmetic outcomes for our patients, I too expect every operation I do to be nothing short of brilliant, every single time. And even when my patients are happy beyond measure with their results, I too am frequently left wishing for more.
Once, many years ago, I heard one of the greatest plastic surgeons of our time say in front of a multinational audience of plastic surgeons, that over the course of his entire career that spanned more than 50 years, he had never done a perfect operation. Not even once! At the time I was flabbergasted to hear such a brilliant surgeon utter such an unexpected and impossible statement. But now, almost exactly 18 years after I opened the doors to my own clinic, I get it. Plastic surgery in general, and aesthetic plastic surgery in particular is a heart-breaking pursuit of the unreachable. Aesthetic and technical perfection in a plastic surgery operating room is a concept we train for, crave, dream about, and plan for, and ultimately resign ourselves to chase unsuccessfully for our entire careers.
And I would not have it any other way.
