Your Plastic Surgery Questions, Answered

Dr. Michael Zenn.

We recently solicited your questions for Dr. Michael Zenn, a plastic and reconstructive surgeon at Duke University Medical Center.

Of all the reader-generated Q&A‘s we’ve run on this site, this one definitely wins the award for the greatest exceeding of expectations. Your questions were far more interesting and diverse that I could have imagined, and Zenn easily rose to the occasion.

Although he “dreads” talking about his profession at cocktail parties, his good replies here will go a long way toward demystifying an industry that generates more than its share of noise and nonsense.

Thanks to Zenn for his answers and to all of you for your interesting questions.

Q: Why does it seem like plastic surgery is becoming more and more affordable with better technology, but the opposite happens for the rest of medicine?

A: Like most things, the cost of cosmetic surgery continues to increase over time. Likely due to reality TV, plastic surgery has become more mainstream and is not something people feel they need to hide.

Therefore we simply hear more about it now — too much for my taste. We are also seeing an exponential increase in the number of cosmetic surgery suppliers — in many specialties and even in non-MD’s. Buyer beware! Cheap prices may reflect a lack of training and board-certification.

Q: What is the industry’s consensus on television shows that portray plastic surgeons?

A: We don’t like them. They are meant to be over-the-top for higher entertainment value but too many people believe everything they see.

Q: Does your profession give you an inclination to regard people as walking fix-up lists, or are you able to mentally leave that at the office?

A: I am able to leave the plastic surgery in the office. It is others who don’t let it go.

I dread being at a cocktail party and someone inevitably asks the question, “What do you do for a living?” Next.

Q: On Wikipedia, the average salary for plastic surgeons is much less than I’d expect. What separates the heavy hitters from the bat boys?

A: The majority of plastic surgeons perform reconstructive surgery and cosmetic surgery. We enjoy balance and the full spectrum of patients and especially like the feeling of helping someone in dire need of reconstruction from cancer, trauma, or birth defects.

Unfortunately, reconstruction means accepting what insurance pays and if you have been reading the papers lately, you know physician reimbursement is heading down. Cosmetic surgery, on the other hand, is not based on insurance.

For busy surgeons like myself, my OR time is always full. I simply cannot do more cases than I do. If I get less and less money for the reconstructive cases, the only way to maintain or increase income is to drop reconstructive cases for cosmetic cases. The heavy hitters you refer to — 100 percent cosmo. Many plastic surgeons would prefer to only do reconstructive cases if payment were equal.

Q: If it were up to you, should certain types of plastic surgeries be covered by Medicare/ Medicaid?

A: Many surgeries are, but not nearly enough. Insurance companies often insist that surgery should treat a functional problem, not a cosmetic one. However, the distinction is not as black and white as they would like and there is a large gray area between the two.

We might all agree that a woman who is a C cup and wants to be a D cup should not be covered by insurance, but what about an 18-year-old girl who has one B cup breast and one D cup breast? Many would argue that this scenario creates a functional problem that is hard to describe as only cosmetic. What about a woman who has had a mastectomy and wants a reconstruction? Cosmetic?

It took years of fighting with insurance companies to get the breast cancer patients covered by law. Currently, official plastic surgery is trying to do the same for kids with congenital deformities.

Q: Where do you draw the line and refuse to perform the type of procedure that your patients request?

A: Whenever a patient is unrealistic in their expectations, no good will come from a surgical procedure. People who want a procedure and simply are not candidates do not get a procedure. Liposuction in a morbidly obese patient is a good example. Breast augmentation for a woman who already is a DD cup is another.

With some procedures like rhinoplasty (nose job), I will morph an expected result for a patient and based on their response, I will might refuse to do it.

Q: Can you easily spot someone who has had some sort of cosmetic procedure? Do you ever walk into a room and all you can see are incisions and collagen and price tags?

A: Any plastic surgeon worth his weight can spot someone who has had plastic surgery — after all, this is what we do for a living, folks. Like most professionals, I can appreciate a job well done or chuckle at a job overdone.

Q: Are plastic surgeons as squeezed by malpractice insurance and HMO’s as other doctors?

A: We most certainly are. A practicing plastic surgeon is sued once every three years on average. Malpractice for some plastic surgeons is so high (over $100k for some in New Jersey) that they choose to pack up and leave the state.

States with tort reform that limit damages in malpractice cases (Texas) have seen an influx of plastic surgeons. The squeeze problem I often have with HMO’s is that they often refuse to cover many worthy procedures they deem “not functional.” It is sad that there appears to be no accountability for those who make these decisions and patients often play into their hands by giving up in frustration.

Q: Do you foresee a time when the rates of plastic surgery for men catch up to those for women, or at least are close?

A: Never. Wrinkles, bulges, bald spots — most men don’t care enough to ever do anything about it. Interestingly though, as the workforce ages and more and more men are working longer, we are seeing more men having surgery to look younger — to help stay competitive in the workplace — for right or wrong.

Q: Which procedures are most common among men?

A: Liposuction of abdomen and love handles, blepharoplasty (eyelift), and facelifts.

Q: Do you think more people would be willing to try cosmetic surgery if some services were offered as outpatient rather than inpatient procedures?

A: Every cosmetic surgery procedure that I perform is outpatient. You come and have the surgery and go home the same day. You do have to return in the morning for a check up. This is how most plastic surgeons operate. If you go to a really upscale practice, you may have overnight accommodations — some rivaling the Four Seasons — but you will pay for it.

Q: What age is too young for plastic surgery?

A: This is controversial but I would say anything under 18 years old. Younger for congenital deformities, but there is something to be said for letting an adult make a decision for themselves. I have yet to see to a cosmetic “emergency” that needed a procedure STAT and couldn’t wait a year or two.

Q: Is there actually a difference between the wrinkles and harm caused to your face if you spent the time in the sun underwater or if you spent it just laying on the beach? I saw amateur snapshots of Mark Spitz taken in 2007 and he hardly looks skin damaged.

A: No difference — same UV rays. In fact, being in water in the sun likely exposes you to more UV due to reflection off the water. How did Mark Spitz escape the sun damage? Indoor pools.

Q: Would you endorse cohesive gel instead of silicone due to the concern over safety issues of silicone? Or do you believe that was all just hoopla? Is it true that breast implants should be redone every 5 to 10 years?

A: Today’s breast implant options are saline or silicone. Saline implants are a silicone shell filled with salt water, silicone implants are a silicone shell filled with cohesive gel. Both implants are equally safe, both have the same safety profile.

The Institute of Medicine found that much of the concerns were hoopla — except for the problems that they both have: rupture, scarring, and infection. Most plastic surgeons and patients will tell you silicone just feels better. Implants are replaced when one of the above problems occurs — about 35 percent will have something fixed after 5 years.

Q: What procedures are most likely to result in “I’m so glad I had it done!” and which tend to give rise to “What was I thinking?” regrets?

A: Most patients who are well informed and are realistic about their procedure are happy they did it. Those in the unhappy crowd often have had procedures with the terms “short scar,” “no downtime,” or “lunch time” attached to them. There is no free lunch.

Q: How have you changed as a plastic surgeon over the course of your career? Have you developed a better sense of who will never be satisfied with their outcome?

A: As you mature as a surgeon, you develop a better sense what you can and can’t do. You also can be more selective in the patients you choose to operate on. I’m not sure we get any better at knowing who will and who will not be happy.

Q: Does plastic surgery always produce a scar which must be hidden?

A: Always.

Q: How does plastic or reconstructive surgery compare to other specialties in terms of research grants? Is there good incentive for medical students to be interested in the field? Do you think that negative perception could cause highly successful students to choose another specialty?

A: Plastic surgery is still a relatively small specialty so percentage of research dollars is small. That said, some of the biggest thought leaders in things like transplantation and stem cell research are plastic surgeons.

Medical students who are exposed to the amazing breadth and challenge that plastic surgery represents are often stimulated to pursue it. Unfortunately, many medical schools are at institutions without a plastic surgery program and only get exposed to reality TV.

Q: What is the best bargain in plastic surgery? Which procedure would give most people the most satisfaction and improvements for the amount of time and money spent?

A: Harder to answer. It really depends what it is that bothers you. Taking all comers, botox for certain wrinkles is the best bargain. It eliminates the wrinkles for up to 4 months and does not require any surgery and therefore downtime.

Q: Have any “microsurgical” procedures been justified economically? What is the “microsurgical” advantage for the unemployed, retired, and children? Does Medicare recognize any premium for this?

A: Microsurgery is not experimental and has been shown to be both efficacious and cost saving for many problems.

Microsurgical reconstruction can save limbs, give back lost function, and limit the downsides of the traditional multi-step reconstruction. Compared to traditional procedures, microsurgical procedures are compensated higher, as the amount of work and the degree of specialization required are higher. Even Medicare will cover some of these procedures, but may not tell you until after your surgery.