JUDGMENT & EXECUTION   

Contrary to the implication of this article's title, what follows does not concern our criminal justice system. Instead, it concerns the judgment which a plastic surgeon employs to determine what plastic surgical procedure(s) is/are appropriate to a patient's problem(s) and the way that/those procedure(s) is/are undertaken, since many plastic surgical procedures can be undertaken in different ways or customized, if you will, to the patients undergoing those procedures.


In my last article for this publication, I talked about the timing of elective (non-emergency) plastic surgery, particularly cosmetic surgery, which usually is a judgment call, one in which both patient and plastic surgeon participate. If my own experience is any indication, many of my patients think that the timing of surgery is the only judgment call related to surgery. Too often I see patients who, by the time they visit me, are satisfied that they have diagnosed their problem(s) and have determined the surgical solution(s) which that/those problem(s) require. For example, I see many patients who, because of the redundancy of skin of their upper eyelids, which translates to a fatigued appearance, assume that surgery of their upper eyelids (known as Bilateral Upper Blepharoplasty) is the solution to their problem. In fact, many times redundancy of upper eyelid skin is a function not of changes in the upper eyelids but of ptosis (droop) of the eyebrows secondary to ptosis of forehead skin/muscle. The solution to such a problem is not Bilateral Upper Blepharoplasty (or at least not just Bilateral Upper Blepharoplasty) but instead Forehead (Brow) Lift, a procedure which admittedly is much more involved than is eyelid surgery but often produces more dramatic improvement in the appearance of the upper eyelids and additionally benefits the forehead, in terms of reduction of horizontal "worry" lines and vertical "frown" lines. In like manner, many patients who are concerned about their weathered facial skin assume, often erroneously, that the solution to their problem is a "Facelift". While a "Facelift" may benefit them, perhaps a more suitable solution to their problem is resurfacing of their facial skin, either by the use of chemicals or Laser which, in the case of the former, digests surface skin and, in the case of the latter, vaporizes surface skin, in either case resulting in removal of the imperfections (such as superficial wrinkles, blemishes, etc.) which populate that surface skin, thereby resulting in smoother, softer, even pinker or more robust looking skin.


Keep in mind that one of the roles of the plastic surgeon, particularly with regard to discussions about cosmetic surgery, is that of a "friendly critic". After I interview a patient about his/her cosmetic concerns, as well as related goals and expectations, and of course after thorough examination of the anatomic areas which bother him/her, I share with that patient my observations of him/her and my conclusions in terms of what aspects of his/her appearance can and should be changed. Once the cosmetic problem(s) is/are recognized and acknowledged by both patient and plastic surgeon, then the surgical solution(s) become(s) obvious to both.


One judgment call remains, though, and relates to the specific method(s) or technique(s) by which the surgical procedure(s) deemed appropriate for a patient's problem(s) is/are undertaken. For example, not all "Facelifts" are created equal. One "Facelift" technique may be designed to address only facial skin redundancy whereas another "Facelift" technique may be designed to address not only facial skin redundancy but also ptosis (droop) of facial fat/muscles. Furthermore, ancillary procedures such as Liposuction or use of fat or silicone implants to augment/enhance various areas of the face may be incorporated into the "Facelift" in order to address specific aspects of a patient's facial appearance. Common sense certainly suggests that, since no two people are alike (other than identical twins, of course), the surgical procedure(s) appropriate to one patient's face certainly may not be appropriate to another patient's face, likewise true of other areas of human anatomy.


Now comes the undertaking, or the execution, of the surgical procedure(s) upon which patient and plastic surgeon agree. Since any plastic surgical procedure, particularly a cosmetic surgical procedure, requires an investment of time and money on the part of the patient undergoing that procedure (not to mention an investment of trust in the plastic surgeon undertaking that procedure), the way that procedure is undertaken is of considerable importance. The choice of surgical instruments, the choice of anesthetics, the setting of surgery, the post operative care, immediately after surgery and also in the days, weeks, and even months following surgery, all contribute, positively or negatively, to the execution of any procedure. Needless to say, when I undertake any plastic surgical procedure upon any of my patients, I attempt to "structure" that procedure in a way which sets the stage for the most favorable result possible. While I cannot control that patient's age, genetic make-up, state of health, etc., all of which will affect the result, I can "manipulate" certain aspects of the surgery and recovery process to my patient's benefit.


Too often patients seeking the services of a plastic surgeon, particularly cosmetic surgery services, assume that all plastic surgeons undertake a certain surgical procedure in the same "cookie-cutter" way and, consequently, the consequences of that surgical procedure will prove the same from plastic surgeon to plastic surgeon. Nothing, of course, could be further from the truth. Judgment and Execution - two key components to a successful surgical experience.





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Dr. Richard T. Vagley, a Board Certified Plastic Surgeon, is Medical Director of The Pittsburgh Institute of Plastic Surgery and a Contributing Editor of Outpatient Surgery Magazine.

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