Body Revisionists: San Diego's plastic surgery industry

Plastic surgeons who cut and clip and nip and sew skin tell why they do it.

San Diego has the second highest concentration of plastic surgeons in the United States, trailing only San Francisco. This I learned from Dr. David Wolf, who heard it at last year's national meeting of the American Society of Plastic and Reconstructive Surgeons. Even if that ranking isn't precise, a look in the phone book confirms that this is a plastic surgical mecca. Full and half-page ads shout of ear reshapings, tummy tucks, skin rejuvenation, eyelid surgery, nose jobs, and more. Complimentary Initial Consultations are the norm and there's Financing Available! In the Pacific Bell Yellow Pages, I counted 126 local physicians offering at least some of the tricks of this trade.

The competition was already building when Wolf opened his practice here in 1981. He was drawn to La Jolla, ""easily the most dense place in San Diego as far as the number of plastic surgeons,"" because ""I like challenges,"" he told me. ""Being sort of arrogant, I figured I was the best. I felt I might as well go where people said, 'Oh, you'll never make it.' ""

Nowadays Wolf is busier than he'd like to be. The day of our interview he was running about 50 minutes behind schedule. A young, delicate-looking blonde sat in the waiting room, having just filled out a patient questionnaire that rested on the sill of the receptionist's window. It revealed that she was considering a nose job. Among her previous plastic surgeries, I noted, were a breast augmentation, liposuction, and dermabrasion.

Some plastic surgeons' offices rank among the fanciest quarters in medicine: marbled or plushed or chromed or otherwise decorated with an intensity that launches them into another orbit - one inhabited (one would imagine) by rich, tasteful patrons, rather than sick people. Other plastic surgeons' offices are more restrained, and Wolf's, located in one of the big medical buildings next to Scripps Hospital, is one of the latter. A nubby, neutral fabric lines the walls and the floors are parquet, but this is a typical doctor's office, upscale but unremarkable.

When Wolf finally burst into the waiting room, he apologized for the delay, then plopped down on the sofa. He's 47, lean and athletic and alert. He wore no white coat, just a buttoned-down shirt, silk tie, and pants under which could be seen a pair of highly polished black cowboy boots. ""One of my patients recently saw the boots, and he asked me, 'Are those just for show, or can you ride?' I said, 'Look, I'm from Texas. I better be able to ride!' ""

His Texas accent is still unmistakable. "There were no doctors in my family. We weren't friends with any physicians. Yet I always knew I was going to be a doctor. From really young. It never changed."" He says as soon as he entered Tulane University's medical school, "It was apparent there was a group of medical students who were very interventionist-prone. Who were more aggressive. They liked to be in charge. They liked to be in surgery. And I was one of them." The memory comes to him that on the first day of school, ""They showed us this really gross movie. The name of it was Radical Hemimaxillectomy with a Nucleation — which is basically taking off half a face. I still am not quite sure why they showed us it. But about half the class got sick and left. And the other half became surgeons!""

Wolf says for him the choice of plastic surgery was also very easy. "It seemed the most complete of all the specialties. In general surgery, all the stomach surgery was being reduced because of Tagamet and other medications that were coming out." Chronic, intractable ulcers that previously had to be excised were becoming a thing of the past. And a lot of [the general surgeons'] vascular surgery was being taken over by vascular surgeons. It was a decreasing specialty as far as I could see.

"Cardiac surgery was not that interesting because they basically did one operation the majority of the time. Neurosurgery was sort of depressing because they worked on kids. I don't mind working on kids. I just don't want to work on kids who are dying. I like kids too much."

"Urology was sort of boring. You know, looking up the bladder wasn't all that interesting. Ob-gyn was boring. So, of all the fields, plastic surgery was sort of neat because it could do it all. People think of just cosmetic surgery. But plastic surgery surgeons are trained in microvascular surgery. We're trained in hand surgery. We're trained in head and neck surgery -- for cancer of the head and neck. We're trained in major soft tissue injuries, in burns, in cleft lip and palate work. Cosmetic is one of just eight or nine fields we're trained in."

Before Wolf received all this specialized training, he spent three years in the Navy in San Diego (from 1972 to 1975). Then he returned to New Orleans and studied general surgery, a standard preliminary step for aspiring plastic surgeons. After five years of this, he went on to three years of plastic surgery training in San Francisco, then moved to La Jolla. Despite his initial cockiness, starting a practice in the cosmetically crammed area ""tuned out to be a tough nut to crack. It took me a while to get busy,"" he says.

Wolf says he built his business by assisting other plastic surgeons and covering for them when they went on vacation, as well as serving as a backup doctor for emergency rooms all over the county, "riding the circuit, we call it," he said, smiling. he says he didn't do any advertising until after he was established. "I was a bachelor and there was a magazine I'd never even heard of, called San Diego Woman, that had me as bachelor of the month. I was sort of tickled by it all. I got so many letters, I was amazed! I got hundreds! And I figured, 'You know, somebody must read that.' I've put a couple of very low-key advertisements in there."

An even more effective way for plastic surgeons to generate business, Wolf suggested, is to cultivate a busy social life. "There's a plastic surgeon in this building who has carried socializing to an art form. I've never been to a party he hasn't been at. And as a result, he's become very popular. The trouble is that I would much rather wear some jeans and cowboy boots and be out either riding or barbecuing with some friends or playing with my kids [from a previous marriage]. Something laid back. I can do [the socializing], and every once in a while I break down and go to parties, and it's funny because I see a lot of people I know. But it's not something I really love doing."

Do people come up at parties and start talking about procedures they might have done on them?

""Oh yeah, all the time. They sort of want to pick your brain and get an idea. You can either take offense at it or be amused. I prefer to be amused. People just want to know. They're curious. And there's a lot of misinformation too. Unfortunately, not everyone who calls himself a plastic surgeon is a plastic surgeon."

This was a reference to the hodgepodge of doctors who do cosmetic procedures. In the largely unregulated field, all you legally need to perform any such procedure is a medical degree. Some doctors choose to undertake plastic surgical residencies and take board exams, the oldest and most widely recognized being those administered by the American Board of Plastic Surgery. But some self-described plastic surgeons skip this certification process. And doctors in other specialties also jump into the fray. Ear-nose-and-throat specialists commonly do nose jobs, for example. Many dermatologists do chemical peels and liposuction; ophthalmologists sometimes excise fat pads around the eyes (a so-called blepharoplasty, or eyelid surgery).

Wolf categorizes the overall quality of plastic surgical work in San Diego as "very mixed." He says, "We have some superb plastic surgeons. We have some plastic surgeons who are okay, but I probably wouldn't be real enthused about having them operate on my family. There are actually some non-plastic surgeons who do nice work, and then there are some who are really dangerous... I spend about a quarter of my time repairing other people's screw-ups."

On the coffee table in Wolf's waiting room rests a volume bound in brown leather that contains graphic evidence of how plastic surgery can go wrong. At one point, Wolf flipped to a page containing before and after pictures of the victim of two previous facelifts, one botched just the month before the photo was taken. ""This was done by another La Jolla plastic surgeon."" Wolf explained, ""He was a little bit older man who was not doing the deeper work that makes so much difference. He's managed to move the hairline up a lot [not a good thing], and the scars were way out here."" This man had actually created a divot, or "witch's chin," where none had been before.

For the corrective work, "I turned a liability into an asset," Wold bragged. "I used some of the fat here on the witch's chin and rotated it back as a flap, to fill in this crevice back there." The woman in the ""After"" picture is smiling broadly, freed by Wolf's scalpel from the indignities inflicted upon her by the previous man's incompetence.

Wolf pages to the back of the volume, where several bearers of oddly misshaped noses stared forlornly from photographs. "Unfortunately, not all of our colleagues do good noses, so I see a lot of reconstructive work, where I get a chance to redo it. Look." He singled out a photo of a woman with long blonde hair, her ethereal beauty marred only by the strangeness of her olfactory organ. It slopes down into a wide base, and on the left side protrudes a bump that resembles a huge and permanent mosquito bite. The view from below, looking up at her nostrils, shows them to be twisted into two bizarre, dissimilar shapes. "This was a relatively normal nose until he operated - just a very poor surgeon unfortunately,"" Wolf commented. "I used ear cartilage to basically rebuild it. Ear cartilage works very well for that.""

I asked Wolf is every plastic surgeon gets bad results occasionally.

"Everybody. It may be that you misevaluate the way something is. For instance, you look at something and think, 'Gee, this is the main problem,' and it turns out there was an additional factor you should have thought about. Or you were trying something new that you heard about somewhere or read about in a paper, and it wasn't a good idea. Or it's just that you were having a terrible day. 'Cause those happen. They key is to keep them to an absolute minimum and when they [do occur] to stand by your patients and say, 'Look, this is not as good as I wanted. I think we can improve on this. If you'll bear with me. But you should just walk away from anyone who says, 'I never have any problems.' I've repaired patients of every plastic surgeon in this area. And I'm sure that some of them have repaired some of mine."

Wolf mentioned another sort of error plastic surgeons are subject to. ""Every once in a while, we will all operate on someone for the wrong reason. We'll operate on someone because we think we can get a great result, even though you sort of sense the patient is not happy with themselves. Even when you get a great result, it doesn't take too many of those to make your life miserable. What they're looking for is someone to make them feel good about themselves. And plastic surgery won't do that.""

It can produce other magical transformations, however. Wolf sprang up from the sofa to get from his assistants another album, the first such book he ever assembled. ""I kept out the gory cases because I didn't want patients passing out. But even so there's some semi-gory stuff here,"" he said with something akin to enthusiasm. ""The least gory is probably this one right here."" A face, its sex indiscernible, confronts the camera. Colors not normally associated with human skin - eggplant purple and angry reds - cover it. Swelling has closed both eyes.

""This is a very pretty girl who was in a motor vehicle accident. A drunk driver hit her."" Wolf explained that while the left eye was merely blackened, the right one had suffered much more serious damage. ""The globe itself was fine, but all the bones around it were fractured. The whole casing, the whole support, was gone. The eye was resting so low that she would never be able to see out of it again. But what I did is I used bone grafts to build this whole area. So this is her afterwards." In the second photo, her skin looks inviolate, unscarred, and her almond-shaped sky-blue eyes appear to be completely normal. "Her eyesight is perfect," Wolf announced. "I actually used this as a board case [for certification]. You have to give these cases and defend them. The fellow who was testing me looked at this and said, 'You really did this?' I said, 'Yes, sir,' and he said, 'I couldn't do this.'"

The album is stuffed with similar reconstructive miracles, the ""most gratifying cases,"" in Wolf's assessment. These days, however, he estimates that they constitute only perhaps 20 percent of his work load. The rest of it consists of cosmetic cases such as those displayed in tow volumes on the coffee table. Devoid of gore, these make for fascinating study nonetheless.

In the front of the "Facial Surgery" album, Wolf has placed the facelifts, that venerable procedure in which the surgeon makes a shallow cut on both sides of the face, from the temples down around the ears, looping up in back of them, and then trailing off into the hair. With the edge of the facial skin detached, it can be lifted up from the substructure, allowing the surgeon to tinker under it like a mechanic puttering under a car hood. He can reposition muscles and connective tissue; suck out fat from the jowls or below the cheeks. The skin is then draped back upward, the excess snipped off. It's common for a facelift patient concurrently to have a blepharoplasty (fat pads around the eyes cut out) and/or to have a browlift (a cut in the scalp or behind the hairline in which the forehead and/or eyebrows are lifted upward, with extra skin excised).

Wolf drew my attention to the very first set of pictures in the book, in which the woman had a facelift, browlift, chin augmentation, and lower blepharoplasty. "This was a woman from New York who works for a Fortune 500 company."" She flew out and told Wolf he had done a friend of hers whose results she admired; now the executive had two weeks to devote to her own surgical remake - and an unlimited budget. (Wolf charges $5800 for a facelift alone.) ""Before,"" the photo depicts an imperious, if rather blowsy looking matron. Above her eyes, the skin has sagged, and age has sculpted a series of lumps and mounds into the lowermost portion of her face. Seen in profile, the chin retreats into a fleshy triangle.

In the ""After"" shot, she certainly couldn't pass for a teenager - but it's difficult to say why not. All the facial pudginess has disappeared. The very shape of her eyes seems to have changed, unveiled as they are from the skin that had collapsed down on them. Her jawline has been radically simplified, into a single clean contour, and all the tangle of excess flesh below her chin has been removed. Perhaps most astonishing is Wolf's assertion that the second picture was taken just two weeks after the surgery. ""She was getting on her company plane to fly back.""

On the next page is a photo of a ""very nice, socially prominent lady,"" Wolf explained. ""But you can see, she looks angry [in the ""Before"" photo]. And she's really one of the nicest women possible."" The picture taken after her facelift, browlift, and dermabrasion shows the long, deep wrinkles around her mouth to be thinned out considerably, the brows tugged upward, out of their involuntary frown.

The facelift photos transfix me. I can't see even a scar in any of them - let alone any hint of the bleeding, the bruising, the swelling inevitable when you let someone cut open your face and remove parts of it (or add some, in the case of chin and cheek implants). Instead the ""After"" people (women mostly, but some men) look...lucky. As if they simply happened to belong to the ranks of the genetically blessed - those rare elders whom the years do not burden with sagging jowls, baggy eyes, crepey drapery hanging from the recesses beneath their chin.

The effect of the rhinoplasties - the nose jobs - varies more. Wolf paused at the photo of a young black woman who came to him with the wide nasal bridge and flaring nostrils that I associate with Africa. The plastic surgeon explained, ""She wanted still to maintain her ethnicity, but she just wanted to bring [the nose] in a little bit, so it wasn't quite so extreme."" In the ""After"" photo, she doesn't look Caucasian (she wouldn't, even if her chocolate skin were milky white), but also I can't help thinking that, for better or worse, she looks less Negroid.

Another nose patient, a young white woman with dark brown hair and dark eyes, appears attractive with the nose she was born with, even though the silhouette of it is convex. If I had met her before her surgery, my first impression probably would have been of someone hearty and robust. Studying the ""After"" photo, I wonder: why on earth should she appear to be a different sort of person, a more sensitive one with that nasal line reshaped into concavity? Yet she does. In other cases, the transformation is even more extreme: paring down a nose and building up a chin has transported more than one of Wolf's young patients from the ranks of the homely to those of the Aesthetically Correct.

Some people are immediately happy with dramatic changes, Wolf stated, but he acknowledged that he also had encountered more mixed reactions. He recalled one woman whose facelift made her look 25 years younger - but also subtly different. Wolf had warned her that the overhaul was dramatic enough to make this a possibility. But it turned out, ""She was really sort of depressed for the first three or four weeks. She clearly would have gone back to her old self, if that had been possible. It took about a month and a half or two months before she really came around to being happy. And then she was thrilled. In fact, she got engaged about six months later, and she wrote back and said, 'That was the nicest thing I ever did for myself.' ""

This story reminded him of one 15-year-old girl, ""a real spunky, sweet gall,"" whose nose he resculpted. ""Her parents came back later when she was about 16 and a half and told me how outgoing she'd become. She'd been elected cheerleader, and her parents said, 'It's just great!' ""

I asked about the strangest request Wolf had ever gotten, and he chuckled. ""I've gotten a lot of strange requests over the years. I don't know,"" he reflected. ""I've had requests for implants for just about anything you can imagine. Everything from buttock implants to pec implants to calf implants.""

Some plastic surgeons do perform these. ""I know it,"" Wolf responded. ""And you know, that's fine. If people want to do that, that's okay. But I don't know. My feeling is, 'Try working out.' That's probably the Texan in me speaking.""

The Texan in him does not balk at liposuctioning various body parts, ""probably the single most popular operation."" He says he was ""cautiously hopeful"" when he first heard about the procedure at a standing-room-only presentation in Honolulu, in 1981. Wolf says the dermato-lipectomies that liposuction promised to supplant ""were great big, horrible operations where you were taking this big chunk of skin and fat, but you were leaving these awful contouring problems and giant scars. As far as I was concerned, [those preliposuction] operations were as terrible as the problems they were trying to solve."" Still, he waited about a year and a half to try the new technique, "because I was too new in practice. If it turned out to be a disaster, I didn't want to start off with that." Since undertaking it, "I've been very pleased."

The second book on his coffee table contains ample documentation of protuberant tummies made flatter; heavy saddlebags whittled down. But again, the photos offer no clue to how the changes occur. I didn't really understand that until I spent a morning watching Dr. Lori Saltz remove fat from someone's body.

Saltz, who's 39, has been in practice for three and a half years. Along with two other plastic surgeons (both men), she shares an office on Prospect Street in La Jolla, just a block from the Museum of Contemporary Art. Set well back from the street, the red-tile-roofed building looks for all the world like some expensive, very discreet small hotel. Inside the door, one finds terra cotta tiles on the floor, faux-marble on the walls. There's also an inner waiting room that looks like the sort of place in which visitors ought to sip sherry and listen to a string quartet. In Saltz's own inner sanctum, huge Oriental prints in heavy frames dominate three of the walls. Fresh-cut sunflowers adorned the top of her very spare, very shiny lacquered desktop. "Plastic surgery," she announced almost immediately, "a lot of times is surgery on the psyche."

"It's very, very complicated. People's expectations are complicated. This is probably the only medical field where nothing less than perfection is usually accepted. If you have to have your gall bladder out, you have to have it out and that's it. People don't question if the scar's not exactly perfect. But people come in here and they have an idea of what it is they expect, and if we deliver less than that, they're unhappy. So it's up to us to determine if we can meet their expectations, or whether their expectations are even realistic. Having been through plastic surgery myself, I know that in all of us, there's some level that you can't talk to."

Saltz had her breasts "augmented" when she was in her early 20s. Two years ago, she had a tummy tuck and some liposuction. "And I'm getting to where I think, 'In a few years, I'll need a brow lift,' "" She says this with a smile. In fact, her face looks flawless, her beautiful dark eyes the high ground in a smooth fair sea. That day it was hard to detect the effects of Saltz's body surgery; she wore a loose-flowing creamy silk blouse over a dark knee-length skirt. But she testified as to one of the psychological pitfalls of liposuction. Somehow, the permanent removal of certain fat cells "gets translated in your brain, unconsciously, to 'I can eat whatever I want and since the cells are gone, I won't get fat.'" The truth, she says, is that "your body doesn't replace those specific fat cells [that were sucked out in the surgery], but all the ones that are left in your body have plenty of room to grow, so if you overeat you will gain weight...and you will not like it.""

Saltz says another unconscious expectation is that "people think they're going to be back to normal and feeling perfect in a matter of days to a couple of weeks — when actually, in almost every procedure we do, for all the healing to take place and all the subtle changes to occur and everything at a cellular level to get back to where it was, it probably takes a year or more. Scars are changing, tissue's maturing, nerves are coming back to life. You may be out functioning and doing great, but if you're going to stand in front of that mirror every single day and evaluate your results, you're going to drive yourself and most likely your doctor absolutely bananas. But that's people in our society today. They want everything and they want it now.

"I tell patients, the human body is incredible. It heals. But you have to give it a lot of time."

Saltz says both her parents influenced her career choice, through their professional examples. Her father was a Portland ear-nose-and-throat specialist whose work often drew his family to the hospital. "I remember the first time I walked into the operating room," Saltz reminisces. "It just felt like home."

Her mother was a professional seamstress who had Saltz snipping and sewing at an early age, and this "definitely carried over," she acknowledges. ""I tell people that the nice thing about sewing on people is that they heal. Things change and mature, and the body remolds to some extent. That doesn't happen with fabric. What you do is what you get,"" she says wryly. ""But I think the feel for tension and spacing and all of that - for keeping things even and smooth - was all developed way ahead. And I liked doing the really tiny intricate stuff. A lot of the French hand-sewing and embroidery that I do is smaller than anything I do in the operating room.""

Though Saltz says, ""I don't ever remember a time when I wasn't going to be a surgeon,"" it took her until high school to decide upon a plastic surgery specialty. She says she considered devoting herself to ears, noses, and throats, like her father, but ""there were a lot of cancer aspects about it that I really didn't like. I think it takes a really special person to work with chronically ill people."" Saltz says some of her medical colleagues tel her they couldn't deal with all the psychological ramifications of plastic surgery, the very part that most interests her.

Saltz is one of only a half dozen women plastic surgeons in the county, a scarcity she ascribes to the length of the training process. "You have to do four years of college, four years of medical school. You have to do a minimum of three years of [general] surgery [training], and a lot of programs require four years now." Only then can you begin your plastic surgery training, ""which is a minimum of two years. So it's a minimum of five years beyond medical school. I did six. That's a long time, and by the time you're done, you're 30, 32, and all your friends have gotten married, and they have kids. They have a life. And you're still waiting to start yours."

Saltz was already married (to an anesthesiologist) when she finally finished her plastic surgery training, and she immediately took time off to have two children. ""I took off three and a half years, completely. And then it's hard to come back. It wasn't hard technically. I spent six months working with Dr. [Merrel] Olesen {one of her current partners], reading and just sort of getting back into it. I assisted him on a lot of cases before I went out and did one on my own. But it felt fine. Because I'd done a tremendous amount of fine needlework when I was out, so the dexterity was still all there. But there were new things to learn and I went to a lot of courses, just to catch up. And of course, every time you apply to anything, they say, 'Well, what have you been doing for three years?' ""

I asked Saltz how many people conceal the fact that they've had plastic surgery.

"Very few people don't tell anybody. But we do have patients who wait for their husbands to go on a business trip, and then they have their surgery. I have women who have had breast implants for 20 years and they come in and whisper, 'But my husband doesn't know.' They waste so much energy worrying about their husband finding out, when in fact I'd be willing to bet the rent that he knows and just considers it something she doesn't want him to talk about. You'd have to be pretty dumb to be that intimate with somebody for years and not know.""

At the other end of the spectrum, ""We have patients who will go on TV and tell everybody. But a majority of our patients - about 60 percent - are smack in the middle. They tell their family and close friends, but they're not telling everybody in the office, or they won't at first. They might after it's over and everything's okay. They're not wholly closed, but they're not out there on the roof either.""

Does she ever turn away would-be patients?

""We turn down people if we think their expectations are going to be too high. You might say, 'I think I can get your stomach this flat,' and if they say, 'I want it flatter than that. If I'm going to pay this much money, I want this result.' Then you have to say, 'Well, I'm not your person.' ""

As another example, Saltz mentioned the case of a woman who wanted a tummy tuck because she'd been confined to a wheelchair for a year and had put on quite a bit of weight. ""And if she had a tummy tuck and some liposuction, she could jump right out of that chair. I mean, you could just tell after talking to her that that was her goal. Now it was true that she had put on some weight and it was true that a tummy tuck would have made her look better. But it wasn't going to change the fact that she had a progressive neuromuscular problem that was confining her to a wheelchair. And had I done her, she would have been disappointed that she was still in the wheelchair.""

Saltz said she sees no reason not to do surgery on most teenagers who come seeking it. ""You don't want to do a rhinoplasty on a kid who's under 15 or 16 because their nose hasn't quit growing. But after that, if they have this big nose and a weak chin, that's not going to change with time. And people teasing them about it and them being self-conscious about it isn't going to change with time. It's just one obstacle you can get out of their way sooner in life, so they can get on with other things.

""I've done breast reductions on younger girls, which is really controversial because they can continue to grow. I did one on a 15-year-old whose mom told me, 'She can't participate in sports. She's socially withdrawn.' And I said, 'Well, as long as you accept the fact that she may need to have it done again, if she continues to grow, let's do it.' We did it during the summer, and her mom says she's just another person. She's participating in gym. She's going to parties. All these things because she doesn't feel so self-conscious about these breasts. And they certainly weren't going to get any smaller. They were enormous! Her pediatrician had said, 'Oh, she'll grow into them. She'll grow into them.' Some guy. This girl had two huge watermelons on her chest and grooves in her shoulders [from the pressure on her bra straps].""

Did the girl's schoolmates notice that her breasts were smaller?

""I did ask her specifically what she was going to do in gym, when she had all these scars, and she said, 'Well, I'll just tell 'em.' I had another girl I did an augmentation on, and she was totally flat-chested. She was a junior . She told all her friends. She was really excited.

""We pin kids' ears. Nobody seems to question pinning their ears back when they're 5 or 6. But somehow a girl wanting her breasts smaller when she's 15 is controversial."" Not that Saltz would accept every such case automatically. She recalled one 16-year-old who was extremely self-conscious about her breasts. ""They were borderline, on the large side of normal. She wanted them off. 'Cut them off!' And I'm just going, 'Hmmmm, something is not right here.' You have to be really sensitive. Sometimes you need to see them several times."" It turned out that this girl had been ""tossed between divorced parents and step-parents and siblings and stuff like that. Her mom said that whenever her stepbrother was home, she walked around the house with a pillow over her chest."" Saltz ultimately declined to do the procedure and referred the girl to psychological counseling ""because I strongly suspected that she might have been abused by somebody."

Does Saltz's practice include racial minorities?

"Sure. I'm doing a black girl tomorrow, a breast reduction. We sometimes have to talk to them about different things. In her case, we have to talk to her about the fact that she may scar a lot worse than if she were white. That's just a fact."

What about racial minorities who want to change their features to look more Caucasian?

"I've never had anybody ask me to do that. That I do think is sad. I think what Michael Jackson has done to himself is really an insult to the black race. He had his nose made Caucasian. And his lips. All of his ethnicity was operated, taken, excised surgically from him."

Saltz has little taste for nose jobs of any sort. "I don't like breaking those bones and mashing them all around. Brow lifts and eyes and other facial stuff — those are really fun to do." But her favorite procedure is probably the "body contouring" work, she said. "I guess part of it is because I've always been unhappy with my body contours. I always wanted to do this and I wanted to do that. I wanted larger breasts. I guess on some level, I relate. So when women come in and go, 'I hate this!' I go, 'Don't I know. But [gleefully] we can fix it!" And they understand. 'Yeah, she does know what I mean.' It's kind of like a hen party. We get in there and we're at the mirrors and we're pulling up our skirts. I show my patients my scars and tell them what my recovery was like."

I missed that phase of the liposuction process experienced by Nadine (not her real name). On the morning of her surgery, Saltz, clad in a tight green surgical top and pants, seemed somehow brisker, tougher, than she had been the first time I interviewed her. Nadine looked tense. She was 32 years old, a native San Diegan. She wore no make-up; very fair skin and very dark eyes, brows, and hair made her look a bit like a madonna. At first impression, she seemed too petite to be undergoing this procedure. But when, at Saltz's request, she climbed upon a stool and hoisted her cotton robe up around her breasts, the voluptuousness of her naked middle region was revealed.

"She has what most women have," Saltz commented. "A little extra. You can almost see the outlines of it." Saltz started tracing those outlines, marking her patient's flesh with a purple pen. She circled a gentle mound surrounding Nadine's navel, then circumscribed an area a few inches above that. She sketched what looked like giant amoebas on the woman's outer thighs, extending partly into each buttock. "The least satisfactory areas to do for lipo is the inner thigh," she mentioned as she moved on to that area. "You can improve it, but usually most of what people don't like is due more to lax muscle or lax skin."

"But how do you tighten that up?" Nadine inquired.

You do calisthenics, Saltz answered. "Have you done that Buns of Steel [video workout]? Oh man, I did that one and I could not move afterward. Be very careful when you start out. They really work on the inner thigh."

To illustrate where she would make her incisions, Saltz swiftly made a dozen or so purple dots, most situated within the creamy white area of Nadine's body revealing the shape of her very brief bikini bottom. "We like to get at [each area to be vacuumed] from two angles. That helps keep it smooth," Saltz stated.

From the target zones, Saltz predicted she would extract a total of 1200cc, just a little more than a quart of fat. That's only two or three pounds. But those pounds would be composed of some of the most tenacious cells in Nadine's body. If in the future Nadine were to gain weight, she would still be able to store fat in the liposuctioned areas, according to Saltz, "because we're leaving some fat cells there." But she would gain fat everywhere else in her body too. "We're changing her proportions. So she won't have proportionally more [fat] in those areas."

Saltz estimated that 1200cc was a little less than the yield from the average liposuction patient. "I'd say normally we do between 2000 and 3000." Saltz's record is 8200cc - more than two gallons of fat cells - extracted in one grueling five-hour session. "And we didn't even touch her butt, from which we probably could have gotten another 2000." In that particular case, as for most "high-volume" patients, Saltz says it was necessary also to cut out excess skin. "Or else she would have sagged everywhere. It's like losing a lot of weight." Cutting out skin of course condemns the patient to big scars, as opposed to the matchhead-sized marks left in the wake of simple liposuction. "But some people are really happy...even though their results are less than ideal," Saltz said. "Like [another doctor's] patient who wanted to wear a pair of jeans. She had terrible skin! But he took enough fat out that she could fit into jeans comfortably. She was thrilled - although from an aesthetic standpoint, if you looked at her naked, you'd go, 'Eh, why bother?' But it made a big difference and that's all she wanted. A patient just has to have the right expectations. Not everybody is going to be a Barbie doll."

Nadine, in contrast, might come close. "She's young. She's got good tone in her skin. It's not flabby. She doesn't have a lot of sun damage yet, although she's got some," Saltz declared later that morning, over Nadine's inert body. It rested on an operating table in a large, chilly room with white walls and speckled linoleum flooring. By 9:35 a.m. an anesthesiologist had inserted into one of Nadine's hands the IV that would deliver some of the drugs she would require. A tube down her throat also carried to her lungs the mixture of gases both sustaining her and keeping her asleep. The anesthesiologist monitoring this pharmaceutical feast sat behind her head, screened from the rest of her body by a blue cloth that also covered her upper torso.

The view from the other end of the operating room was more surreal. The (seemingly) headless naked body lay lifeless, disfigured by a host of small puncture wounds. Here and there blood trickled from the tiny orifices, a bright red that contrasted with the dark plum color of Nadine's carefully painted fingernails.

Saltz had punched the holes in Nadine's skin with a tool that resembles a glorified awl. She'd moved so briskly that I'd hardly noticed the violence of the stabbings. Then the surgeon and an assistant had picked up blunt infusion cannulas attached to what looked like giant hypodermic syringes. They had dipped them into a bowl containing an epinephrine solution and swiftly, sloppily, had squirted the clear fluid into the incisions. It takes a good 15 minutes for the drug to cause the blood vessels to constrict, Saltz told me, "and you just have to sit there and twiddle your thumbs and wait. That's really, really hard for most surgeons. Some of my colleagues can't stand it. They'll wait about 30 seconds and then start. Then they ask me how I get the fat to come out looking so clean."

The fat is drawn out through other cannulas. These look a lot like knitting needles, and in liposuction's early years they were always connected to machines that created suction, not unlike the arrangement of a vacuum cleaner. Some doctors still use these, but "I hate the noise," Saltz commented. In the last few years, syringe-generated suction has become available. This allows the surgeon to create a vacuum by pulling back on the syringe plunger, locking it in place, and drawing the fat into the chamber of the syringe with a pumping action. As Saltz began inserting the tool into the holes, and pumping away over Nadine, rock classics broadcast by FM 96.5 filled the operating room.

There's a creepy quality to the sight of the cannulas moving under the skin. I kept thinking of the creature that bursts out of Sigourney Weaver's abdomen in her nightmare in Aliens. The long, pointed liposuction implement looks as if it too should break through the skin, ripping open the body's covering. "We're too deep for that to happen," Saltz dismissed my concern; the skin is too tough.

Her sawing motions drew into the syringe a gloppy mixture that varied in color, depending on how much blood was mixed with it. Some was as light as pureed peaches. Other extractions look much redder, reminiscent of tomato sauce with tiny pieces of chopped onions floating in it. Periodically, Saltz squirted the extracted material into the hole in the top of a yellow Rigi-Box. Later it would be stored in a special container and picked up by a medical waste disposal firm that contracts with local plastic surgeons.

The fatty soup exuded no detectable odor. I asked Saltz if it varied in texture from one person to another. "Some people have mushier, softer fat," she said. "Men tend to have real fibrous fat that's hard to get out. The fat cells are smaller; it's harder to break up."

Badly done liposuctions can leave patients with a lumpy, uneven appearance that's worse than what they started with. To avoid this, Saltz squeezed and pinched and kneaded and patted Nadine's flesh relentlessly; instead of a knife-happy surgeon she looked more like some hypersensitive baker. "I'm just feeling how smooth it is," she explained as she stroked the skin. "This is very tactile." As she completed each side, Saltz squatted down to scrutinize the profile of her handiwork. "See, when she stands up, she'll have a real nice curve," she predicted.

For this Nadine paid $4200; she spent a little more than an hour and a half under general anesthesia. After Saltz sewed up the last incision, she disappeared, leaving her nurse and surgical technician to muscle Nadine into the stiff white girdle she would have to wear for six weeks. As she was outfitted, I had a clear view of the underside of her breasts: no telltale scar there. So their fullness was God-given. Back in Saltz's office, I asked the surgeon's view of the future of breast implants, now that the silicone gel variety have met such a catastrophic fate.

"We'll always have breast implants," Saltz predicted flatly. "I mean, breasts have been associated with sexual appeal for millions of years. You wouldn't believe what they've put in breasts over the years: wax, ivory, fat from other parts of the body, sponges, silicone. Just amazing." Like many plastic surgeons, Saltz believes that the silicone implants are essentially safe and should not have been banned. Some women did have complications, she acknowledges. "I have one black girl who has rock-hard contractures in her breasts. They are rock hard. But her breasts were flat. I mean, totally flat on her chest and sagging. I say, 'We ought to take these things [the hardened implants] out.' But she won't let me. She's not happy with them, but she would be a lot unhappier without them. She won't let me undo it.

"Women keep coming back, and after a while, I go, 'Why would anybody undergo eight or nine operations on their breasts?' Why? After I'd gone through my third or fourth, I'd just say, 'Get rid of 'em.' But these women, they want them so badly, they're willing to go through this. That tells you the demand is going to be there. Then all the do-gooders say, 'Well, society's made them like that.' Well... they're a sexual organ. And we like to appeal to the opposite sex. Men sit around and pooh-pooh these women: 'Oh well, they should be happy with what God gave them.' But the second that men get a little gynecomasty [overdevelopment of the male breast tissue], they race in here to get it out so fast, it makes your head spin. Not only that. It's covered by insurance!"

Saltz shakes her head. "If they had an operation for penile implants that had the success rate that breast operations do, I'd love to see what would happen. But our breasts don't have to do anything but sit there. Whereas penises have to work."

I found a less sanguine perspective on the future of breast enlargement when I talked to plastic surgeon Gary Nobel. Nobel had just returned from this year's annual plastic surgeons' meeting in New Orleans, where the news was grim. "It appears that the manufacturers are getting more and more backed into a hole," he said. "One by one, they're all dropping out of business." It was just possible, Nobel suggested, that all breast implantation would have to stop, at least in this country. "One of the attorneys who represents the doctors was saying it's just another thing in America that we're going to drive offshore. We're going to keep all the litigation here, which is non-productive. And people will go out of the country to have their breasts enlarged."

Nobel is a youthful-looking 53. He looked genuinely troubled by the implications of this possibility. "The thing of it was that [breast enlargement] was the one cosmetic procedure that a lot of young people saved their dollars and dimes for. If they have to fly over to Europe to have it done, it'll make it out of reach for a lot of people." Litigation has already pushed the price of implants sky-high. "Even saline," said Nobel. "The price of that implant three years ago was something like $250 a pair. Now it's just about $1000. The same implant."

Nobel says he and other people at the recent meeting were troubled by Dow Corning's recent announcement that the company would pay more than $4 billion in settlement to women claiming that their silicone gel implants had damaged them. Dow's capitulation "just opened Pandora's box. You wonder if [Dow] knows something that we [plastic surgeons] don't. But if there were something hidden, I really truly believe that we'd be seeing more patients [with serious problems]. I've had some people with ruptures. I've had some people with some capsular things. But by and large, the problems have been very, very few. To my knowledge, there is no great number of people saying, 'I've developed arthritis.' And I've done about 3500 augmentations."

Nobel says he was roughly the 20th plastic surgeon to settle in San Diego. That was back in 1973. He had just finished his plastic surgery training at the University of Michigan, where he had gotten an undergraduate degree years before. As an undergraduate, "My family didn't have a lot of money, so I had to work." He got a job at an Ann Arbor hospital and eventually wound up working as a "scrub tech" in the operating room. "The laws were different then. You didn't have to have all this different training to be a scrub tech." Nobel held that job throughout his college years and on into medical school. "I liked surgery. I'm technically very good at what I do with my hands. Intellectually, I'm okay, but I certainly would not say that I could be a research scientist." However, manual challenges "have always been very easy for me. And it's hard to stress me. I find it relaxing to operate, rather than stressful."

The meticulousness demanded by plastic surgery attracted him to the specialty. "And it's nice making people happy. It's very gratifying. It's financially rewarding, but when I went into it, I didn't know that," he stated.

I told Nobel that I'd seen a 1989 survey by the firm Medical Economics that placed plastic surgeon incomes at $211,250, about the middle of the surgical specialties. On the other hand, I'd also read a 1991 article in the L.A. Times that stated plastic surgeons in Southern California can easily make more than a million dollars a year.

"I think the first figure's incorrect...too low." Pressed to estimate the average income for local plastic surgeons, everyone from newcomers to well-established veterans, Nobel guessed that it would probably fall between $350,000 to $450,000 annually.

If a plastic surgeon specializes in cosmetic surgery, does he make more money than he would if he only did reconstructive work?

"Absolutely," Nobel answered. Insurance companies generally pay for reconstructive work, "and they pay far less," he said. Furthermore, most plastic surgeons "consider, right or wrong, that cosmetic surgery is sort of a luxury item. It's not a necessary thing. So you're not doing it as charity." In contrast, a reconstruction done on a Medi-Cal patient might not even bring in enough money to cover the surgeon's costs. "And it may be a far more difficult procedure than doing a cosmetic procedure."

The amount of potential cosmetic work is virtually unlimited, he pointed out. "Everybody gets old. Everybody or most everybody needs or could have their eyelids done. Or they could have a facelift done at some point in their life. Whereas everybody doesn't have a cleft lip, thank God. Everybody doesn't have a bad car accident."

Nobel said that probably 95 percent of his current work is cosmetic, only 5 percent reconstructive. "And the reason people switch over is, one, the remuneration, and secondly, the lifestyle." Those who do reconstructive work are "on call at all hours of the night, getting sworn at, spit on, you know. When you get busier in your established practice, it's hardly fair to schedule a patient for a facelift on Monday morning, someone who's already paid their money, and then be up all night long, taking care of someone who's been in an accident or whatever. It would be different if you were in a community where there were not [a tremendous number] of other plastic surgeons and no one else was doing it."

When he first came to town, Nobel says he was on the emergency room staff of 15 different hospitals. "I'd be running all over the place! There was one Saturday that I did a fractured mandible at El Cajon Valley, one down at Bay General, and one up in Escondido at Palomar Hospital! I put on a lot of miles. But it built a practice. Nowadays, people do it in different ways, and I don't think it's as good. A new guy coming out advertises, markets his practice."

Nobel has never done this, he says. "I've given a few talks, but basically, for as big a practice as I have, I've done the least advertising of anyone. I guess I don't have any moral qualms against it. I just have been basically as busy as I want to be."

He commented that he doesn't understand the logic of plastic surgeons who are well established but continue to advertise aggressively. "I mean, it's not like putting a few more cans of beans on the shelf. A surgeon can only do so many cases a day. And if you start pushing that beyond a certain point, then the quality of what you're doing is going to [decline]. It's not like you can just sell 14 more suits or whatever." Some surgeons "cheat," Nobel says. "I've never done this, but there are people who start one case [and have an assistant do the work while] they go start the next case. You can increase your numbers that way. But I don't think that's right."

Pricing of plastic surgical procedures is a highly complex matter, he indicated. "You can go into this town and have a facelift done, and the price of the facelift - meaning a lift of the neck and the jowl and maybe the lateral temple a little bit - can vary anywhere from possibly as high as $10,000 down to maybe $2500. The same facelift. Different doctors. Different reputations. Different areas. And certainly if you go into Beverly Hills, you're going to see an even higher price tag.

"Now, you [the plastic surgeon] can get yourself into a bind if you're too much on the low side. People think that they're getting a lesser facelift from someone who's charging only $2500 than from someone who's charging $10,000. But sometimes the more highly compensated people aren't doing as good a job as some of the people in the middle. Now, should you go to Mexico and have your facelift done there, save a little bit? Not usually a good idea. Though I know of some there who are pretty good surgeons."

Were there fashions in plastic surgery, I asked Nobel; whether noses, say, had evolved over the last 25 years? "Noses have turned out to be less pug and less radical a surgery. You're taking less away and trying to fit the [other] features. Whereas old nose jobs used to be all ski jumps and little tiny tips."

Things like the movies influence such changes, he said. "Look what fat lips have done," Nobel remarked. "You know, when I was in training, we used to have people come in and they wanted lip reductions. They wanted chunks cut out of their lips to make them look smaller. And now everybody wants Julia Roberts-type lips, and hers I'm sure have been blown up. They're not really her lips. They've either been injected with fat or collagen or something."

Nobel told me that occasionally patients walk in "who want things done that they're not rational about. I saw a lady today who is an old patient for other things, and she wanted something done to her nose. But her nose looks perfectly fine to me."

What do you do then?

"I told her I think it looks perfectly fine. Now that may be stupid. Sometimes they do just walk out and they're obsessed by it and they go to someone else. But I have to live with myself. And the most important thing is not to cause any harm."

For that reason, Nobel says he doesn't do biceps or other muscle implants, though male patients have requested them. He estimates the ratio of men to women in his practice at perhaps 1 man for every 15 to 20 women. "The interesting thing, at least in my observation, is that of the men, the percentage who are gay is much higher than the percentage of gays in the general population." They come for all sorts of procedures. "Just to look nicer. They're very into appearance, and some are very meticulous. They just maybe care more about the way they look than some of the rest of us."

Does Nobel foresee having plastic surgery himself someday?

"Oh, I think about it," he laughed. "I'm getting closer.... Whether I do it or not, I don't know. My dad's 85 and he looks like he's in his early 60s, although he doesn't have the sun exposure that we have here. I don't know. But I've done a bunch of other plastic surgeons. "I've done both of my [former] wives," he elaborated. "I've done my mother-in-law.

I've done my children. This is a younger picture of my daughter," he said, grabbing a photograph of a very pretty young woman from the shelf in back of his desk. "Her chin wasn't very prominent. So the question was whether to put in a chin implant or do some liposuction on her. I wound up just doing some liposuction underneath the chin. Even though she's not heavy, it made her chin line better. She was probably about 20 or so.

"I did the nose on this son of mine," he said pointing to another photo. "He had broken it and the tip was a little bit bulbous, so I just put that in line with the rest of it. I haven't done anything on my youngest son and my younger daughter, though they've all had their share of lacerations that I've sewn up over time.

Is it an occupational hazard of plastic surgery to be more critical of everyone's appearance, even out of the office?

"Oh yeah. How do I deal with that? Well, I would never walk up to someone and say, 'You have a big, ugly nose,' or anything like that. But you do always talk about it in the sidelines. Either with your wife or whomever you're with. You say, 'Gee, I could just do wonders with her neck,' or 'Wouldn't that be a great nose to fix? Her face would just be so much softer and so much nicer with a smaller nose.' You do that all the time." He laughed. "Makes people nervous."

I asked Nobel if he thought that by doing a lot of cosmetic surgery, he was in some way contributing to our society's preoccupation with superficial appearances. He looked thoughtful, then plunged into this answer.

"I'm sure you're contributing to it. There's no question that if you do a facelift on one lady, you get friends of theirs who come in afterward. Now, whether they've been thinking about it as well or there's pressure on them to have it done (because their friend is now looking better), I don't know. I think that's just something that is part of our lives."

Maybe it shouldn't be, he ventured. "Maybe the best thing we could all do would be to throw all the mirrors away. All the reflections. So that we never had to see what we looked like. I could look at you, but I wouldn't know what I looked like myself. And of course, you might look like trash. You couldn't comb your hair or put lipstick on. But that might be the best world." The plastic surgeon sounded dubious.

Suddenly, he was struck by the thought of an encounter he'd had at the meeting in New Orleans. He says he ran into the wife of another plastic surgeon, a woman who quite obviously had never availed herself of any of her husband's cosmetic wizardry. "I was sort of wondering why she had never had anything done and thinking, 'Do I want to talk to this big, fat lady?' And I sat down and talked to her for a while. And her ability to speak and to talk was so overwhelmingly beautiful, I didn't see her appearance. It just wasn't important. She was unbelievably interesting." For a moment, he looked transfixed by the memory of that conversation, then he shook his head, as if to clear it. "But not everybody's like that. Unfortunately, we live with reflections and we live with other people's opinions of how we look."

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