The plastic surgery lasted seven hours. The patient was a woman in her midfifties in for a face-lift along with an endoscopic brow-lift, upper and lower blepharoplasty, and fat injections to her lips. She complained that her eyes seemed increasingly deep-set, and she disliked her forehead creases. She told her plastic surgeon that she wanted to "soften her look." I entered the room just as the patient was going under. It's easier that way. Linking the surgical process to someone I've met makes it impossible for me to achieve an emotionally neutral, aestheticized distance during the operation.
Each time, I anxiously watch the monitor, scanning heart rate and blood pressure. I shudder when they are wrenched from their anesthetic sleep, the whole body heaving up and arching when the ventilator is pulled from the mouth. I worry that they won't be able to reconnect consciousness to their surgical bodies, that they will die. And then after, in recovery, left alone with the patient and family, I feel responsible, telling them the plastic surgery went well as though I have any idea, really. I suspect, with experience, I would get over this and would be able to separate more readily the human from the surgical field.
This patient's procedure took place in a large plastic surgery room in a hospital. The staff was very concerned to keep me far away from any of the sterile areas, and nurses were busily relocating me. Two huge Sony television sets faced the operating table. These would be used for what is called an endoscopic procedure. The endoscopic unit, as Oscar M. Ramirez describes it, consists of "a camera, xenon light source, two video monitors," an endoscope along with "special [periosteal] elevators and manipulators". The sheets were lifted from the patient, then redraped very carefully to avoid any pressure points of fabric, which could lead to blood clotting. During long surgeries like this one, blood clots are the greatest concern.
Another plastic surgeon told me that she wouldn't operate for longer than five hours because of the degree of risk. "I just don't think it's a good idea. I think you put the patient at higher risk when you put them under general anesthesia for a longer time. They have risks to their lungs, they have risks of blood clots, so I really limit the plastic surgery. I've had patients ask me if I'll do their breast implants and abdominoplasties at the same time, and I've said no." One of the problems plastic surgeons face is that patients tend to prefer combining procedures one big plastic surgery, in other words.
Cost is often the primary concern. If a patient were to have implants and a tummy tuck at separate times, she may not be able to afford the additional funds required for hospital and anesthesiologist charges; indeed, the total cost could increase by several thousand dollars, not to mention the additional recuperation involved, extra time off work. The plastic surgeon began by suctioning out fat from her belly for injection into her lips. He explained to me that there is some anecdotal evidence that the fat from some areas of the body is more volatile than fat from others, meaning that if you gain weight, the newly augmented lips might expand as well! The process of suctioning out the fat seemed so violent, plunging back and forth with the suction tube into her soft abdominal skin. "She's straining against me," the plastic surgeon complained to the anesthesiologist, who was instructed to sedate her further.
The anesthesiologist, in perusing the patient chart, was not especially pleased to note that the patient had claimed to imbibe between four and five alcoholic beverages a day. I spoke with the anesthesiologist about her experience with this plastic surgeon, for whom she had great respect. Two years earlier, there had been a fatality. The evening following her breast augmentation, a young woman rose to go to the bathroom and died from a blood clot. "Every now and then, these things happen," she commented, but I sensed that the memory continued to agitate her, this death of a young woman for no good reason.
As he plumped up her mouth, the plastic surgeon explained that the patient suffered from what he calls incomplete oral closure, meaning that the teeth touch each other before the lips meet. He believes this configuration ages the face by forcing certain muscles to compensate; thus he plumps up the lips to supplement the deficiency.
He turned to the brow. The lights in the room dimmed when the two large television screens flared awake. I felt as though I were viewing an art installation, not plastic surgery. A tight circle of light beaming down from the plastic surgeon's headlamp contained the faces of the plastic surgeon and the patient, and the paired screens glowed blue.
The plastic surgeon made two incisions in the patient's hairline, each approximately an inch and a half long. He gently pried the skin apart from the periosteum and, with a drill, made what he called a bone tunnel to define the endoscope's route; he then inserted a wire to make sure the tunnel went all the way through.
A periosteal elevator raised the skin from the forehead. Hearing the scalpel rasp against bone unnerved me. In this aestheticized technological space of television screens and monitors soothingly flickering orange data and a table full of harmoniously arrayed metal instruments in an unrecognizable variety of curves and angles, body sounds seemed out of place.
He then inserted the endoscope, a long thin instrument with a camera at the end, which gives one visual access to what would otherwise be out of visual range. Use of the endoscope allows doctors to make smaller incisions, because the scope reveals to them the underside of the face, otherwise visible only by rolling back the whole forehead. Many plastic surgeons consider the technique revolutionary, but others think the results are less impressive than the old-fashioned coronal brow-lift or even aesthetically undesirable.
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