With the American Society of Plastic Surgeons reporting 5.7 million reconstructive proceduresand 15.6 million cosmetic procedures performed in 2014, a 3-percent rise from 2013, plastic surgery is increasingly a normal occurrence, though it retains a certain stigma in the public eye, amidst cries of vanity and off-color pop culture representation. SRQ sat down with three area professionals to excise the myths and misconceptions and cut to the heart of the matter. 

SRQ: When people hear “plastic surgery” they usually jump straight to the cosmetic side, but that’s not all of it. What else is covered by the practice and how is it separate from the cosmetics side of it? Dr. John Strausser, Plastic Surgery of Sarasota:The American Board of Plastic Surgery has eight different areas that they require a board-certified plastic surgeon to cover before they will become board-certified.  This ranges from neurologic type surgery to the cosmetic that you mentioned. Hand surgeries, burn injuries, all kinds of reconstructions with grafts are covered in these eight different categories, cosmetic being only one-eighth of that. It is not the mainstay of what the board certification is about. 

Why do you think that the cosmetic side has become the most popular and most prevalent? Dr. Alissa Shulman, Sovereign Plastic Surgery and Sarasota Memorial Hospital: It’s media. Cosmetic is visible, or its acceptably visible. We have all dealt with cranial facial issues or hand issues; those are all functional issues. If they are visible, they aren’t glamorous. Someone who was born with a cleft lip or pallet, that’s not glamorous. Or someone who is about to miss a breast because of breast cancer, it’s not glamorous. Dr. Raja Nalluri, Nalluri Plastic Surgery: I would agree. About 85 percent of plastic surgery nationwide is reconstructive procedures and only 15 percent is cosmetic, but because of the media and what people find interesting, there is a disconnect.  Strausser: Let me interject another thought here, and it has to do with the economics. Cosmetic surgery and aesthetic surgery are ones that are not insurance-based and not hospital-based in many cases and often not peer reviewed. Because of the cutbacks in reconstructive surgery, many physicians in fields outside of plastic surgery are taking on cosmetic procedures, ranging from injections with Botox to breast augmentations. They promote their cosmetic surgery because they do not become referral bases for other doctors and are looking to appeal directly to the public. 

Does that provide difficulties in the profession? Shulman: Endless. You’re competing with non-plastic surgeons and people do not understand that they aren’t plastic surgeons. They will label themselves as cosmetic surgeons, and in a layman’s mind the two are equal. Strausser: It is very important to understand that there is no license to practice plastic surgery. Once you have a medical license, you can call yourself any kind of specialist that you want. Cosmetic surgery is generally fairly safe to perform, especially if you’re only doing injections, but people are doing it outside of the formal training for the economics. Nalluri: Patient safety is the primary concern and the challenge that presents. The challenge really is to the patients who are coming in, responding to an advertisement or going to who has the biggest, fanciest radio ad, not knowing if that person is truly qualified and not having any other way other than looking at online reviews, which really don’t tell you the story. So it is a challenge for us to try and educate the public to make sure that those surgeons are properly board-certified by the American Board of Plastic Surgery. That is the only licensing board that truly can certify plastic surgeons with the adequate number years of training that we believe is necessary to safely perform surgery. 

When people hear about plastic surgery they think vanity, but it is about more than vanity, yes?Shulman: When patients come in sometimes they have to apologize and say “I can’t believe I’m being so vain,” and I tell them first off, don’t apologize, that’s nothing to apologize for - people want to look good. People are staying healthier longer, especially here in Florida; 50, 60, 70 years old is not even old here, and they are keeping themselves healthy and it would be nice to look close to how you feel on the inside.  We can’t stop time, but we can at least help you look closer to how you feel on the inside. 

How does each of you define success with a patient? Strausser: Patient satisfaction. When they come in and say thank you, and send their friends in to come see you, then you know you’ve done a good job. 

When it comes to cosmetic or reconstructive, what are the most common procedures that you all are asked for or that you find yourself having to do in Sarasota and Bradenton? Shulman: I do a lot of breasts. I am breast and body; I don’t do much face anymore. Even in art, when I was in art school before all of this I didn’t do many faces in art school. I am a torso kind of person. So I do a lot of breasts, both reconstructive and cosmetic. For the most part, being a girl helps with that. The identifying parts of the human form and the female form: breasts, belly, torso and all of that, women can be a little more self conscious about that, and being female probably helps a little bit. 

How has the technology improved in that area, what capabilities do you have these days? Shulman: The implants have gotten better. That was a big issue, the implants back in the early days, back in the seventies. We didn’t have the FDA testing, we didn’t have the requirements and we all thought it was great to have implants. Then, in the ‘80s and ‘90s they found a problem with them. They fixed the problem, but while we didn’t have implants we started moving tissue around to make a breast. That evolved out of necessity. And now-a-days, we can thank the media for women being a little more aggressive when they say “If I am going to get breast cancer in one breast, then I want them both off; I want a new set.” And it is a little easier to provide that now, the technology is a lot better for a reconstruction and patients are a little stronger in determining what they want. Strausser: I am a little worried about the media- driven demands, and I think we are going through a phase right now with the bilateral mastectomy for the LCIS, just like many years ago when we were doing radical mastectomies for every cancer patient that came through. I think this is a fad, and we will medically find treatment that won’t require as many mastectomies to be done either unilateral or bilateral, at least I am hopeful. Even though we can do phenomenal jobs with reconstruction of the breasts and other areas, it is not the natural tissue and it is not what was put there originally, and we would like to preserve that if we can. That is our goal, if we can preserve tissue rather than reconstruct it, then we have done a good job. 

Do any of you ever have to say no to a procedure? Shulman: All the time. That is the biggest part of our job. 

What will make you say no? Nalluri: Often times people will come in for a procedure, such as liposuction as a common one, and going through a battery of questions, I first ascertain what the patient’s health status is and what their diet and exercise routines have been. I would say at least 10-20 percent of the time I recommend non-surgical approaches and to come back in six to twelve months before jumping into surgery. I also make them aware that whether they have a tummy tuck or liposuction, it doesn’t improve their health whatsoever. Long-term studies have shown that rates of diabetes and diseases do not go down after cosmetic surgery. Strausser: I have five criteria that I use to screen my patients: the anatomy must be right, the physiology must be right, the sociology must be right, the psychology must be right and the economics must be right. When those five criteria are met, then you can be one of my patients. Just as Dr. Nalluri said, I reject about 20 percent of those who come in on one of those criteria.  

When I think of skin cancer, I don’t immediately think of plastic surgery, I think dermatology or oncology. How does that fit into your practice? Strausser: A third of my practice is devoted to taking care of patients with skin cancer. Surgical removal of skin cancer is the standard of care, but if you’re going to have something taken off of your face or a potentially visible part of your body, you’d certainly rather have a plastic surgeon put you back together afterwards. 

What is the procedure like for this? Are we talking grafts? Shulman: It just depends where the tissue has been removed from. There are certain parts of the body that are very useful in terms of having “a little extra” there. Some parts of the body there is extra tissue, but if you’re looking at the nose, there is no extra tissue there so you are borrowing from something nearby and trying to make it look like where you’re borrowing it from and where you’re putting it looks fairly natural. There are lines on the body and as you get older, you get more lines, which makes it a lot nicer because we have more lines to put our scars in. People think that plastic surgeons don’t leave scars, but every time we cut we leave a scar, we just know where to hide them. Nalluri: Dr. Shulman is being humble in that the skills that we possess as plastic surgeons. The way we handle the tissue, how our incisions are precise, how many sutures, how many layers, and our skill in putting tissues together and creating a final outcome has a tremendous difference in how the final result looks. 

How has increased technology allowed you to choose where you put these scars? Has it gotten better?  Shulman: No, I don’t think it has changed. That is anatomy that we are born with, that has not changed in how many millions of years we’ve been around for. Nalluri: Sutures haven’t changed much, and the lasers don’t really add much. It truly boils down to the skills.

Does the topic of youth cosmetic surgery come up a lot and do you all have any opinions on when is it too young? I imagine that with reconstructive there is not a time when it is too young. Shulman: Absolutely, reconstructive is reconstructive. Nalluri: There are guidelines put forth by the American Board of Plastic Surgery. For breast augmentation, the board’s recommendation is the age of 18 for saline implants and 22 for silicone implants. Anyone that has those procedures done at an age younger than that is having a procedure not condoned by the American Board of Plastic Surgery. Liposuction is another one, which should start at the age of 16 or 17, depending on the individual circumstances of that patient. Rinoplastica can happen earlier.  Nallurri: At 13 or 14, skeletal maturity is achieved and at that time it is reasonable, but before 13 or 14, I would not recommend. Shulman: Sometimes it’s not just emotional maturity, but different parts of the body reach their maximum maturity at different ages. I haven’t done ears in a while, but by five or six, your ears are about three-quarters of how big they will be as an adult. So if you wanted to work on someone’s prominent ears, then you could at around five or six.  We are all born with whatever potential features we have, but that doesn’t mean we work on them from the time we are born. We have to look for maturity. 

Amongst all of the things that we can do, what can’t we do yet?Nalluri: People ask me all the time to have scars go away, and while it seems like the most basic elements of plastic surgery, we can certainly improve scars, but we are not able to take them away completely. 

Really, why? Or I guess, do we even know? Shulman: Well the change that occurred causes you to have a scar. So even if you cut out a scar, you’re still going to leave a scar. If you re-surface a scar, you’re still going to have a scar. The changes go all the way through, and they are not reversible. When we make scar revisions, it is always whether we can make a cut that will improve where that scar lies. It may be less noticeable, but it is still a scar.

Is there anything exciting coming down the pipeline, research wise, that you all are waiting for that will be a game changer for your field? Nalluri: Tissue engineering, but it is pretty far away. And by tissue engineering I mean the growth of human cells, human organs, or portions of tissue. Plastic surgeons are very innovative in the field of medicine in general; the first kidney transplant was performed by a plastic surgeon. And if we could grow a breast that matched a patient’s existing breast in four to six weeks and applied it as a flap, it would be a perfect match for that patient.

SRQ: Final word: art or science? Shulman: It’s both. It needs to be both. We would never say just pure science.