Opinions about elective plastic surgery span the spectrum, running the gamut from heated defenders to impassioned deniers. Area plastic surgeons address those questions, bringing to light the motivations behind patients’ desires for plastic surgery, the future of the profession and why they got into—and ultimately stay in—the field.

SRQ: What are the most common procedures you perform on a daily basis? Dr. Brian Derby (Sarasota Plastic Surgery Center): For me it’s predominately breast augmentation, blepharoplasty—upper and lower blepharoplasty (eyelid job)—and liposuction. It’s kind of commensurate with our society. Things are getting a little more, “What can you do, doctor, without a knife?” And fillers—there were around over 2 million filler procedures done last year alone. So people always want to figure out a way to do things conservatively without a knife. Like how fat can be donated from your body and put in your face, or breast or wherever it needs to be. 

And these are all considered non-invasive? Derby: Non-invasive in the sense that there’s no incision. These are things that you do basically with a small poke-hole through the skin and that’s for both the harvest of the fat and for placement of the fat. Dr. Charles Rodriguez (Riverchase Dermatology and Cosmetic Surgery): My practice is a little bit different. My practice is centered in Venice and the demographics there are a much older population. So the procedures that we do are about facial rejuvenation. I do more facelifts, brow lifts, neck lifts and non-invasive procedures as well, like fat grafting and fillers and Botox, and then skin resurfacing-type procedures like chemical peels or Rejuvapen, which is another type of dermal injury and resurfacing type technique to try to rejuvenate some of the effects of sun damage. We have older, healthier, active patients down here that are out and about and they want their appearance to keep up with their energy level. They want to look rested and youthful, like their inner energy and spirit. Dr. Harry Wright (Hillstrom Facial Plastic Surgery): My practice centers mostly about the head and neck—procedures that rejuvenate the aging head and neck. The orbital frame—that area of the face around the eyelid—is becoming more and more popular. In that part of the face the aging process doesn’t necessarily make you look older, but that particular part of the anatomy will make you look tired if it’s aged. And that’s the particular angst that drives patients towards eyelid surgery, which is one of the surgeries we perform most commonly that couples with facial rejuvenation procedures like facelift, neck lift and rhinoplasty. And as the dermal fillers become better and more reliable, the trimming of the lower eyelids, faces and lips becomes more and more popular over time. A lot of that is driven by the changing face of beauty. With the internationalization of beauty, the concept is fuller and fuller lips are becoming more in vogue. The sultry curves of the body are becoming more in vogue. Those trends reflect what we do as well. 

You are all seeming to touch on the fact that it’s mostly women coming into your practices. What do men come in for? Derby: Men are just as eager to find ways to drop back the years or lessen that fatigued look around the eyes. I would say probably 50 percent of my patients are men that undergo blepharoplasty; far less so for facelifts or neck lifts. Guys tend to do okay with that, but when I see a guy come in for a cosmetic facial consult, usually the terms that I hear are: “Doctor, I’m tired of looking so tired. I look so fatigued. What can you do with all these bags under my eyes?” Despite the fact that they may have low hanging neck, a very full neck, a line that goes from their chin down to their chest—that’s not bothering them. It’s mostly their eyes. I got a lot of younger guys requesting gynecomastia surgery, or breast reduction. A lot of body builders request that in particular. I’ve seen a lot more of that in recent history for whatever reason. Things come in waves. Rodriguez: Brow lifts as well. A lot of them have heavy brows and want to have their eyes opened up and look more rested. A lot of men are concerned with their “turkey gobbler.” We’ve had some men come in especially after recent cosmetic treatments that are non-surgical. There’s one treatment that we have called Kybella, which is an injectable; it’s a fat dissolving treatment that is injected into a double chin to try to reduce the fullness there. Men especially have been some of the first people coming in for that because they like the idea that they’re not going to have a scar. We also have CoolSculpting, another type of non-invasive technique that can create an injury to the fat cells underneath the chin to reduce the fullness and get rid of the double chin. When a guy comes in thinking about having a facelift, there is definitely a more macho issue that you have to consider. You need to spend more time talking to a male patient about incisions and visibility. Are your friends going to give you a hard time? Like, “Dude did you get a face lift?” That’s something you have to discuss with the patient ahead of time. Wright: Those men that come to my practice probably account for less than 10 percent of my practice. It’s often that they’ve been brought in by their wife who was a patient. They’re frequently not looking for something that requires needles and knives, Kybella for example. Botox is probably the most popular treatment that I use on men. They certainly do enjoy dermal fillers. Certain aspects of the male anatomy, male brow for instance, is notoriously intolerant of mucking around. Think Mickey Rourke or Kenny Rogers. If you overdo the brow it shouts from across the room: surgery. It looks surgical, it doesn’t look harmonious and it’s not a good result. It’s these examples that you see daily that may make men shy away from surgeries that might otherwise be helpful. On the other hand, for other aspects of the anatomy, for instance a heavy turkey gobbler neck, men have even more options than ladies do. You can do direct excision of the neck skin on a man and even though that places an incision on the neck it heals relatively well because we have hair-bearing skin on our neck that hides that incision. When women look in the mirror they don’t like the way they look in pictures. But men hate the way that skin catches in their necktie. I feel like I’m still seeing over 90 percent women in my practice but the social stigma that goes with facial cosmetic surgeries is going away for men.

What are some of the reasons why some of your younger patients are electing to get plastic surgery? What are some of the motivations behind it? Derby: I’ll touch on a broad topic and that’s social media and how quickly people can communicate with each other. Icons in mainstream media lead the trends—it’s Kylie Jenner’s lips or her sister’s Botox, et cetera. I think people are just so much more aware these days of shape and structure and appearance. It’s not uncommon for people to be calling from across the room, “When are you getting your lips done?” It’s not taboo anymore. People are much more accepting of cosmetic surgery as something that is real, available, accepted and that society should be tolerant of. And that trickles down from the older folks into the younger generation and is communicated so effectively on social media. For young folks, what they’re primarily interested in is creating more curvature—giving themselves more of an hourglass look for women, but that doesn’t mean that men aren’t interested in body contouring. There are lots of younger folks who have been motivated by the presence of these massive weight loss TV shows and seeing what people go through. Lots of people are losing weight in that capacity. That leads to a lot of excess skin that people typically come in to my office to have cut out. And I see a ton of that in terms of body contouring in young folks. Rodriguez: There’s definitely a generational difference. The baby boomers, the ones that are retiring and coming down here, with the women there’s definitely very little stigma about plastic surgery and the men are coming around to having procedures done and not being worried about being viewed as strange. As you get into the younger generations, it’s much more accepted and those men and women are responding to things that they see in the media or with friends. With men, they may be very conscious about their appearance or very physically fit and they’re coming in to get liposuction done to their abdomen because there is that last area that they want to improve. It’s very accepted in the younger population. They’ll come in and just say, “When can I get it done? How long is my recovery going to be? How soon can I get back to the gym?” That’s really their main concern and not really who is going to know what I had done. Wright: Until very recently the way that you were presented to the public was something you could very carefully cultivate and manicure—you had almost total control over. But with social media like Facebook, Twitter, Instagram, now people are bombarded with images which they have no control of. You can be tagged in an image that you didn’t necessarily consent to and it’s out there. You may not particularly care for the way you look in that image. That draws out a lot of the angst we see now in our younger patients. There is even a phenomenon called a “profile-plasty.” People want to improve their profile because that’s how they’re seeing themselves presented in social media. It’s important to be sure that a patient has proper motivations for undergoing surgery. Improvement of your appearance and the picture for social media: not necessarily the most proper motivation for cosmetic surgery. 

Are there any situations in which you would refuse plastic surgery? Derby: Not only are there instances, but it’s also your obligation to. For instance, when you’re discussing a procedure with a patient, not even a surgical procedure, but Botox or fillers—if you find that their motivation is not proper then you are obligated to decline to offer them surgery. When in your discussion with the patient you find that their expectations of what a good outcome will be and your aesthetic, your thoughts of what the outcome will be, if those two things don’t mesh then you probably shouldn’t do it; they probably won’t have a good outcome. We want our patients to be happy, so if you’re not seeing eye to eye with your patients then you’re obligated to tell your patients no. I have a couple of patients who come back to see me almost on a monthly basis wanting fillers and they don’t necessarily need any more, and I tell them that. In doing so you engender a trust with your patients, the public, the staff, with everyone you come in contact with. We don’t offer surgery on demand, it’s a conversation. You need to feel comfortable with your surgeon but your surgeon needs to feel comfortable with you as a patient as well. Rodriguez: It’s important to establish with the patient what their expectations are and to know if they’re realistic expectations. You can’t have a patient who is 80 years old come in with pictures from when they were 20 and say, “Can you make me look like this?” You have to explain to the person that this is not something that is going to be possible no matter what technique or how much we try or how much filler we put in. Every measure that we exhaust under the sun, there is only so much that we can do. And you have to know what you’re capable of doing and know what the patient’s expectations are—are they realistic? Derby: It’s my job to make sure that the patient and I mesh, and that their goals are very clear. That I either coached them through why what they’re seeing doesn’t exist, that they don’t need to be so concerned about it and they should be content with who they are because I don’t physically see the deformity that they may identify. That’s equally—in terms of engendering trust—as important to that patient as building a rapport with the population. If you can close the conversation like I do with my patients, with the notion that if you were my family member, this is what I would do for you, it generally breaks the ice completely. There are certain people that you shouldn’t operate on but it’s a process—we have standards. Patients generally respect that highly. Wright: The management of patient expectations is a huge part of what we do that folks just don’t realize. I find that for those patients that come to see me after a consultation or surgery elsewhere, discussing with them what it was that led to the issue at hand, be it a bad outcome or not meshing with that other provider, it frequently boils down to a breakdown in the communication. If you’re having a consultation and feel like you’re not being understood or you’re not understanding what that provider is discussing with you, you have to listen to your gut—it would be foolish to ignore your gut. We’re all surgeons so we form what is considered to be the core providers of a lot of different surgical procedures, but we are doing a fraction of procedures actually performed in this area. A lot of people are injecting Botox. Everybody and their brother is injecting fillers. But we are the core providers for that. So when we are discussing with a patient what they consider to be a good outcome—what are their expectations for a good outcome—and you get to a point where you realize that the level of rejuvenation they’re looking for simply isn’t going to be had with a filler in a way that looks normal and natural, then you’re obligated to start talking to them about surgery. But not everybody who does fillers is a surgeon. So if all you have is a hammer, every problem is a nail. That’s why when you walk around in the shopping malls you can spot from across the room people who are just over-filled. Somebody was trying to get a facelift-type result out of using just filler or just Botox, and that simply doesn’t look natural. That’s a shame but that’s where we are in the business now and that’s likely not going to change. The only thing we can do is inform the patients.

Do you ever combine your services with that of a psychologist? Wright: We all practice psychology! Derby: Completely agree with you. Wright: And that’s to our benefit and the patient’s benefit. There are certain procedures that test your ability to hold your patient’s hand and tell them it’s going to be ok. And you’re obligated to do that not just because you’re a doctor, but because you’re a human being. There are a certain fraction of patients seeking cosmetic enhancements—they carry a diagnosis of Body Dysmorphic Disorder, wherein the impression of what they look like doesn’t mesh with reality—and in those fairly rare cases you’re obligated to gently broach that issue with that patient and chances are that patient already suspects that this is the case. Rodriguez: It’s important to emphasize the consultation when it’s done appropriately—it’s a time-consuming process because it needs to be thorough as far as us explaining to the patient or outlining to the patient what all of their options are: your non-invasive options, your slightly more invasive options and then your most invasive options. Then you need to make your psychological assessment to see if the patient is really understanding what you’re telling them and if their expectations are realistic. At the same time you’re also making your medical assessment—is the patient really medically safe to go ahead? We all come from a background in some other field of medicine before we became plastic surgeons, so we’re all doctors before we’re surgeons. Derby: We each have a little psychologist in us. It is a true relationship. It is certainly not just: appendix burst, go take it out, problem solved. You are with them every step of the way and you’re gauging the whole time whether or not this is somebody that you feel like you can develop a healthy relationship with. You offer them perhaps their breast augmentation in their late twenties or their early thirties, then their mommy-makeover in their forties with breast augmentation and tummy tuck and that transitions into ongoing fillers and Botox and off-the-shelf products like Restalain and Juviderm. And then facial rejuvenation in the older patient population. When I see somebody, I’m really looking at it as a long-term relationship. Rodriguez: When you see before and after pictures of your success stories, and those patients are tired and worn out and look like they’re ready to be thrown aside, and then they’re smiling and happy and they come into your office just extremely grateful—that’s the reason why we do this. Wright: Early in my career I asked a mentor of mine: “How long before your patient that you just operated on is no longer the last thing you think about before you go to sleep as you’re staring up at the ceiling?” And he said: “Never.” You think about your patients all the time. Your desire for them to have a good outcome, your prayers for them to heal well never stops. Rodriguez: The rest of medicine is moving towards a model of 10 minutes with patients, you’ve got to see 60 patients in a day and you’ve got to move and move and move like it’s an assembly line. It’s very impersonal—look at the chart, look at the labs, write the prescription and get them out, get the next one in. And there’s no relationship. Plastic surgery is not like that at all. It takes time and there’s a lot to follow up on. Then when you have a patient that has a good result then those are patients that will be your patients for years.

What would you tell somebody walking into the door wanting plastic surgery, what can they expect? For instance, how long are recovery times? Derby: I tell people in terms of a medical recovery it’s generally about a week. I keep that simple. Bruising and swelling—for the majority it’s present for about a week. After that things progressively improve. I generally tell people you’re not going to be socially ready for a big event, if it’s on the face, [for] about four to six weeks, so I ask a patient—don’t plan to do this two weeks before a wedding. Wright: When a patient asks about recovery, it’s important to ask, what are your intentions—what are you wanting to do? Are you talking about how long before you can take a walk around the block? That evening in most cases. How long before I can go back to work? A week, maybe two weeks. How long before I can start working out again? That’s generally three weeks, and that’s often the toughest pill for patients to swallow. We’re asking them to not do the things that keep them sane. If a patient has an event coming up—if she is going to her niece or nephew’s wedding and she’s at that wedding but not necessarily a centerpiece at that wedding, then that’s six weeks. And if it’s your son or daughter’s wedding where you are definitely a centerpiece in that wedding and you don’t want any aspect of this procedure to interfere with your enjoyment of that—three months.  

An article recently came out on Fox Health about doctors—especially in New York—using Snapchat to broadcast their surgeries. Would you ever consider using this approach in your practice? Wright: There are certain markets in this field that are just different—New York, Miami, LA. Although they have surgeons who are very well-trained, after a while their results just start to look surgical. And that’s not because they’ve forgotten how to do surgery, it’s because patients almost demand it. In those markets, patients want to look like they’ve had something done, almost as if it’s a status symbol. That’s not the case here. I’m overjoyed at that because I wouldn’t be able to practice here. I want my patients to look natural. My biggest compliment is if nobody ever knows a patient was in my office at all. So as far as applying social media, Snapchat, Instagram—my suspicion is that those are used more in an effort to gain notoriety than it is for an educational purpose. I don’t know that anybody ever really learned anything of value regarding facial cosmetic surgery or robotic cosmetic surgery on Twitter. My suspicion is that it’s clever marketing and only that. I rely on my reputation and word of mouth. Rodriguez: I’m very old-fashioned. Most of my patients are from word of mouth and other patient referrals and from other referral from physicians in the community.  Nowadays everybody coming in is a well-informed patient. The older patients use the Internet to go to educational sites—like the American Society of Plastic Surgery—and they’ll look at educational information about surgery or they’ll go to YouTube to watch some of the surgeries done. I’ve seen Millennials come in and they’re more concerned about what my reviews are on whatever site it is that they’re on. I think they are more concerned about what the social comments are on there and less about the educational aspects of the procedure. I know it is important now that our reputations are out there, but the foundation starts within the community and other practitioners and with your patients. Derby: Those are definitely the tried and true methods—a good reputation and just being a good person, being a good guy to your patients. To have another patient come in strictly based on word of mouth, that is a wonderful feeling. As far as social media goes, I don’t think anyone in this room would do anything to compromise patient confidentiality with an app like Snapchat. As easily as information is available these days and you can communicate very quickly with your patients, there are regulations and rules to follow. Using Snapchat is more about being flashy and fancy—I don’t think it would necessarily stand before a medical board.


About Our Participants:

Dr. Harry Wright, MD graduated magna cum laude from Longwood University and completed a master’s degree in immunology, where he published extensively on the subject of wound healing and autoimmune diseases. He earned his medical degree at the Medical College of Virginia where he was the recipient of the Grandis Family Scholarship. Wright completed his residency in head and neck surgery at Vanderbilt University Medical Center in Nashville. Wright was then selected to complete a fellowship in Facial Plastic and Reconstructive Surgery with the American Academy of Facial Plastic and Reconstructive Surgery. His expertise includes rhinoplasty, revision rhinoplasty, laser skin rejuvenation, fat transfer and comprehensive treatment of the aging face. 

Dr. Charles L. Rodriguez, MD is a Board Certified Plastic Surgeon who provides comprehensive plastic and reconstructive surgical care to patients in the Venice Island office of Riverchase Dermatology and Cosmetic Surgery. Prior to joining Riverchase, Dr. Rodriguez was a solo private practitioner for 10 years in Venice. He earned his BA from Harvard University and his doctorate from New York University School of Medicine. He completed his general surgery residency at North Shore University Hospital and his plastic surgery fellowship at Penn State University Medical Center. Rodriguez was recognized for his outstanding skills and honored with the Stephen H. Miller Award for best Resident Instructor as well as Intern of the Year Award in general surgery. Rodriguez specializes in cosmetic surgery, skin cancer reconstructive surgery, breast cancer reconstruction, body contouring and complex wound reconstruction. 

Dr. Brian M. Derby, MD performs aesthetic and reconstructive surgery of the face, breast and body. As a double fellowship-trained oculoplastic and aesthetic surgeon, Derby performs the latest techniques in browlifting, eyelid lifting, smoothing of lower eyelid bags, tear trough correction, complex eyelid revision surgery, facelifting, necklifting, facial/breast/hand fat grafting and fractionated CO2 facial laser resurfacing. Derby regularly employs the most up-to-date techniques for breast augmentation, breast lifting, breast reduction, breast reconstruction, and breast implant selection. Derby routinely assists his colleagues in Sarasota with reconstructive challenges following Mohs skin cancer excision, breast cancer excision, and trauma. In 2015, he was awarded Best Research Paper of the Year by the Aesthetic Surgery Journal at the American Society for Aesthetic Plastic Surgery’s (ASAPS) annual meeting and accepted an invitation to serve as a peer-reviewer of research articles, prior to their acceptance for publication, by the Aesthetic Surgery Journal.