Cosmetic and Qualified

The healthy reality of plastic surgery

by Hannah Westerman; illustration by Olivia Stenholm

When training his residents, plastic surgeon Dr. Herluf Lund has a unique way of explaining why he thinks conversation with a patient is important before removing any clothing for the physical exam. He tells them, “It’s a bit like dating; you really should get to know the young lady before you ask her to take her clothes off.”

Before agreeing to perform a surgery, Lund says, “I want to know what they do. I want to know how many kids they have. Are they married, not married? Are they in a relationship? I want to know about what they are interested in, why they’re interested in it, and then we talk about the procedure, the pros, the cons, the recovery process and then finally we do the exam.”

After the initial conversation, Lund will do a physical exam to judge the practicalities of the surgery that the patient is requesting. There will then be several more conversations between that exam and the actual surgery. Lund stresses that plastic surgery is not a decision to rush through.

After graduating with three bachelor degrees in theater, sociology and biology, Lund attended medical school at Washington University School of Medicine. He completed his general surgical training at the University of Texas at Houston

and then returned to Washington University for his plastic surgery residency. He started his own private practice in 1991.

The theater degree may seem inapplicable to a career in medicine, but Lund actually sees a direct link between his artistic pursuits as an undergraduate and his eventual specialization in plastic surgery.

“Most people I know in plastic surgery don’t go into it for monetary gain because there are far better, faster ways to do it than that. They go into it because they have this kind of weird bent towards the artistic side or the creative side. Plastic surgeons are very innovative people.”

He mentions that the first successful human kidney transplant was performed by a plastic surgeon. Dr. Joseph Murray, a reconstructive plastic surgeon, transplanted that historical kidney in 1954, revolutionizing transplant surgery. Murray went on to win the Nobel Prize in Physiology/Medicine.

When Lund speaks about plastic surgeons, past and present, he talks about them like brothers and sisters in arms. It is a community of doctors often misjudged and sensationalized by Hollywood and constantly under threat of invaders. Lund draws a clear distinction between plastic surgeons and cosmetic surgeons. He discusses how the new title of “cosmetic surgeon” is a symptom of a wave of pseudo-medical boards providing certification to those without specialized training.

By calling it cosmetic rather than plastic, Lund says, “doctors who are dermatologists and ear nose and throat and ophthalmologists and general surgeons and internal medicine doctors and all these sort of peripheral doctors can then claim that they are now cosmetic surgeons. It’s a very confusing situation for the public and it’s not easy, because believe it or not, people form organizations and then claim that this organization is then capable of doing board certification. There are really only 24 recognized boards by most of medicine. There are hundreds of what we call pseudo-boards including one called the American Board of Cosmetic Surgery which does not have a residency program in any way. You can go out and take this written test and pay a fair amount of money and then you get this diploma that says you are now certified by the American Board of Cosmetic Surgery.”

It’s frightening to imagine that the doctors operating on you may never have had the proper training. But Lund advises that ensuring your safety is all about researching your doctor beforehand.

“Do your homework…look for someone who is certified by the American Board of Plastic Surgery, which is one of the 24 certifying boards. That doesn’t necessarily mean that the plastic surgeon specializes in whatever procedure you’re looking for. If you’re looking for someone who’s doing cranial facial, you want to look for somebody who is also a member of that society. Because we have lots of subdivisions in plastic surgery, we have lots of societies. I’m mainly a cosmetic; I’d be a member of the American Society of Aesthetic Plastic Surgery.”

Lund believes that the biggest misconception about plastic surgery is that it is all cosmetic.

“The term plastics means to mold…So plastic surgeons also do a lot of reconstruction, not just breast reconstruction, but people have cancers taken off their face, people have trauma, things like that where you want the plastic surgeons to step in.”

He waxes admirably about the history of his “people.” Sir Harold Gillies, who is widely regarded as the father of plastic surgery, was a doctor

during World War I. Faced with devastating injuries, Gillies wasn’t satisfied with amputation. He wanted to rebuild what was lost. This led to the establishment of the field of plastic surgery.

Plastic surgeons perform all kinds of reconstruction, such as fixing cranial facial deformities or breast reconstructions after mastectomies. Lund mentions that hand surgery was done by plastic surgeons who were used to working on more delicate structures. Currently, a majority of burn care in the United States is done by plastic surgeons. You’ll also find plastic surgeons in the emergency room. Lund has been a plastic surgeon on call for emergency rooms, though he admits he’s getting too old to pull the crazy allnighters required.

Many people don’t even think to look for plastic surgeons in what Lund sees as an extremely influential field. “A tremendous amount of plastic surgeons are in academia, in labs working on things like growth factors and stem cells and all

that. That’s because they’re the guys that are looking for that innovative manipulative thing. How can we trick cells to do things or trick tissues to do things that they didn’t before?”

The myth that plastic surgery is exclusively cosmetic may have resulted from changes in insurance policies. Reconstruction, which involves long and delicate surgeries, used to be well reimbursed by insurance companies and Medicare. Plastic surgeons could make a living performing reconstructive procedures.

“15 years ago though, that suddenly changed. The insurance companies, Medicare, the government started paying much less for reconstruction. Their perception of the value of reconstruction went down to the point that some insurance companies even threatened to stop covering things like  breast reconstruction.”

Outraged at this threat against coverage for breast cancer survivors, Lund and a fellow plastic surgeon drafted a bill that said that any insurance company that offers breast mastectomy as treatment for breast cancer has to also offer reconstruction. The bill, House Bill 192, passed the state legislature of Missouri and went on to influence national law. Despite this win for reconstruction coverage, plastic surgeons were still forced to rely more and more on cosmetic surgeries for income.

Lund has been around long enough to observe the changing attitudes and trends of plastic surgery, particularly cosmetic procedures. The number of male patients is increasing rapidly though the percentage of male patients compared to female patients is still very small. About 10 percent of his patients are male. In Lund’s opinion, women are also much more comfortable talking openly about plastic surgery. He believes this new openness is a factor in the increasing number of procedures like breast augmentations. But cosmetic surgery is more than just breast augmentation. Lund has noticed three particular trends in cosmetic procedures over the last five years that reflect the recent advances in plastic surgery.

“The use of non-surgical treatments to rejuvenate skin or tissues—fillers, different types of technologies that can help tighten skin—that’s gone up dramatically because people want to stay looking younger. In the world of surgery, what’s gone up dramatically is the use of fatty tissue. We now have the technology to be able to borrow fat from one place of the body and to be able to move it to other places of the body to add volume.”

Though Lund specifically mentions that most patients are not coming in asking for a “Kardashian butt,” the biggest area of growth in fat transfer is the buttocks. The procedure is nicknamed the “Brazilian Butt Lift.” His bafflement at the nickname seems to have less to do with its attribution to Brazil and more to do with its procedural inaccuracy. “It doesn’t truly  lift,” he explains. “But it does add volume.”

Another increasing trend, though in much smallernumbers than the other two, is labiaplasty, the trimming or tailoring of the labia. Lund casually muses that the surgical trend may be in relation to fashion trends, specifically tight-fitting yoga pants.

Though Lund clearly supports the destigmatization of plastic surgery, he doesn’t believe that it’s the right choice for everyone. “I probably reject about 10 percent, fifteen percent of the patients that come into the office.”

Some, he says, are rushing into a large decision during an emotional time or lack the maturity to think through the decision. But he mentions another group—patients with body dysmorphic disorder.

“These are people that no matter how they look or how they perceive themselves or how everybody else perceives them, they see faults with their body everywhere. They see faults with their nose. They don’t like their ears. They don’t like the way their breasts look. They’re unhappy. But it’s not a realistic unhappiness. They may have perfectly beautiful facial features or no issues at all with their breasts or issues with their abdomen. But they have no ability to perceive it. These are people that can become plastic surgeon-oholics. They’ll be in the doctor’s office constantly and they may sound like a plastic surgeon’s dream for their accountant, but they’re a nightmare and it’s wrong to operate on those people.”

This is when Lund’s belief in the importance of conversation with patients comes into play. It’s an opportunity to see if a patient is emotionally and mentally stable for surgery. “You actually have to be quite a bit of a psychiatrist to be a good plastic surgeon,” says Lund.

In the midst of psychiatric obstacles, there are many worthwhile moments. Lund describes a boy he once knew who volunteered at a local hospital. The boy was around 16-years-old, and Lund remembers vividly the boy’s bright red hair. The boy grew it out into a red mess of an afro and always wore a big cap. He slouched everywhere he went.

“His mother brought him up to me one day and it turned out that he had really prominent ears. His ears stuck out quite far. And he’d been teased all his life. And so we fixed that and I ran into him about a year later and he had his hair trimmed really short and he was walking upright and he didn’t have the hat on. You used to see this guy and you just thought he was one of those people who slouched, that he was anti-social and now he engaged with everyone. He said ‘Doctor, it’s the ears. You fixed my ears and no one bothers me.’ It made my day. It gave him selfconfidence. That’s the reason the majority of people seek some form of cosmetic surgery.”

According to the American Society of Plastic Surgery, 15.6 million cosmetic procedures were performed in 2014. Over 4.4 million reconstructive procedures for tumor removal were performed. There were also 177,000 for scar revision and 130,000 for hand surgery. Clearly plastic surgery is so much more than the sensationalized spectacle that the public loves to gawk at. Lund takes a firm stance on plastic surgery reality shows like “Botched,” saying that he would never participate in one.

“‘Botched” and other things like that tend to show the bad outcomes and portray it like it happens much more frequently than it really does…I hear this all the time…People will say ‘Oh I could never. Oh I just don’t like plastic surgery. I don’t like those fillers they put in women’s lips. They look so artificial. I would never have a face lift—I don’t want to look like Kenny Rogers.’ And I point out to them that that’s a pretty rare phenomenon that people wind up looking like that. Why you notice Kenny Rogers or why you notice the over-done lips is because it strikes you as so abnormal. The vast majority of face lifts and the vast majority of lip augmentation or whatever will walk right by you and because they were done so subtly and correctly, you don’t notice it.”

The entire field of plastic surgery should not be judged by its magnified mistakes, many of which are not made by properly-certified plastic surgeons. Plastic surgeons have done and continue to do so much for the field of medicine. They improve lives by helping the survivors of trauma or disease. They help a person change something that has been holding them back from developing self-confidence. Most people will either be treated or know someone who’s been treated by a plastic surgeon in their lifetime. When you look at the reality of plastic surgery, the stereotypical assumptions about the type of people who perform it and receive it are false. A plastic surgery patient can be anyone, and a plastic surgeon is just a doctor trying to do what’s best for the patient.