Face to Face: Surgeons Trade Secrets

The face of actress Catherine Deneuve flashed on screen. An exquisite oval, high of cheekbone, firm of jawline with a perfectly projecting chin. “Look at Vogue, Cosmo, GQ,” cosmetic surgeon H. George Brennan was saying, “all these beautiful faces have ideal underlying skull structure. . . .”

The message was clear. All the nipping and tucking money can buy won’t help if your inheritance from the family gene bank includes skimpy temples, a flat forehead or receding chin.

Selective ‘Augmentation’

What will help? Perhaps a “designer implant.”

In the past, Brennan said, “Our approach to face lifts was simply to tighten the skin. What did we have at the end? Someone who was tight and ugly.” But now, with selective silicone “augmentation,” he added, “they look better at 45 or 50 than they did at 17.”

Implants, fat fills for aging hands and refinements in liposuction--the fat-sucking procedure that in five years has become the nation’s most demanded cosmetic surgery--were among attention-getters as 150 surgeons gathered in Newport Beach through the weekend for the third annual symposium of the Foundation for Facial Plastic Surgery.

There were workshops, too, on public relations and advertising--what one doctor described as “physician, sell thyself”--on dealing with “window shoppers” (consultation fees is one way) and on “How to Prevent a Lawsuit.” (More than one doctor showed a picture of a surgical mishap at his own hands).

Good Job of Selling

With 500,000 cosmetic surgeries now performed each year in the United States--93% on women--surgeons seem to be doing a good job of selling. But an increasing patient load is not likely to translate to lower fees charged by U.S. cosmetic and plastic surgeons, only 5% of whom are women. According to figures quoted at the conference, the average price for a nose job today hovers around $3,500, while a new chin can cost $2,500.

But Brennan, a Newport Beach surgeon who is founder-president of the foundation, looks on cosmetic surgery as an investment. It is the young face that is valued socially and in the workplace, he said. “This isn’t narcissism. This is survival.” And, he said, a $4,000 nose job on a teen-ager translates to “pennies a day” by the time she is 65.

The subject was new faces of 1988. Dr. Pierre Fournier, a pioneer in liposuction, had come from Paris with a report on liposculpturing, a technique for removing jutting jowls, chipmunk cheeks and second chins by sucking out the fat manually with a syringe.

Fournier is inventor of the “hand fill,” a procedure wherein aging hands with prominent veins are transformed into chubbily youthful hands through injections of fat cells removed from a better-padded part of the body. “It must be your own fat,” he said in an interview, “but almost everybody has a nice fat bank.”

He uses the same technique to plump up aging faces, a procedure he developed through experimentation on his own. Fat injection, he says, is a viable technique for “any part of the body where volume is needed,” including the breasts although, he said, “they don’t want to hear of this in the States” because doctors fear it may interfere with detection of tumors.

Fournier no longer uses a liposuction machine, similar to a vacuum cleaner, to remove fat cells, preferring the control a syringe affords. Slapping his right thigh he said, “If you remove three syringes in one saddlebag”--he slapped his left thigh--”you remove three here.” With a machine, he said, his lips making an exaggerated whooshing noise, unevenness is a real danger.

Dr. S. Randolph Waldman’s presentation was on the lips of the ‘80s, which he described as “large, large lips,” diamond in shape. There is hope for aging lips that have, as the Lexington, Ky. surgeon put it, lost their “youthful pout.” Fat injections, implants and “lip lifts,” achieved with a thin incision beneath the nose, are among possibilities.

In the area of what one doctor dubbed “designer genes,” the chin implant is the most popular, followed by cheeks (to achieve a Linda Evans-Bo Derek ideal.) “You can get small, medium or large,” Brennan said, or, if money is not a consideration, opt for something custom-made in the range of $1,500-$2,500 per implant. Because the silicone rubber is solid, not a liquid, the new chin or temples will not “migrate,” Brennan said.

Mid-facial implants, he said, are growing in popularity with Asians, who frequently are flat in the areas alongside the nose and under the eyes. And forehead implants can take care of concave foreheads, “very common in men.” Pear-shaped faces? “Ideal candidates for temple augmentation.”

Anglo beauty standards have been eagerly adopted by Latin-American women, said Dr. Samuel Rosete of Mexico City, but Rosete said he encourages patients to augment without de-ethnicizing. He smiled. “Everyone wants a Brooke Shields nose,” but this nose may look “ridiculous” on a Latin face. “We do fewer cheekbones in Mexico,” he added, “because we have high cheekbones” to begin with.

Dr. M. Eugene Tardy Jr., who teaches surgery at University of Illinois, emphasized that doing a face is not like “making pottery,” that faces are asymmetrical, that not everyone should have the same nose, ears and lips and sometimes the best advice to the patient is to tell her “things are really very nice the way they are.”

“The enemy of good is excellent,” Dr. Stewart Fordham, a Los Angeles plastic surgeon, was saying. He tells patients, “I can only go so far. Maybe you should go to someone else. They want a Sophia Loren this or a Robert Redford that. Well, those people were born that way.”

Fordham, who has degrees in psychology and art as well as medicine, says the facial surgeon is an artist but, unlike an artist, “can’t make a nose and say, ‘Oh, come back next week and we’ll move it around a little bit.”’ He cautioned colleagues not to become preoccupied “with current popular concepts of idealized human features” at the expense of good judgment and anatomical soundness.

And, he has learned, “You never can predict the results, no matter how good you are.”

In the ‘70s, he said, surgeons were giving women cute, upturned noses but “many of these women had difficulty breathing. One surgeon said, ‘Make the nose look good. They’ll breathe through their ears.’ ”

Fordham said he has been getting very good results with a skin expansion technique for removal of tattoos, which heretofore responded only to burning or sanding, both of which cause scarring. The procedure involves insertion of a silicone device filled with sterile water under the skin for eight weeks. When the device is removed, the stretched skin is used to cover the tattoo.

Brennan said cosmetic surgery has reached the stage where “usually in a week, (the patient) can fool the world,” able to make a public appearance without “looking like they’ve lost a fight.”

Still, he cautioned: “Patients have to realize that cosmetic surgery is surgery. It is not magic. And there are potential risks,” such as anesthesia reactions and scarring.

In the field, the distinction is made between plastic surgeons (those who do reconstructive repair surgery) and cosmetic surgeons (those who do elective beautification procedures). However, the cosmetic speciality was not established when this organization was founded in 1977 and it has retained its original name.

Dr. Keith J. Wahl studied a face that, captured by video camera, was being projected on a TV screen and he suggested that a forehead lift might be in order. “As people get older,” he said, “their eyebrows come down and they tend to look angry and sad.” But that can be righted with a hairline incision and a little tucking.

Wahl talks in terms of the three Rs of cosmetic surgery, “resurfacing, replacing, reshaping.” With aging faces, he said, “It’s like dealing with a sofa that’s been sat on a long time.” It needs to be rebuilt and then recovered. Thus, implants and skin peels.

In his San Diego practice, Wahl uses computer imaging to design new faces. He shows patients their “before” faces on a TV screen, then asks, “What is it you see about yourself that you’d like to change?” Often, he says, they respond, “Oh, my God, I look like that ?” and it is not uncommon for them to opt for what doctors call “adjunct” procedures. Someone who came in for a new nose, for example, might also have jowls removed.

Computer imaging makes it possible for the doctor-artist with his magic wand to draw, and re-draw, new and improved features on the patient’s TV image until he and the patient are satisfied.

“Some doctors pooh-pooh it,” he said. “They think it’s hucksterism.” But Wahl, who is an etched-glass artist as well as a cosmetic surgeon, tends to dismiss the skeptics as people who just “don’t have the artistic skills” to use imaging effectively.

What else is in the facial cosmetic surgery future? More implants, the surgeons agreed, and, in the view of Fournier, more “removing fat and recycling it.”

Fordham spoke of preventive measures and said he is optimistic that doctors will be able “to retard hair loss” through drugs that will act on the male hormones.

Do these doctors take their own medicine? Brennan smiled. “I can’t name names but I’ve operated on many of the people here.”

The challenge to cosmetic surgeons, as he sees it, is to “get people to break certain philosophical and religious barriers” and reject the idea of growing old gracefully. “There’s so much work out there to be done. . . .”