GOOD HEALTH MAGAZINE : Medicine...

Over the past decade and a half, Dr. William Wei-Lin Shaw has performed some of the most miraculous operations imaginable. He has sculpted new body parts--feet and hands and mouths--from ones grotesquely malformed at birth. He has reformed faces--jaws and noses and chins--eaten away by cancer. He has reconstructed appendages--legs and scalps and genitals--severed by machines or crushed in automobile accidents.

During the past 15 years Shaw also has done tummy tucks and face lifts and nose jobs. He has made small breasts large and beefy thighs slim. He has pinned protruding ears and lifted sagging buttocks. Eyelids, cheeks, necks, ankles--virtually every part of the anatomy that is subject to the toss of genetic dice or the ravages of time is a candidate for his expertise.

Shaw is a plastic surgeon.

Like many in his speciality, the 48-year-old chief of plastic and reconstructive surgery at UCLA has undertaken a variety of surgical cases, some of which are considered beyond hope, others that are debatably outside the bounds of necessity.

Plastic surgery is a field of medicine that has grown phenomenally over the past two decades. In the past 10 years, the number of procedures has doubled. Last year alone, there were at least 2 million plastic surgery operations in the United States. This year about one in 100 Americans will undergo plastic surgery, although estimates vary since plastic surgeons are not required to report the number or kind of procedures they do.

Thus far, most operations, more than 60%, have been classified as “reconstructive”--that is, they involve functional rehabilitation of parts of the body maimed by accident, disease or birth defect. Because they are considered medically necessary, reconstructive plastic surgeries are covered in large part by health insurance.

The rest (and by far the fastest-growing area of plastic surgery) are operations that are considered “cosmetic”--that is, purely aesthetic procedures designed to perfect the look of the body. Although prices range from a few hundred dollars for nonsurgical treatments, such as collagen injections to smooth wrinkles, to more than $10,000 for face lifts and hair transplants, patients must pay most, if not all, costs themselves.

Cosmetic surgery is no longer the prerogative of actresses or aging dowagers. Today’s typical patient is, according to the California Society of Plastic Surgeons, a product of “Mainstream U.S.A.”

A recent survey by the Chicago-based American Society of Plastic and Reconstructive Surgery found that fewer than one quarter of all cosmetic surgery patients had household incomes of more than $50,000 a year. About a third were in the $25,000 to $50,000 bracket, and another third had household incomes of $25,000 or less. (Nearly 10% did not state their income.)

“Even in Los Angeles, the entertainment capital of the world, a patient for cosmetic surgery is as likely to be a schoolteacher as she is to be a starlet,” says Dr. Henry J. Kawamoto, president of the California Society of Plastic Surgeons.

And the she may be also a he . Although men represented about 5% of plastic surgery patients in the early 1980s, they now make up 20% to 25% of such patients, according to a number of estimates.

The popularity of cosmetic surgery is said to be a by-product of two sociological phenomena: divorce and dieting. While dieting can result in sagging skin, divorce demands that people, sometimes late in life, start looking and feeling their best. And what better way to build confidence than with a new head of hair or a new set of breasts?

Women, especially feminists, it would seem, might have compunctions about subjecting themselves to the pain and risk of plastic surgery for purely cosmetic reasons. Not so, insisted Ms. Magazine. Women may have burned their bras in the 1960s, but in the 1980s they have come to prefer bigger bras to no bras. Cher, who may have has succumbed to the surgeon’s knife as often as any modern entertainer, is, according to Ms. editors, an exemplary 1980s feminist. She has used cosmetic surgery as a way to “reinvent herself.” Plastic surgery is for “real women” who “dare to take control of their lives,” the editors said in the magazine.

Not everybody is so enamored of plastic surgery.

“It (getting plastic surgery) has to do with a feeling of entitlement--with believing you are entitled to have a perfect body,” explains one Los Angeles psychiatrist, many of whose patients have considered cosmetic surgery. “As far as I’m concerned I am entitled to a perfect body only after I have a perfect personality. As soon as I’m always nice, always patient, always insightful, then maybe it’s time to start thinking about letting someone work on my behind and belly with a knife.”

Like many plastic surgeons who are highly trained and whose skills are much in demand, UCLA’s Shaw has little time for jokes or philosophy.

The question of who needs help the most, who is most deserving of treatment--those are distinctions that Shaw, as a surgeon, is unwilling to make. To be sure, he says, there are cases at the ends of the spectrum: A child with a congenital cranial deformity that makes him look positively monstrous is surely more in need of a plastic surgery than a perfectly gorgeous actress who wears a size C bra but would prefer a size D. But what of the child with a severe birthmark versus a woman with abnormally small breasts or a man with abnormally large ones? Is one more worthy of a surgeon’s attention than another? Does one have more severe psychological problems than the other? How is a doctor to choose?

The role of a plastic surgeon is to be an architect and artist as well as a physician and surgeon, Shaw says. He is as pleased to help a patient enjoy the finer things in life as he is to help another regain some semblance of normality.

Shaw’s job, as he sees it, is not to save lives but to improve the quality of life. That means reconstructing body parts both so they function better and look more appealing.

“What has happened to plastic surgery over the past century and in particular during the past 20 years is the story of what is happening to all medicine,” Shaw says. “Where doctors once worked solely on major epidemics and other matters of life and death and pain, they can now focus on how to improve lives. Some of the life-and-death questions, of course, remain. But the focus in medicine has clearly shifted.

“More and more, the emphasis is on improving form and function, which is what plastic surgery has always done. It is simply a field (that has been) ahead of its time.” Time was when cancer victims had to live with having their bodies mutilated by surgery. Survivors of accidents often had no choice but to have one or more limbs amputated. Thanks to plastic surgery, working in tandem with orthopedics, neurology and other specialties, that is no longer the case.

For years, before coming to UCLA, Shaw had been director of microsurgery at New York University and chief of plastic and reconstructive surgery at Manhattan’s Bellevue Hospital, an inner-city medical center renowned for salvaging traumatized limbs.

Even in a field that has long been considered progressive, Shaw was viewed as something of a maverick because of the lengths to which he went to perfect both the art and science of his work. The result in New York was an impressive track record and a spectacular list of “miracle” surgeries.

In an eight-hour-long operation in 1979, Shaw and a team of five doctors and as many nurses made headlines for successfully reattaching the leg of a New Jersey policeman who had been crushed between two cars. In another multi-hour operation that year, also involving a large operating team and sophisticated reconstruction techniques, Shaw reconnected the severed hand of an aspiring young musician who had been pushed in front of a subway train. In 1985, in an operation involving eight doctors, all of whom were simultaneously working on two other trauma victims, Shaw and his colleagues again made headlines, this time for reconstructing the legs of a Manhattan woman who had been pinned for six hours beneath a fallen construction crane.

Within months after coming to Los Angeles, as chief of UCLA’s plastic and reconstructive surgery department, Shaw had overseen equally difficult and extraordinary cases. In 1989, for example, UCLA surgeons reattached the scalp of a young Los Angeles factory worker whose entire head of hair, from the top of his forehead to the nape of his neck, had become entangled in a machine and had been ripped off his head.

This fall, members of the UCLA plastic surgery team operated on another male, a psychiatric patient who had amputated his own penis with a knife.

The policeman whose leg was severed is now retired from the force but has a working leg. The woman whose legs were crushed spends her summers walking five miles a day on the beach. The musician whose hand was severed--though not able to play the flute at the concert level--is an occupational therapist, helping others recover from similar traumas. The factory worker is back at work with a full head of hair.

Only the fate of the young mental-health patient is in question. Even he has made tremendous progress. Already he is urinating normally and his doctors have reason to hope that one day he may even have normal sexual function.

“Twenty years, even 10 years ago, these operations would have been unthinkable,” says Dr. Jay Orringer, who directed the surgery. “Today they have become almost routine.”

The routine, however, is far from simple. Although many cosmetic procedures are done in outpatient clinics or in private physicians’ offices and take anywhere from two to six hours, complex reconstructions are invariably done in sophisticated medical centers and can take the better part of a day or night.

By almost any standard, the surgical teams are enormous in size, often including numerous plastic surgeons, several anesthesiologists, half a dozen nurses and, depending on the procedure, a neurologist, an orthopedist, a urologist or any number of other specialists. Often, psychologists and psychiatrists are called upon to counsel the patient after surgery.

The procedures themselves are painstaking, highly complex ordeals. Plastic surgeons have learned that they cannot simply reattach severed parts or casually cut out excess body tissue. Bones must be carefully set together if the body is to be properly reshaped; nerves must be painstakingly reattached if sensation is to be maintained; blood vessels must be reconnected if tissue is to remain alive.

Because the tissues involved are often so small and so delicate--nerves are the size of thin spaghetti, and blood vessels can be even finer--plastic surgeons frequently must work under a microscope with needles barely visible to the naked eye and thread too fine to be seen except when it catches the light.

Microsurgery--the technology that helped to save the young man’s penis, the musician’s hand and the factory worker’s scalp--has been in use for the past 20 years, but recent advances have broadened the speciality.

Perhaps the most dramatic application has been in Shaw’s area of speciality--what is known as “microvascular free-flap surgery.” Essentially, this surgery involves removing bone, muscle, skin or fat from one area of the body where tissue can be spared and transplanting it to where it is needed.

For example, rather than enduring a disfiguring mastectomy, women with breast cancer can now have a diseased breast removed by a general surgeon and another breast constructed by a plastic surgeon from tissue in the abdomen or buttocks--all in one operation.

Before microvascular free-flap surgery was developed and refined, surgeons were forced to rely on artificial implants or simple grafts of skin and bone. Too often, the artificial implants would be rejected by the body and the grafted tissue would die, which meant more operations and longer hospital stays, explains Dr. Harry Buncke Jr., of Davies Medical Center in San Francisco, the first American to use the free-flap technique on humans. But free-flap surgery has overcome both of these problems by moving functioning blood vessels and nerves along with transplanted tissue.

Eventually, plastic surgeons hope to use these techniques to create “living spare parts” for plastic surgery. As hearts and livers are now transplanted from recently deceased donors, so arms and legs and noses may one day be successfully transplanted to traumatized or congenitally deformed patients.

“The only challenge that remains in our way,” Shaw told an international conference of prominent plastic surgeons last year, “is controlling the body’s tendency to reject foreign objects, without seriously compromising the patient’s ability to fight off infections. We are making progress.”

The next step, Shaw says, will be to create artificial body parts that are surgically infused with living blood vessels and nerves. Although this may sound like science-fiction, it is now being done on an experimental basis in animals. And only last year Shaw used the method on a cancer patient whose nose had been completely eaten away by disease and chemotherapy.

Starting with bone tissue from the patient’s pelvis, Shaw shaped what was essentially a prosthetic nose. He then implanted the “nose” with man-made blood vessels and surgically attached the appendage to the patient’s arm. There, blood vessels had an opportunity to establish themselves and begin to grow. Finally, when it was clear the nose was alive and functioning, Shaw surgically removed it from the patient’s arm and attached it to the patient’s face, where it now functions normally.

In a different but equally futuristic arena, plastic surgeons are also experimenting with ways to operate on patients before they are born.

Last fall, for example, Dr. Walter Sullivan, chief of plastic surgery at Wayne State University and Children’s Hospital of Michigan, published reports of the success he has had in repairing cleft lips “in utero.” Although only performed on mice, the experiments illustrated the apparent ability of the fetal tissue to heal without scars.

“This,” according to Sullivan, “offers two possibilities that could revolutionize medicine: First, we may be able to spare children the necessity of living with disfiguring birth defects or the scars that normally occur after corrective surgery. And second, if we determine precisely why fetal tissue does not form scars, we may be able to harness that characteristic and apply it to adults.”

In other areas, plastic surgery has already been revolutionized. New and detailed understanding of the anatomy of the brain, for example, has allowed plastic surgeons to be much more aggressive in treating trauma cases of the head and in correcting deformities of the face.

Plastic surgeons can now safely open the skin on the head and cut loose bones so that eye sockets can be repositioned and the shape of the head itself can be re-formed. Gaps in normal bone structure can be filled in with bones from the patient’s rib or pelvis. Cranial bones that are too prominent can be filed down. Dr. Paul Tessler, a French plastic surgeon, is generally credited with having been the first to develop these techniques in the 1960s, but they are now widely used in hospitals and medical centers.

Among the patients who have undergone such surgery are children who suffer from Down’s syndrome, a chromosomal aberration that results in facial deformities as well as mental retardation. In some quarters, the operation has been controversial because it is seen as benefiting families more than patients.

Recent studies have shown, however, that following reconstructive surgery, Down’s syndrome children are assumed by other children to be friendlier and more intelligent than those who have not undergone such procedures. If that is the case, many psychiatrists and educators agree, it could have a dramatic implications for these children’s social lives and their performance in school.

But what about people who use plastic surgery to improve on what is already normal? Are the results as dramatic for them?

Presumably, given the frequency with which they undergo it, many actors and models think that plastic surgery enhances their careers. Anecdotal evidence also suggests that in executive suites promotions are more likely to go to individuals who appear young and energetic. As a Wall Street Journal story put it, “A new face may not get you promoted but many executives think it can help.”

Troubled about the possible adverse emotional consequences of remodeling the body and face for purely cosmetic reasons, psychologists and psychiatrists have begun systematic studies of the effects of plastic surgery on patients. So far, the evidence has been somewhat contradictory, although it is clear that body image can have a profound impact on a person’s emotional well being, according to USC psychiatrist Dr. Marcia Kraft Goin, author of the 1981 book “Changing Body: Psychological Effects of Plastic Surgery.”

The good news, Goin says, is that with time most people adjust to changes in their appearance. The bad news, according to Mary Ruth Wright, a psychologist at Baylor College of Medicine in Texas, is that even when the change is for the better, flatter stomachs and smoother faces do almost nothing to change an individual’s relationships with other people.

Many of the techniques that have so revolutionized reconstructive surgery have made cosmetic surgery safer, better and longer-lasting. Face lifts, for example, used to do little more than tighten the skin of the face, with results lasting only about two or three years. Now plastic surgeons literally lift up the entire face, removing skin where there is too much, adding fat where there is too little, shifting muscle where it is necessary.

One of the procedures growing fastest in popularity was developed in the late 1970s by another French plastic surgeon, Dr. Yves-Gerard Illouz. Known by various names, lipoplasty or “body contouring” is a procedure that surgically sucks fat from the body.

Although no remedy for cellulite, stretch marks, flabby skin or overall obesity, the technique can be used on buttocks, ankles, abdomens, flanks and other parts of the body where recalcitrant fat protrudes and resists diet and exercise.

The risk of serious complications from these and other procedures has diminished in recent years, but that does not mean there are no risks associated with plastic surgery. The danger of excessive scarring, life-threatening infections and other complications runs about 5%, although it can average as high as 10% for liposuctions and abdominoplasties, otherwise known as “tummy tucks.”

Perhaps the worst problem for would-be patients is finding a surgeon. Not that there is any dearth of them. There are so many with so many different kinds of qualifications that patients have no idea where to begin looking.

Many surgeons, even the good ones, are increasingly doing operations in offices and clinics rather than in hospitals or medical centers. Although having a minor operation done in a well-equipped clinic is not necessarily dangerous, having any operation done by a surgeon who is not well enough qualified to be affiliated with a reputable hospital can be dangerous indeed.

In Washington last spring, the House of Representatives Subcommittee on Regulation, Business Opportunities and Energy heard one horror story after another from patients who were the victims of botched surgeries by incompetent surgeons.

Following a six-month investigation into alleged unscrupulous practices by under-qualified physicians, the subcommittee’s chairman, Rep. Ron Wyden (D-Ore.), concluded that plastic surgery is “a dangerously under-regulated medical field” where physicians can practice with no special licenses.

Although speciality boards were created to standardize credentialing, there are now thought to be several dozen such boards in plastic surgery. Only one--the American Board of Plastic Surgery--is recognized in plastic surgery by the American Medical Assn. and the American Board of Medical Specialists and requires written and oral examinations, a minimum of a three-year residency in general surgery or orthopedics and an additional two to three years of specialty training in plastic surgery.

The American Society of Plastic and Reconstructive Surgeons, the main professional organization of these board-certified plastic surgeons, has done its best in recent years to warn consumers of the hazards of going to under-qualified doctors. But recently it also, in the view of some critics, has exacerbated the problems by equating cosmetic surgery in the public’s mind with vacations, cars and ordinary household purchases.

In October, the society introduced a nationwide financing program, not unlike those offered by some individual surgeons, to help middle-income individuals find a way to pay for plastic surgery. Administered by Household Retail Services Inc., a subsidiary of Household International Finance, the program features loans that promise “no drain on credit-card limits, no annual fee, small monthly payments, no minimum financing amount, prompt credit approval and confidential arrangements.”

Explains Dr. John Jarrett, president of the society: “Financing plans have made options like vacations, a second car or a change in furniture possible for middle-class Americans--and cosmetic surgery is no exception.”

The federal government has unwittingly contributed to problems associated with plastic surgery when the Federal Trade Commission in the late 1970s opened the way for doctors to advertise their services.

Since then, the public has been deluged with aggressive advertising campaigns, some quite misleading.

One of the best known came to light during the hearings of the Subcommittee on Regulation, Business Opportunities and Energy. It involved an eight-page fold-out in Los Angeles Magazine that featured, among other things, a well-endowed female model clad in a bathing suit and standing next to a sleek sports car. “Automobile by Ferrari. Body by Forshan,” the ad read.

In fact, the subcommittee concluded that Dr. Vincent Forshan, a plastic surgeon from Rancho Mirage who placed the ad, had never worked on the model. She had been the patient of Dr. Charles Smithdeal, a Los Angeles plastic surgeon. Smithdeal subsequently took out his own ad, using the same model, another Ferrari but a slightly different message: “Body by Smithdeal.”

“Advertising is a two-edged sword,” concludes UCLA’s Shaw. “It is important for the public to be aware of what’s available in a field that is changing so rapidly and (that is) capable of doing so much for so many people.”

On the other hand, he cautions: “The ability to advertise bears no correlation to the ability to operate.”

WHAT IT CAN COST

Average Price Range Procedure National California New York Liposuction $830-1,750 $967-2,088 $1,397-2,264 Eyelids $1,800-2,330 $2,072-2,570 $2,099-3,117 Rhinoplasty $1,974-2,370 $1,887-3,135 $2,384-3,217 Breast Augmentation $1,974-2,370 $2,289-2,825 $2,509-3,067 Facelift $2,980-3,860 $3,153-4,216 $3,928-5,534

Male plastic surgery: Repair (e.g., of dog bite wounds) Scar Revision Burn Care Tummy Tuck Cheek Augmentation Collagen Injections Hair Replacement Nose Reshaping (rhinoplasty) Hand Surgery (trauma and/or birth defect) Female plastic surgery: Eyelid Surgery (blepharoplasty) Breast Lift (mastopexy) Buttock Lift Liposuction Birthmark Removal

MAN’S GROOMING BY COLETTE TABER FOR CELESTINE COUTIER, L.A.