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deep admiring for my co-authors, I bow low before them and say: Thank you, thank you so much.
When I was starting my office in Bonn, Germany, I had a patient from Luxembourg who is a writer and painter. He had an ugly, deep-impressed scar in the lower half of his nose. In another clinic somebody had excised this and sutured the edges together. Soon af- terwards the scar was depressed and as obtrusive as before. The patient asked me, “Could you do it so that this scar will not be so striking, so conspicuous?” I thought of multiple Z-plasty and answered, “Yes, but it is a more complicated and demanding technique.”
He agreed.
Even when the nose did not become perfect by far, the patient was satisfied, because a decent job had been done. He came to us and asked for blepharoplas- ty, forehead lift, facelift, and liposuction of the trunk.
But he did not suffer from body dysmorphic disorder.
After the fourth surgery, he tried to convince his wife, without success, to have liposuction in our clinic. He When I was starting this publishing project more
then 2 years ago I modestly asked my publisher Springer if they would accept publishing work by 10, 12, or perhaps even 15 world-renowned celebrities in this field of surgery, if they agreed to write their guest chapters. Gabriele Schroeder from Springer said “You may try”. From the 15 I started to dream of, all 36 co- authors made their efforts in this very busy world and submitted their contributions motivated by the wish to help the young plastic surgeon to whom this book is addressed, because they are all inspired by the spir- it of love, humanity, harmony, beauty, and friendship.
I am looking at this wonderful necklace of 36 pearls shining not only with excellent ideas but also with profound wisdom. They spread their knowledge for the sake of aesthetic plastic surgery, its patients and our younger colleagues who will mostly benefit from it – not only are excellent techniques described and
“prescribed”, but also very wise advice on how to make our surgeries as safe as possible. Touched by
Final Philosophy
Dimitrije E. Panfilov
Fig. 75.1. a Very striking, impressed scar in the lower half of the nose. b Multiple Z-plasty planned. c Three months later the scar became unobtrusive
then made a present for my wife, who serves as the
“good spirit” of our clinic: ten self-recorded audio cassettes with country music – they are both very fond of it. He became a good friend of our clinic. And the story started with a simple scar. One of Solomon’s sentences in the Bible says: “Who wins a friend, gains riches.”
I learned the following lesson in 1995 in Yokoha- ma.Joseph E. Murray (Harvard Medical School, USA) is the only Nobel Prize winner among plastic sur- geons. He was awarded the Nobel Prize in 1990 for, among other things, successfully conducting the first kidney transplantation on twins in 1959. After this, almost one million patients could profit from his method. Murray conducted much research on the physiology of kidney transplantation, he became founder and president of many medical societies. For many years he was president of the American Asso- ciation of Plastic Surgeons.
At the opening of the 11th World Congress for Plastic, Reconstructive, and Aesthetic Surgery in Yo- kohama, on 16 April 1995, he delivered the following ceremonial speech: “Plastic surgeons in surgical prog- ress: skin grafts, transplantation, microsurgery and craniofacial surgery”
He started off with a 5-cm-wide circular burn on the back of a female patient’s foot. He continued with further slides: the surgically cleansed defect, trans- planted skin taken from the patient’s body covering the defect at 1 day, 1 week, 1 month, 1 year.... Some of the 1,400 plastic surgeons gathering there from all over the world are stunned: “Why does the Nobel Prize winner start off this key lecture with such sim- ple surgical procedures which even beginners in our profession are able to conduct?” The answer came with the following slide: “This is what the wounded foot looks like 20 years on. This Jewish woman has become my office’s best friend. She referred more pa- tients to my practice than all public relations activi- ties were able to attract. My dear colleagues, if you manage to win many friends in your offices, then you are on the right track.”
That set the tone. He had started off very low-key, very modest. After that he presented his numerous highlights–he did even this without pretension but with a philosophical undertone. Meanwhile he de- fined the qualities of a good scientist. He counted three:
1. Curiosity 2. Fantasy 3. Endurance
Apparently, these three qualities are sufficient.
After the 45 min talk I could not help myself, I had to congratulate this noble man. With his initial drum- beat he expressed my sentiments exactly. I will never forget the moment when I felt his hand in my hand: it was like touching the divine kindness itself. A rather extraterrestrial feeling.
I wanted to invite him to our symposiums which take place every second year. I therefore asked him for his business card. “I don’t have one”, he said without any fuss and started writing down his address and telephone number on my business card. “Do you not have business cards as a principle?” I asked, not very smartly. “I don’t have any principles either”, he re- plied. I must have screwed up my face into the shape of a question mark. He smiled and went on: “You know, principles are often just patterns of behaviour which come into use when stimulated from outside. I prefer to react with my complete nervous system – as I was somebody else yesterday, am somebody else to- day, and will be somebody else tomorrow. As humans we are constantly changing....” Within 5 min of small talk, this unusual person managed to convey to me a kind of knowledge which some teachers have failed to achieve in 5 years.
Paracelsus said: “The true ground of medicine is love.” But the love cannot be taught. It is immanent – one has it or not. Illustrative of this is Fred’s sentence from the anthology Children’s Letters to God: “Dear God I would like to become a physician, but not for the reason, you would imagine.”
From my first teacher, the late Peter Rudolf Zellner, I learned the importance of photographic documen- tation. While on duty during night I had an unusual injury of the hand to operate on and found an inter- esting and original operative solution. At the morn- ing conference I explained what I had done. My chief asked, “Did you take photos?” “No, I was so excited with new idea”, I answered. “Then you have operated in vain, nobody will believe you.” Since that time I have taken over 60,000 photographs, documenting every step. The photographic documentation in this book would not exist if I had not learned this lesson.
My last teacher, Gottfried Lemperle in Frankfurt, now living in San Diego, also became my friend. His chapter in this book is extremely important. He did not teach me only the surgical technique, but also the scientific work and how to think over all medical rules and dogmas critically again. It was very impor- tant for me, so I am proud to have written some chap- ters for his books. For the journal Aesthetic News we did not dare write “ten commandments” but we wrote
“ten don’ts” together, which I am allowed to repro- duce here by permission of the Aesthetic News editor.
What an aesthetic-surgically active physician must never do:
10 Dont’s
1. Do not risk a “beauty surgery procedure” with- out having received thorough training in this particular field beforehand – best become a plastic surgery specialist (after all, one does not steer an airplane without having finished pilot training).
2. Do not start consultations, operations or visi- tations under time pressure. Patients need your full concentration: Your relaxation provides a pillar of confidence.
3. Do not recommend a surgical procedure which you would not also, in the same way, conduct on your wife or daughter. Never take an opera- tion lightly – even if you are well-experienced.
4. Do not make promises about an aesthetic op- eration which cannot possibly be kept by surgi- cal methods. Do not keep back any informa- tion on particular difficulties and do not play down any possible complications.
5. Do not call a consultation finished before ev- ery single inquiry by the patient has been talk- ed about appropriately. You do not want to sat- isfy yourself but your patients: they often have a different idea of what they want. Never agree to an aesthetic operation unless there is a real chance of improvement.
6. Do not agree to make an operation on just any patient. An obscure motivation and unrealistic expectations will lead to frustration on both sides.
7. Do not conduct surgery on a patient without thorough examination preceding the opera- tion. You must not agree to, or make a state- ment about an operation on the telephone or based on a photograph. Find out about the pa- tient’s mental condition, look inside a nose that supposedly needs to be operated, test the state of the skin, examine a breast for possible lumps, do the “pinch test” preceding liposuction.
8. Never attempt to break new time records dur- ing the operation. If you were your own patient you surely would not want to be operated in re- cord time. Maximum concentration is neces- sary during the operation: a talkative surgeon is as dangerous as a talkative taxi driver.
9. Never be unavailable for your patients after the operation. This is the duty of a conscientious surgeon.
10. Do not believe you did not come across com- plications, do not believe you had no unsatis- fied patients. They are part of our medical field; even the best experienced surgeon has them. Look at them with the eyes of your col- leagues.
One really should not try to lift all faces definitely and for ever. After older plastic surgeons come younger ones and they shall have the chance to do or redo some good job. We should remember what the French surgeon Ambroise Paré said in 1575:“I am only dress- ing (bandaging) you, God will cure (heal, recover) you.” Udo Fiege, a plastic surgeon from Düsseldorf and a friend of mine, expressed it more cynically:
“Plastic surgery is the only handicraft where the ma- terial itself repairs the failure in its work out.”
Still, no plastic surgeon in the world can say they have not had any complication. Well-educated and experienced surgeons very seldom have complica- tions, and these are mostly minor complications, which we are able to treat successfully. Ulrich Hin- derer, co-author of this book, was secretary-general of the International Confederation for Plastic Surgery for 8 years. He is not only an excellent surgeon and very productive scientist, but also a great lecturer and friend–“everybody’s darling” so to say. He, however, had a unique complication. Finishing his key lecture
Fig. 75.2. Ulrich Hinderer and his beautiful “complication” at the ESPRAS congress in Rome 2001
in Kloster Seeon at the National German Congress 1999, he spoke about facelifts and possible pitfalls. At the end he showed a perfect pair of female faces: be- fore and after lifting and said, with a quiet undertone:
“This is my greatest facelift complication; after the treatment finished, I married her.”
You have now a book in your hands with many proven reliable techniques but also some new ideas and suggested solutions. Alone in the first half of the book there are 363 counted and (listed) registered
“ideas, tips and tricks” as well as 39 chapters of my own and 36 guest chapters. We tried to demonstrate the new understanding of the face. Special attention was paid to different “mosaic stones” of the face in- cluding the third and fourth dimension, demonstrat- ing also the combined procedures with decreased ag- gressiveness, risks, and complication rate. It is the basic substructure. The 36 chapters by world-re- nowned celebrities are like cream and chocolate over the “gateau”.
I did not ask from my co-authors to incorporate their chapters into a prescribed concept. Some of them are real “guru’s” – how could I dare? I left all the freedom to my co-authors. That is why there will be some repeated statements, techniques, and graphic images. But these are all original texts and pictures. I just recommend accepting these chapters as a bunch of mottled flowers. And they are very fragrant.
But, we encourage our readers not only to read and learn from this book. It could serve also as inspiration for the next steps: the young plastic surgeon should think further, producing new ideas and solutions.
Perhaps until the cyberfuture reaches us and genetics take the place of aesthetic plastic surgery. Will our kind of surgery become superfluous (unnecessary) when we are able to order eyes, noses, lips, breasts, and even our descendants in some sort of gene shop.
At the end of my presentation “Anthropo-design: aes- thetic surgery is becoming a human applied art” in New York’s Museum of Arts and Design, 2004, I was asked about the future of beauty. I answered: “It lies in the ugliness. With aesthetic surgery, as you have seen, today a lot is possible and tomorrow in a genetic beau- ty boutique everything will be available. Everybody will become beautiful and it will be very boring. Then, only people like Sammy Davis Jr., Woody Allen, or me will be interesting....” It was said self-ironically, but could become true. I would like not to be here if this future comes.
Although not officially documented but according to some references Gaspare Tagliacozzi, the father of European plastic surgery, was born on 19 January 1545 in Bologna. Exactly 400 years later, I was born.
His book De Curtorum Chirurgia per Institionem was the first European book of plastic surgery. Let me end my text with a sentence by our great predecessor:
Sed, ut neque in universa medicina, imo in omni actionum genere, cuncta firma sunt et aeterna, ita neque hic, quod iam diximus, perpetuum est (But, as in the whole of medicine, and in everything we do, nothing is unchangeable and eternal, so is this, what we were talking about, not established for- ever).
The last word I give to a patient of our clinic who is a board-certified psychologist. I think her decision making and experiences before and after her surger- ies are very interesting also for us plastic surgeons.
Psychologist and her Facelift I have done it–Bingo!
I was most annoyed by the traces of time in my face, especially on photographs. Narrowing lips, tense features around mouth and nose, an obvious tendency to pudgy cheeks, a tired look, flabby fa- cial skin.
Such realistic photographs quickly disappeared into my drawer ... so that nobody would get to see them ... the photographs looked terrible ... that was Wrinkles might be the old people’s medal for me?
bravery – although I believe not every trace of a tough life needs to be visible to everybody at first sight. So I decided to change things.
Rather coincidentally I stumbled upon an article about the possibility of soothing out nasolabial wrinkles – one of my greatest annoyances–by in- jecting hyaluronic acid. I consulted a dermatolo- gist who confirmed that the risks were low and that wrinkles in the nose area would be filled up from the inside; I made a decision for surgery. About 3 months later, the barely visible changes had van- ished, my nose was back to normal.
In the following time I searched the Internet for private clinics that offer aesthetic plastic surgery; I was especially fascinated by pre- and postsurgery photographs of patients who underwent eye lid corrections. My determination was growing that I would make a start with upper and lower eye lid lifting. Of course I had to confront myself with the risks as well.
My friend could not share my “wrinkle prob- lem” at all. Instead she mentioned something about personality and inner values ... and that she found me attractive ... I should look around, who else at my age could compete with my proportions ... and my face ... no ... by no means any changes ... I would look so good ... I should accept my wrinkles ... they were an essential part of my personality ... and, be- ing a psychologist, I should think about what I am
trying to compensate for by undergoing surgery ...
what my real problems were... etc.
When I told my husband, who is a psychiatrist, that I was seriously considering facial beauty sur- gery, his reaction was very unenthusiastic, even disconcerted. In our discussions he repeatedly ex- pressed his worries about irreversible, fundamen- tal complications that might result from surgery.
He often stressed he loved me the way I am.
In summary I may say that my plan was initially met by rejection and lack of understanding ... ex- cept for my brother who is very close to me. He lis- tened to my “wrinkle worries” carefully ... and to my own surprise ... he could understand my prob- lems; he also agreed to accompany me to my first consultancy meeting.
I singled out three clinics (carefully looking at their qualifications) in my area. Yet after the first consultation, I felt so reassured that I refrained from further consultations. My brother shared my impression that we had found an experienced, competent, and apparently even friendly surgeon.
Two weeks after our conversation I went for an upper and lower eye lid correction. My husband accompanied me on the morning of my surgery, which was conducted as an outpatient treatment. I could barely wait for it, I was very excited.
In the afternoon of the same day, I was allowed to return home with my husband. I did not feel pain; it was more like a slight tension around the eye. My first encounter with the mirror did not startle me since I was prepared for it: Bloodshots beneath my eyes, the cheek regions were swollen.
My doctor told me it would get better with every day.
And it happened accordingly. A week after my operation the protection bandages were removed and the threads were taken out. I was overwhelmed by the results. Although a slight swelling of my face
could not be overlooked, two big, radiant eyes were looking at me from the mirror. The tired expres- sion was gone, the eyes seemed much fresher. I could hardly believe it ... I was happy. Finally being able to put make-up on without the eye shadow be- ing wiped away by a sagging lid fold. On the tenth day after my operation I went back to work.
My husband was visibly relieved that my surgery went without complications. My friends and ac- quaintances said I looked so relaxed and fresh, just like returning from holiday.
Meanwhile I grew more and more annoyed by the remaining “facial deficiencies” I mentioned earlier. The nasolabial wrinkles seemed to be even deeper now with regard to the eyes; and anyway ...
the “rest of my face” did not match those amazing radiant eyes. I decided on having a facelift.
My husband accompanied me to a consultation 5 weeks after my lid correction. I was glad, even re- lieved, that my husband lost his initial scepticism after this intense and informative discussion about my facelifting operation, and that he insisted I should, if I was still determined at all, carefully choose an experienced surgeon (in theory he still opposed the decision).
One week later I underwent facelifting surgery in combination with a body fat transfer treatment (filling up the wrinkles between nostrils and the corner of the mouth, cheek bone augmentation, and liposuction). I chose to take a handlifting treatment by body fat transfer at the same time.
Again I was optimistic ... I completely trusted my surgeon. My first surgery was successful ... why should it be different this time?
And so it happened.
As I was feeling rather well after the operation, except that I felt a bit tired, my husband could take me home only half an hour later. The following day I returned to the clinic accompanied by my brother
Fig. 75.3. Psychologist a before and b after her facelift and autologous fat transfer
to have my head bandages removed. My face was seriously swollen and haematoma, so-called bruis- es, appeared around my eye lids, around my cheeks, and in the throat region. I could only sleep on my back, which gave me a hard time; I had to keep my head calm and could hardly talk; the first 2 days my diet was limited to liquid food as my lips were swollen as well. To my own surprise I did not feel pain (as I had previously expected); there was only this tension, and occasionally a slight twinge be- hind my ear.
I felt better every day. The first stitches were taken out only 8 days after the operation ... and the first postsurgery photographs were taken. Al- though my face still showed some bruises and slight swellings, the result was more than satisfy- ing when comparing the “before/ after” photo- graphs.
Finally I was allowed to wash my hair again ... I relished this otherwise perfectly natural routine. I felt a different person after that.
Three days later the last stitches were taken out.
The remaining bruises were covered, I had put on some light make-up around the eyes, my lips were brought out by lipstick ... I felt good.
More photographs were taken immediately after that ... this time I was completely stunned by the before/after comparison. I could hardly believe what I saw. Yes, that was me!!! Gone was that stern expression, my mouth had much softer contours, my eyes were bright and radiant ... the deep nasola- bial wrinkles had disappeared ... It was like a mira- cle to me, it was a surgical miracle.
It was not a new nor a strange face, it was my face. That was what I felt like inside, that was who I was and who I am.
My brother was quite literally kicked out of his boots ... he could not help but keep looking at me and was amazed by what he saw. He said he would now have to rethink his family relationships: while he had always had an elder sister, he now had to get used to a much younger sister.
My husband has kept his reserved attitude ... he finds me beautiful but he also found me beautiful before. I noticed, however, he paid more attention to his weight after my facelifting
After the last stitches were taking out, I went back to my usual work, went shopping, got petrol for my car ... I ran into the people I knew from before my operation. The reactions I received were quite diverse.
My father immediately said: “What have you done to your face? You look like years ago, like a young woman, a girl ... your lips look fuller ... what have you done?” Apparently, and to my astonish- ment, he has kept a detailed picture of me at a younger age; he could hardly believe that I was ac- tually matching his memorised image again.
My friend’s three daughters, 3, 5 and 7 years of age, insisted on a good-bye kiss when I left which took me and their mother by surprise. The 7-year- old scrutinized my face ... and said it looked so different; she could not say in what way it looked different except that the lips were “thicker”. The youngest girl was keen to touch my face.
My friend herself was amazed by the changes;
she said my facial expression was much “clearer and more open”.
Wherever I went, whoever I met, I perceived predominantly positive reactions, verbal and non- verbal. Admiring looks and compliments have be- come part of my daily life.
I would not describe myself as having been an uncertain or unhappy person. Yet I feel much more assured and happier after the operation and I feel more self-confident with other people. My happi- ness and my positive attitude towards life are now reflected in my face. I feel in line with my looks.
I feel harmony with myself, everything seems to fit together: my spirit, my body and, since only re- cently, my face. That was not always the case ... pre- ceding the facelift operation and before the eye lid correction these components were in disarray.
In scientific discourse this feeling of coherence is considered a managing resource which increases people’s resistance against stress factors and serves as a condition for better and permanent health.
Plastic surgery “lifted me up”, not only from the outside but also from the inside.
Dipl. Psychologist Dr. Karin Junglas Birlinghovener Straße 39
D-53757 St. Augustin, Germany e-mail: k.junglas@t-online.de
Bibliography
Please see the general bibliography at the end of this book.
