Repairing the ravages of time

JOHN GAULT June 1 1975


Repairing the ravages of time

JOHN GAULT June 1 1975


Repairing the ravages of time


He asked me if I’d ever seen an operation before, and I told him I hadn’t, though as a reporter I had seen people who’d been smashed up in car accidents, burned in fires and drowned. He said it really wasn’t the same thing, because this operation was on a face, and it could unnerve even those who’d seen other types of surgery. If I felt woozy or anything, he cautioned, I was to just walk out of the operating room.

His nurse reinforced these instructions.

I entered the room just as Dr. Harold Silver, the cosmetic surgeon, was about to start cutting: first, the eyes, and then, when that was finished, the face-lift itself.

The patient, a woman of about 50 — thus a typical face-lift patient by age and sex — was heavily draped in green garment and most of her head was covered.

Only the face was visible; the eyes were puffy, cheeks pudgy, neck skin loose.

There were a few lines sketched on it. To her right, a hanging plastic bag of intravenous tranquilizer slowly dripped its contents into her arm. Her face was frozen, but she was awake —very anesthetized, but awake. I noticed that my host was lefthanded. He cut above the eye, along the natural line of the upper lid, trimmed off a strip of skin, nipped off tiny bits here and there, then pulled out and cut off deposits of fat. He was quick and very sure and there was little bleeding. Then he did the same on the other eye. He kept talking to the woman from time to time, murmuring really, calling her “sweetheart,” and she’d answer him in

her dreamy but quite aware way.

I wasn’t just pretending to be fascinated. I was. I was also awestruck at the skill of this man. I was hoping the fascination would overcome the other thing I was starting to feel.

That other feeling became overwhelming when he started on the lower lids. He cut along the eyelash line and with scissors planed down into the “bags.” Then, using small scissors and tweezers, he cut out the fat which created those bags, also nipping off skin along the incision. His anesthetist, a warm, motherly woman, asked me if I

wanted a chair and I said no, I thought I’d better get out for a few minutes. I tugged off the mandatory surgical mask as I got outside the door and gulped air. She came out too.

“Was it hot in there?” I asked hopefully. “Or is it just me?”

“It’s just you,” she replied, offering me coffee and condolence.

In a few minutes I returned to the operating room. Dr. Silver mimed applause and his eyes smiled. Then he proceeded to stitch up her eyelids, which he’d finished trimming in my absence. Beethoven’s Fifth was coming through on the stereo system; normally he prefers Mendelssohn for operating, but I guess he was in a Ludwig Van mood that day.

I stayed through until the very end, through the facelift itself. In the following week, I related the experience to all sorts of people. Some of them thought I was crazy; others thought that anybody who’d go through a face-lift and eye-job was crazy. Well, I told them, I’d discovered a paper prepared at Johns Hopkins which indicated that most people who desire face-lifts tend to have some emotional problems. That doesn’t mean they’re crazy, of course (although there was a fellow down in North Carolina who was so unhappy with the cosmetic surgery done on his penis that he shot the surgeon dead). What the Johns Hopkins team discovered concerning potential cosme-

John Gault, an associate editor of Maclean’s, writes often on medicine.

To the conservative wing of the medical profession, cosmetic surgery is immoral, talent wasted on a spoiled, screwed-up few

tic surgery patients was that they displayed very few of the attitudes psychiatrists and psychologists feel are necessary for a person adjusting to middle age. Such attitudes include a variety of interest, an open mind, a healthy self-regard and a realization that one’s capacities change, and that help from others, at the proper times, should be welcomed. Face-lift patients showed up poorly when these attitudes were tested. Generally, they were lonely people, according to the study, and what the facelift did for them was help them to convince themselves they weren’t as old as their birth certificates indicate, for as long as they appeared young to others then they certainly couldn’t be old in their own minds.

Dr. Flarold Silver used to believe all of those things — not only believe them, but care about them. The textbooks said that unless a person has a good, solid, objectively valid reason for seeking cosmetic surgery, then he or she should be denied it. “At one time 1 thought what 1 was doing was not valid,” he told me, “because the feeling [of the medical profession] was that if patients got themselves together as total entities, they wouldn’t be preoccupied with their physical appearances.

“Well, that’s bullshit.”

Twenty years of practice and a fiveyear, firsthand study of all branches of psychology have taught him that objective validity has nothing to do with anything. People were telling him what they thought he wanted to hear because they wanted cosmetic surgery; he was telling himself what he wanted to hear because he wanted to do that surgery. “As I became more aware that people will say anything if they want something done, and that you will say anything if you want to do something, it was a great relief — not to have to sit in judgment of other people, I mean.”

Still, he reserves the right to turn down patients. There are medical grounds, of course: corpulence, high blood pressure, coronary problems and diabetes are the main ones. He will also turn away people his instincts tell him he will be unable to communicate with 100% — people who will expect more than he tells them he can do for them. (He won’t reveal what he normally charges for the various cosmetic services he provides, and because the services are not covered by any insurance program, public or private, there is no way of finding out. For the same reason there is no way of determining how many such surgeries are done in Canada each year.)

The staple operations are the eye-job, the nose-job and the face-lift. They represent to Dr. Silver more than 500 operations a year. The simple difference between corrective (plastic) surgery and cosmetic surgery is that the latter involves making people who look normal look better (hopefully) while the former is devoted to making ugly or misshapen people look normal (or more normal). There are still vestiges of controversy about cosmetic surgery within the medical profession: the conservative wing thinks it’s immoral, plain and simple, for a talented surgeon to spend his time supporting the vanity of a spoiled, screwed-up few.

Which was one of the reasons he shifted the great bulk of his practice from the hospital — where, he says, the nurses were taking constant shots at his patients about the fact that they, the nurses, had sick people to look after, and that excluded Dr. Silver’s spoiled, middle-aged brats — and into a suite at the Royal York Hotel in Toronto. He is the only doctor who operates out of a hotel. There were other reasons as well, including the fact that he likes to control his environment: he designed the suite personally and handpicked a compatible and highly skilled staff, including

the anesthetist and two crack surgical nurses. The suite, done in various shades of brown mostly (he likes earth colors), includes a spacious operating room and a recovery room that will accommodate four patients at a time.

But there are any number of other advantages. For one thing, the hotel atmosphere, as opposed to that of the hospital, promotes rapid recovery. The patient I witnessed being operated on was on her way home within three hours after surgery with dark glasses and a scarf covering the stitches. No bandages. She may or may not have eaten a full meal and had a drink that night; that would have been up to her. Maybe she took a 222 or something for the pain, but probably not because there wouldn’t have been very much. Pain, as Dr. Silver knows and McGill’s world-renowned pain specialist Dr. Ronald Melzack has proven, is created or at least enhanced by the expectation of pain; Dr. Silver’s whole approach is designed to eliminate that anticipation.

Out-of-town or even in-town patients can stay at the Royal York, and do so both anonymously and far less expensively than in a hospital. Hospital beds in Toronto start at more than $ 100 a day, while two-room suites at the Royal York

Cosmetic surgery — in fact just about all plastic surgery — is as closely related to the arts as to medicine. It is sculpture certainly in that bits and pieces of the medium are sliced, trimmed, or even (as in the case of nose-jobs) chipped away. (Or, in the case of implants - silicone to fill out sunken cheeks, for example - it is construction, adding to rather than taking from.) These photographs show the rather vital planning stages, preliminary sketches if you like, for the two most common cosmetic surgery procedures — the eye-job (blepharoplasty) and facelift (rhytidoplasty). Cuts are made along the lines, skin is peeled back and curved scissors inserted to plane away the excess fat; the skin is thea clipped off, the new edge brought together and neatly, virtually invisibly sewn.

The purpose of the exercise is to make the recipient look better but not different. She should never have to admit having it done

start at $75, and single rooms can be had for as little as $29 a day. The food may not be the best in town, but it’s a helluvalot better than hospital fare. Not that he has that many out-of-town clients — he is not a jet-set darling. Nor does he want to be.

When young Harold was growing up in the Jewish ghetto in London, his father, who was in the dress business, warned him, “If you work with the rich, you eat with the poor” (and vice versa). He’s 47 now, but he’s kept that advice in mind and he applies it indiscriminately to his patients from all the economic strata: payment at the time of the operation. The great majority of his patients come from the middle class, which dispels the suspicion that cosmetic surgery is something the very rich indulge in when they get bored or fitful. He does a great many schoolteachers, for example. Without giving anything away in terms of fees, he points out that a good many teachers (again, for example) would think nothing of spending $2,000 for a summer in Europe. When you think about it, $2,000 for a “new” face is no big thing.

Face-lift and eye-job patients (usually both are done at the same time, though they may be done separately) are generally female — 85% to 15%, though 10 years ago it was 97% female — and between the ages of 30 and death, an epoch when North Americans particularly begin to show dramatic signs of aging. What happens, essentially, is that skin loses its elasticity and begins to sag and creates jowls in the cheeks, wattles under the chin and wrinkles everywhere. Bags develop under the eyes, and the upper lids become puffy with fat. Other parts of the face may lose fat, which the cosmetic surgeon sometimes replaces with silicone injections. Dr. Silver also does breast implants and the occasional abdomen trim, but not in his office; these are hospital operations. His specialty is “facial rejuvenation,” and his interpretation of a successful one is one which makes the recipient appear undramatically changed and happy with what’s been done. She should never have to admit that she’s had it done. Her friends should be able to look at her and say: “You know, there’s something different about you, but I’ll be darned if I can figure out what it is. Anyway, you look better.” It’s unfortunate in a way, he says, that cosmetic surgeons — like airline pilots — are so rarely known by their successes. He’s had disappointed patients, caused by what he calls “miscommunication” — the patient didn’t

understand what Silver said he could do. By eliminating the risky recipient at the outset and by retaining a sense of tension during every procedure — he looks relaxed, but certainly not nonchalant — he limits his failures almost to the point of nonexistence. Properly done, a facelift lasts five to eight years and longer, depending on the age of the patient and rate of degeneration; the operation can be repeated any number of times, if so desired.

Dr. Silver finished stitching the woman’s eyes just as the Fifth concluded. I mimed applause and he took a little bow and smiled. “Now,” he told

his patient, “we’ll do the rest.”

He made incisions about an inch behind her hairline from the top of the forehead down to the top of the ears, then down along the front of the ears where they meet the cheeks; the cuts then proceeded up along the back of the ear and across to the neck hairline, behind it actually, about an inch into the hair, and then down. With a pair of long-handled, short-bladed, curved scissors, he planed the skin away from the fat layer so that it became a flap. This was done without micrometer or calipers, by intuition honed by experience. With an electric needle, he cauterized the blood vessels underneath, one by one, then swabbed and cleansed the exposed areas; there was no bleeding to speak of afterward. This procedure virtually eliminates the one major complication of face-lift surgery: under-theskin bleeding, or hematoma.

He then pulled the fat layer more tightly together with stitches which

would remain forever under the skin. Then he pulled the skin toward and over the incisions, and tack-stitched it; part of the ear was momentarily covered by skin that had once been in front of it. He began to trim away the excess skin, again very surely and quickly — a slim strip here, and one maybe half-an-inch wide there. When he was done the new perimeter fitted precisely, with stitching, in place. The scars would be almost totally undetectable (except in strong light, with a magnifying glass) because of their position and because of the precision cutting and fitting. (There was a very Bunuel scene taking place in the operating room: while he was stitching the face, his anesthetist, most of her role completed, was doing needlepoint; I could not resist turning my head, tennisfan fashion, from one to the other; the Beethoven — I think the Seventh was playing by that time —added another bizarre aspect, because both seemed to be stitching in time to it.)

Dr. Silver cleaned up the blood on the woman’s face and head which had dripped out before cautery; there was no seepage. She was taken to the recovery room to rest off the effects of the tranquilizer; her face was bandaged, but only until she was ready to go home a few hours hence. The eye stitches would be removed two or three days later, and the other stitches a week afterward. She complained, sleepily, that her face didn’t feel tight enough, which I suppose is natural since she was expecting that sort of sensation. Dr. Silver assured her it was just right. I could see how effective the work had been: the pudgy cheeks were gone, and the wattle under the chin had disappeared. I can’t comment on the eyes, because there was a lot of stitching, but the cheeks looked very youthful. Her operation had been virtually painless, though there are accounts of unhappy ordeals recorded by face-lift recipients. Some even go into a state of shock, but that is extremely rare.

Since the day I witnessed the operation, I’ve been asked a number of times if I would recommend cosmetic surgery, or even, someday, have it done myself. The answer to both is probably not. I would certainly recommend Dr. Harold Silver to anybody who wanted it and whom I considered relatively sane, because I’ve seen him work; but I can also recommend a good carpenter or hairstylist without paying unqualified homage to either craft. As Dr. Silver himself says, anybody can cut a diamond with an axe. But that doesn’t mean you’d take the Hope to him. 'v?