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Stanford Report, August 20, 2003

Plastic and reconstructive surgery residents learn more than surgical technique Learning to talk with patients is nearly as important as surgical skills


Stanford Hospital residents in plastic and reconstructive surgery spend their last year focusing on three specialties. They operate on people who have been badly burned, they treat children born with facial deformities and they do cosmetic surgery: procedures such as nose jobs, breast enlargements and liposuction.

Cosmetic surgery is more than just cutting and augmenting. On their surgery rotation, residents learn the delicate art of negotiating surgery with patients.

"Their expectations have to meet our expectations," said Anna Kuang, MD, who finished her residency in June. "If they’re overexpectant, no matter what you do for them, it would seem like a failure in their eyes. And that’s not what we want."

On the four-month rotation, each senior resident sees patients at a weekly clinic for community members who want cosmetic surgery. David Apfelberg, MD, who retired two years ago after 28 years in private practice in Palo Alto and Atherton, volunteers his time to teach residents. He and other local cosmetic surgeons supervise residents in consultations and surgery.

Since the surgery is done by residents, Stanford charges about half the going rate for procedures. Apfelberg said patients shouldn’t worry, however. The residents are within months of finishing the program and are accomplished surgeons.

Among the things Kuang valued most through working with Apfelberg was learning how to work with patients before they enter the operating room. "A skilled surgery knows when to operate and when not to operate," she said.

Kuang explained that patients often have unrealistic expectations. A cosmetic surgeon has to be able to negotiate with their patients in order to match their hopes for the surgery with what is possible from the procedure.

Cosmetic surgery patient Daniel Gil, 58, was easy to accommodate, Kuang said. Gil, a retired machinist who lives in Newark, Calif., had a facelift in time for a family reunion.

"He was honest with us," Kuang said. Gil wanted to lose the excess skin below his chin and the tired look under his eyes.

After his facelift, Gil returned for a follow-up appointment. He reported that cousins from Mexico who hadn’t seen him in 10 years were amazed by his looks at the family reunion. "They’re my age and wrinkled," he said. Gil said he was anxious about having a resident do his facelift. "I was very scared at the first visit, but as I was informed, I started to relax," he said. Gil said he wanted the surgery to make him look as young as he feels.

Kuang started in general surgery, but chose to specialize in plastic surgery because she likes operating all over the body: hands, feet, breasts, face. "And it requires not just technical skill, but also has an added sort of creativity and artistic side to it," she said.

Kuang learns new surgical techniques all the time by watching her colleagues, she said. "Everyone has their own tricks. You write them down and see what works for you." Kuang is starting a fellowship in craniofacial surgery in Seattle this fall.

Most plastic surgeons end up doing some cosmetic surgery, Apfelberg said. It’s easier to build a good reputation for cosmetic surgery than for reconstructive surgery on injuries.

"A plastic surgeon’s reputation boils down to how good a facelift or nosejob he or she does," he said. "A satisfied patient then refers a cousin or real estate agent."

With the economic downturn, Apfelberg said the clinic has been seeing older people who are back on the job market after layoffs, competing with younger people. "They just want to feel confident about their appearance and don’t want to feel old and tired," he said.

Medical center surgeon gives child reason, not to mention ability, to smile (10/23/02)

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