Dr. David Jansen, a cosmetic surgeon at Tulane University, says he's seen his share of less-than-acceptable results and has repaired quite a few.
"We all do a lot of that," he says of plastic surgeons. "We all kind of fix up each others botches, because we all have them. We don't all hit homeruns every time." Some, however, result from people trying to save money and time by going outside the country to practitioners who may not have the expertise and credentials required by the American Society for Aesthetic Plastic Surgery, which oversees plastic surgery professionals in the United States and Canada.
"What we're seeing a lot more of is people going to Mexico and Thailand for surgery," he says. "I see people who had all types of surgery in Thailand from gender reassignment (sex change) to facelifts. Mexico is more liposuction."
Although liposuction is relatively simple to perform, when it isn't done correctly it can leave the skin dimpled, body areas misshapen and uneven, and can cause excessive bruising.
"Liposuction is easy to do, you just follow a few procedures," Jansen says. "Everybody's doing liposuction ... and therein lies the rub. There are even plastic surgeons who don't do it well; you have to work at it. [The problems surface] usually where they got too aggressive." That can result in fat removal that leaves hills and valleys on the skin. "Then you have to rob Peter to pay Paul. You have to take fat from somewhere else and insert it in the valleys."
When the procedure is performed outside the country, patients often don't know the job has been botched for about two months, because it might look normal the first week or two, he says. By the time they realize things aren't kosher, they're either unwilling to return to the foreign doctor or afraid the results won't get better the second time. So why would people take the chance of going out of the country to have a surgeon reshape their body? "Cost," Jansen says. "A lot of the guys working down in Mexico are not trained formally, so they can charge a third or quarter of what doctors charge here. They don't assume any liability. It's not a huge problem, but it's getting more prevalent."
Other popular cosmetic procedures -- breast augmentation and facelifts -- also can become problematic if a doctor doesn't have the experience to balance what a patient wants with what they can handle. American doctors have been conducting those procedures for several decades, but still have trouble with facial nerves and with adding too much to the breast size.
"Breast problems include breasts that are augmented too big, are uneven or (if the doctor) violates some area of the breast," he says. This can result in creases in the breast, uneven sizes and even the "death" of a breast nipple if the blood flow to it is cut off during the procedure. Some women who desire a C or D cup don't have the body to support it, a situation the plastic surgeon should broach with the patient. "It takes a little experience to tell the patient that what they want won't work right," he says.
Facelifts are commonly performed procedures, but it takes some experience to tighten the skin without damaging the nerves that stimulate the muscles for expression. A wrong move can damage a nerve and result in a droopy mouth, for instance. Plastic surgeons say the trend in both breast and face surgery is toward less invasive techniques and smaller incisions that cause less scarring and last longer. "In the last five years, we've been doing a lot longer-lasting facelifts," Jansen says. "It should last 15 to 20 years if it is properly done."
Part of being pleased with cosmetic surgery results hinges on how open and honest a doctor is in guiding a patient toward a positive outcome and determining whether that person really is a good candidate for surgery.
"If someone's expectations are out of proportion, if there's no balance with what they want and what we can do, that's a red flag that they're not a candidate for surgery," he says. That includes a woman who wants a larger breast size than her frame can handle or overly dramatic changes to her nose, for instance. Advising a patient against a procedure, or recommending a less dramatic change doesn't always work, however. "They'll tend to shop around until they find someone who will do what they want," Jansen says. Unfortunately, they usually can find a surgeon willing to perform the procedures even if they shouldn't. Pop singer Michael Jackson's overly dramatic changes in his face and body color over the years is an excellent example, Jansen says. The rhinoplasty he underwent to change his broad nose to long, straight and narrow was a disaster, Jansen says, leaving the singer with a nose that collapses when he breathes. Overall, the dramatic surgeries he's had performed on him over the years have left the singer looking freakish and aren't easily reversed.
"I tell our (medical) residents that it pays dividends if you can define and make sure that what you can do as a surgeon and what the patient expects are on the same page," he says. "You spend a lot of time making sure what the patient wants is something you can do ... and that it will look normal on them. If you can't, you've got to let them know ahead of time. That's where a lot of problems develop."
Some techniques for ensuring that balance include computer-generated images of what nose jobs, facelifts and eyelifts will look like on a specific individual. For breast augmentation patients, some doctors will develop an implant bra in the size a woman desires then have them wear it around for a few days to determine if the size is too large.
Another aspect of good doctoring advice is to help people realize that the procedures they think they want may run counter to either their appearance or their lifestyle.
"People's expectations are often unrealistic or not well thought out," Jansen says. Lots of women, for instance, want to have their lips augmented to be larger and puffier; one of the most common examples they bring in to show doctors are pictures of actress Pamela Lee Jones' lips. "There are some women they would look stupid on," he says, "and the surgeon should do his best to talk the patient into something that more appropriately fits her personality and her career."
Not all plastic surgery is elective; about 40 percent of Jansen's cases involve reconstructive surgery to repair tumors, destruction caused by trauma and other medical necessities. "That's where you really learn to operate, then you move on to the other things," he says. "A lot of professionals feel surgeons should spend the first 10-to-15 years doing reconstruction, then move into cosmetic surgery. If you can rebuild a guy's entire face that's been blown off by a shotgun, you can do the other procedures. Most of us do a mixture of both."
Of the standard cosmetic procedures, liposuction is the most common overall, statistics show, followed by breast augmentation, eyelid surgery and facelifts. Nose jobs have fallen in popularity over the past five to 10 years, mainly because people are more comfortable with ethnic features and with looking individual in general. Most rhinoplasty today is performed as functional procedures to correct breathing problems or obstructions, doctors say.
The best defense a patient has is to take some time in selecting a plastic surgeon, listening to the doctor's suggestions and maintaining a reasonable expectation of what any one procedure can do.
"The best way to choose a doctor, in my opinion is by referral from another doctor you trust or a patient who has had the procedure done," Jansen advises. "We're a results-oriented business. A patient with good results will tell seven patients. One who has had bad results will tell 15." After collecting recommendations, patients should investigate how the surgeon was trained, whether they are a member of the Board of Plastic Surgeons and whether they are in good standing with that board. Experience is key and becoming an excellent plastic surgeon takes about seven to eight years of training, Jansen says. "If you're going to have someone operate on you, you want someone who's done the procedure 50 to 100 times; you don't want them trying new things on you."
He advises against choosing a surgeon from an Internet Web site, even if it's been developed by the doctor because you have no way of judging the past results. Other sites are developed to match patients to doctors who have paid money in order to get such referrals.
Patients also should avoid the impulse to decide on surgery and schedule it in a hurry or try to add on procedures during the surgery.
"Patients need to be informed consumers," he says. "If you're having elective surgery, there's no hurry. I get nervous when a patient comes in and wants surgery the next day; it's like impulse buying.
"Doctors should give patients options and best-case scenarios. The doctor should talk to you like a normal human being. You should feel comfortable with the doctor. You want to lay some groundwork; there is a little leap of faith."
Although men increasingly are looking to cosmetic procedures to smooth wrinkles, lift their eyelids and tuck their tummies, women still outnumber their more masculine counterparts two-to-one when it comes to cosmetic surgery. Other non-surgical procedures also are gaining popularity among both sexes, including microdermabrasion and techniques to remove hair, tone down wrinkles and more, with some procedures being conducted in spas and hair salons. Again, the bottom line, Jansen says, is look at the operator's experience and qualifications and talk to other patients who have had the procedures done.