Medical Student Jacques Ma recently attended the operating theatre with Dr Richard Bloom who was performing a tummy tuck procedure. Read his engaging story below.
It’s Not All About Plastic
By Jacques Ma
Whilst hurrying after doctors in the Prince of Wales Hospital in Hong Kong, I was startled to see a patient with known obstructive sleep apnoea being prepped for upper gastrointestinal surgery. With no bowel obstruction, perforated ulcer or known cancers, I did not understand why this morbidly obese patient was having anything except airway-opening surgery that he obviously needed.
The mystery was solved by scurrying after a doctor into theatre: the patient was undergoing a bariatric sleeve gastrectomy. The procedure involved excision of the majority of the stomach’s greater curvature, including the fundus, thereby removing the site of production of the ‘hunger hormone’ ghrelin. By decreasing the secretion of this hormone, but leaving those parts of the stomach that control gastric emptying, the patient will be satiated after ingesting 150mL of volume instead of 2L. This, accompanied by permanent lifestyle changes and a high-protein-low-calorie diet, aims to results in permanent weight loss – a lifestyle goal recommended to all patient groups suffering from obstructive sleep apnoea.
Having always struck me as a purely cosmetic procedure intended to achieve weight loss, I was prompted to reconsider the notion of bariatric surgery when this patient requested a letter to prove otherwise. Whilst the request was for insurance-claiming purposes, I could not help but wonder whether the extended functionality of the procedure in treating his sleep apnoea deemed it non-cosmetic. The comorbidities of obesity are numerous, so as long as bariatric surgery alleviated them to some extent, the primarily weight reduction procedure would no longer be considered cosmetic?
I had also wrongly assumed cosmetic surgery to always be performed by plastic surgeons – of course bariatric surgery was to be carried out by an Upper GI surgeon. Suddenly the boundaries of cosmetic surgery seemed so much more malleable; my previous construes of cosmetic surgery based on impression and myth crumbled away to reveal a world that piqued my curiosity with its unexplored depths. Notably with the recent Korean cosmetic boom, plastic surgery has become a gold-dusted industry enticing for the opportunistic among us.
Determined to unveil the truth behind its glamourous appeal, I decided to dive into the world of Plastic & Cosmetic Surgery to see for myself, and what better way to start than to attend theatre and interview a plastic surgeon?
And so it was on a Friday morning, donned in the most fashionable and comfortable interview attire – scrubs – I pushed open the door to the operation theatre. Sterile colours immediately greeted my eyes and reminded me to steer clear of the invisible force field three inches from the table and tools. Upon identifying myself, I was welcomed jovially by plastic surgeon Dr Richard Bloom and other theatre staff – all set to the upbeat music drifting out of speakers in the background.
Staying behind the barrier of sterility, I peered at the table to see a gaping horizontal incision across the patient’s abdomen. During the following two hours, I witnessed my first ‘tummy tuck’: excess skin and fat were excised with precision and weighed, the layers were sutured together with care to minimize scarring and the umbilicus reconstructed. I was awed by the transformation that yielded such convincing results – had there been no sutures, I would not have guessed that any surgery had been performed at all.
In between sprinkles of banter with colleagues, Dr Bloom kindly kept up a commentary for me while his hands operated deftly on the patient. His years of experience were evident in his sure-handedness and laid-back manner. Leading Specialist Plastic Surgeon and fully qualified Fellow of the Royal Australasian College of Surgeons, Dr Bloom spent over 20 years working in Melbourne public hospitals and has been in private cosmetic surgery practice in Melbourne since 2003. He now focuses his surgical skills on cosmetic surgery of the breast, body and face. Yet I was intrigued – what had motivated Dr Bloom to choose plastic surgery after graduating from Medicine at Monash? And why had he honed in on cosmetic surgery in recent years?
With a full theatre list ahead, I had Dr Bloom’s espresso’s worth of time between cases to find answers, so I delved straight in. Dr Bloom’s interest in plastic surgery can be traced back even before he started medicine to an early work experience with a plastic surgeon family friend. This interest grew through medical school, with his clinical years of medical school and internship focusing this interest into a career goal. Dr Bloom’s advice for the temporarily (hopefully) aimless like me is to “grasp every opportunity to explore your interests”. Passions are discovered in the most organic ways but we can catalyse this by heeding his advice – the fact that you are reading this newsletter means you have taken your first step!
Within plastic surgery, there are a plethora of sub-specialties and cosmetic surgery is but one. Contrary to the common belief that plastic surgery is less demanding due to the generally-health patient demographic, Dr Bloom has worked with all sorts of patients from skin cancer and hand surgery to post-bariatric and trauma including limb reconstruction. While it holds true that patients are not in acutely life-threatening conditions, Dr Bloom opined that they had higher expectations precisely because the surgeries were fully elective for more cosmetic than functional purposes. Unlike other specialities that treat pathology, plastic surgery patients demand perfection instead of a cure with minimal damage, so plastic surgeons are under a stress of a different nature, with perhaps an even greater magnitude.
The challenge and the diverse patient profiles and operations a plastic surgeon can perform is exactly what Dr Bloom loves about his work. “There is literally no part of the body that a plastic surgeon does not operate on, be it skin cancer of the head or deformity of the toenail.” The constantly changing spectrum of plastic surgery re-energises him and keeps his passion fresh and alive. Dr Bloom’s surgical pathway is the epitome of career goals and the key is to “really choose a job that you are passionate about”.
However, the ‘gold mine’ image of cosmetic surgery is still hard to shake. The mention of cosmetic surgery alludes to a multi million-dollar industry of commercialized procedures serving purely aesthetic purposes and targeting those insecure about their bodies. Like black sheep in a white flock, any doctor can claim to be a cosmetic surgeon despite not receiving training in plastic surgery. For this reason, Dr Bloom believed such malpractices to have tarnished the general reputation of fully qualified cosmetic surgeons, resulting in skewed opinions of the profession. The innate conflict of interest is enhanced in cosmetic surgery where procedures are usually not clinically necessary. “No surgery is risk-free; we do not perform surgery on a whim.” Although a plastic surgeon can be considered the artist of doctors, they are still first and foremost doctors. When a patient comes in requesting specific modifications, it is up to the plastic surgeon to exercise professional judgement to determine the necessity of surgery, particularly in cases of body dysmorphia where patients insist on rectifying flaws in their appearance that may not actually exist.
Apart from the associated stigma, labelling procedures as cosmetic is practically important for insurance and Medicare where “medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons” are not covered. The issue of where to draw the line is a constant tug-of-war and exceptions only serve to further blur the line. Revisiting the initial trigger for this discussion, some bariatric surgeries are covered if comorbidity requirements are fulfilled. Functionality is designed to be the tie-breaker but merely considering clinical necessity would not do certain patients justice. The system seems to recognize this: an example raised in the interview is the rebate provided for breast lifts within seven years of giving birth. Certainly, such a procedure can serve no functional purpose and sagging breasts following childbirth is only natural. With surgical advancements, the definition of cosmetic surgery continues to be moulded by shifting public opinion of what should be considered necessary – and who knows, perhaps age-defying procedures like wrinkle removal may become exempt in the near future.
It is common consensus that holistic patient care should cater for all aspects of wellbeing, including mental, psychological and social. Low self-esteem induced by feelings of inferiority about one’s appearance can be a barrier to social relationships and result in psychological distress. In view of the public opinion on cosmetic surgery gravitating towards increased acceptance, I would not be surprised if cosmetic surgery solely for aesthetic improvement – for instance, rhinoplasty for someone with an unflattering nose – becomes ‘necessary’. When it comes to this, however, benchmarks and regulations will have to be stipulated for fair assessment of necessity. There would be a gold standard for the perfect appearance and looks would be quantified by the percentage of deviance. Society would be swept by a beauty trend similar to South Korea’s, with everyone clamouring for the gold standard and beauty pageants becoming mundane battles between clones.
I speculate but one thing is for sure: the world of plastic surgery is breath-taking with its incredibly dynamic potential. After my brief taste of the wonders it holds, I cannot wait to embark on my journey of discovery in clinical years. My great thanks to Dr Richard Bloom for aiding me on this expedition.