How to Become a “Good” Plastic Surgeon?

Abstract

Thirteen articles were collected on the qualities and attitudes needed to become a good plastic surgeon.

11.1 Goddess of Imagination

At the left of Truth one sees Imagination, who positions herself to adorn and crown Truth.—Denis Diderot (1751)

Plastic surgeons are seen by those of other specialties as imaginative, original, inventive, and ingenious people. In the field of plastic surgery, many new ideas and skills are developed by surgeons and researchers. To develop new methods or improve surgical skill, creative activity is needed. Creativity is a phenomenon, whereby something new and somehow valuable is formed. Creative minds in plastic surgery have imagination that sparks the “brainstorming of ideas” [1].

To develop creativity, as Dr. Joseph Murray emphasized, scientists should remember three important words: curiosity, imagination, and persistence.

We can easily perceive what curiosity and persistence are. Curiosity is an emotion related to natural inquisitive behavior such as exploration, investigation, and learning. Persistence is the determination to do something even though it is difficult or other people oppose it.

For the concept of “imagination,” however, the exact meaning is unclear from simply examining the definition: the creative ability to form images, ideas, and sensations in the mind without direct input from the senses, such as seeing or hearing.

Instead, I could find the “goddess of imagination” in a painting and a relief.

Denis Diderot (1713–1784) edited the Encyclopédie (1772) and devised a figurative system of three main branches of knowledge: “Memory”/History, “Reason”/Philosophy, and “Imagination”/Poetry. He put Anatomy, Physiology, and Medicine in the domain of “Particular Physics,” a part of “Reason.”

In the frontispiece of the Encyclopédie (first volume, 1751) drawn by Charles-Nicolas Cochin, many goddesses symbolizing each part of the book are depicted (Fig. 11.1). Diderot wrote, “Truth enveloped in a veil and radiating light which parts the clouds and disperses them. To the right, Reason and Philosophy are busy, one in raising the veil from Truth, the other in tearing it away. At the left of Truth one sees Imagination, who positions herself to adorn and crown Truth.” It is thought that Diderot believed the imagination is essential to “adorn and crown” the truth, while reason and philosophy unveil the truth.

Fig. 11.1

The frontispiece of the Encyclopédie (Encyclopédie de Diderot et d’Alembert Tome I—A à E ou, Dictionnaire raisonné des sciences, des arts et des métiers Publication de 1751) drawn by Charles-Nicolas Cochin (1715–1790). Truth enveloped in a veil and radiating light which parts the clouds and disperses them. To the right, Reason and Philosophy are busy, one in raising the veil from Truth, the other in tearing it away. At the left of Truth one sees Imagination, who positions herself to adorn and crown Truth

In the bronze door of the Library of Congress Thomas Jefferson Building, a “goddess of imagination” is carved in the relief panel by Olin Warner (1896). In the allegorical figure of the goddess with her head turned to proper right in three-quarters profile, her right arm is bent with hand pointing skyward and her left arm is holding a lute. She wears classical dress, and a pair of small wings is attached to her head and a larger pair to her shoulders. The interpretation of the allegory of “imagination” is up to the imagination of the viewer.

Improvement in standards, modification of routine, and pioneering of new ideas in plastic surgery require innovation through creativity in which imagination sparks penetration beyond known boundaries [1].

Using Reason and Philosophy, we can unveil the truth. Using Imagination, we can adorn and crown the Truth, just as Diderot wrote.

11.2 Observational and Deductive Reasoning Ability for Plastic Surgeons

When you have eliminated all that is impossible, then whatever remains, however improbable, must be the truth.—Sir Arthur Conan Doyle

When I visited Edinburgh, I enjoyed looking around Surgeons’ Hall Museums. Among the many famous surgeons from that city, Dr. Joseph Bell (1837–1911, Fig. 11.2a) caught my eye. He was the model for Sherlock Holmes (Fig. 11.2b), the protagonist of the famous detective stories written by Sir Arthur Conan Doyle (1859–1930).

Fig. 11.2

Portraits of Dr. Joseph Bell (a) and Sherlock Holmes (b). Available at: https://uploads.disquscdn.com/images/8c5097f928af9024000cad554ace64793a4ff5bbf3a4669bec12fa6a46b8c0db.png. Accessed July 15, 2019

A letter from Doyle, a doctor as well as writer, to his teacher Dr. Bell, was displayed there. Doyle wrote, “It is most certainly to you that I owe Sherlock Holmes … Round the centre of deduction and inference and observation which I have heard you inculcate I have tried to build up a man.” In fact, Dr. Bell not only had the medical knowledge for diagnosis but also a great skill for being able to simply look at a person and tell their trade, their place of residence, their status in life, and many things about them. Reading the displays, I realized that observational and deductive ability is very important to detectives as well as physicians.

On my way home, I was reminded of my previous article and new idea about the reasoning which a good surgeon should have. I had written that a good doctor is the physician or surgeon who solves the patients’ problem: correctly diagnoses their illness, cures them with safe evidence-based procedures, and is honest to them. A good surgeon should know how to operate, when to operate, and when not to operate [2].

In medicine, decision-making relies upon empirical knowledge as well as rational thinking to understand natural phenomena and determine causal inference [3].

In the sixteenth and seventeenth centuries, empiricism was developed by Francis Bacon and John Locke, where perceptions of natural phenomena were considered the ultimate source and judge of knowledge for assessing causality [4]. However, observations alone are not sufficient. Thereafter, inductive reasoning is needed to create causal inferences from observed instances to future instances.

Surgeons as well as physicians need to have an ability to see a problem and find out what steps are needed to solve that problem. When the scattered information is given to a surgeon, inductive reasoning—the ability to combine information to form conclusions—is needed.

For cardiovascular surgical training, Spencer found four activities very helpful in the development of deductive reasoning: (1) considering imperfect results to be more educational, (2) origin of imperfect result (a. diagnosis, b. technique, c. concept), (3) creating a hypothesis consistent with the data, and (4) the process of decision-making [5].

Like Dr. Bell, the skills of deduction and inference, the deductive reasoning, are also mandatory to plastic surgeons as well as cardiovascular surgeons. This is the ability to use general rules to find specific problems [6]. It is applying medical principles to the specific problem of the patient, as Sherlock Holmes did.

When a female patient, accompanied by her husband, appeared in my clinic with a swollen cheek and said that she had fallen down the stairs, I needed to grasp the atmosphere between them to ensure there was reasonable doubt about the possibility of assault. Deductive reasoning was needed in my observation and diagnosis.

Thinking about the above abilities that good plastic surgeons should have, I reached the conclusion that plastic surgeons, including cosmetic surgeons, should be as scientific and logical as they can be. Also, they should be humble, because the human body is a holy dwelling place for the soul.

11.3 The Artist’s Creativity and the Plastic Surgeon’s Creativity

Creativity is a phenomenon whereby something new and valuable is formed. Both artists and plastic surgeons need creativity [7]. Improving standards, modifying routines, and pioneering new ideas in plastic surgery require innovation through creativity, in which one’s imagination sparks progress beyond known boundaries [1].

Creative processes were discussed in the late nineteenth and early twentieth centuries by the scientists Hermann von Helmholtz (1896) and Henri Poincaré, succeeded by the theorist Graham Wallas. In his book Art of Thought (1926), Wallas presented a five-stage model of the process underlying creative insights and illuminations:

• 1. Preparation (preparatory work on a problem that focuses the individual’s mind on the problem and explores the problem’s dimensions).

• 2. Incubation (where the problem is internalized into the unconscious mind and nothing appears externally to be happening).

• 3. Intimation (the creative person gets a “feeling” that a solution is on its way; however, this stage can be a substage).

• 4. Illumination or insight (where the creative idea bursts forth from its preconscious processing into conscious awareness).

• 5. Verification (where the idea is consciously verified, elaborated, and then applied) (Fig. 11.3).

Fig. 11.3

Joseph Murray is receiving Nobel Prize from King Carl XVI Gustaf in 1990

Most arts, such as musical composition, painting, or literary work, may follow the above four—or five-stage creative process [8].

Since a plastic surgeon is called on to make aesthetic judgements and convert them into reality, either by reshaping a part or reconstructing it to match the original, it has been proposed that creative abilities are essential to surgical problem-solving [7].

Januszkiewicz adapted the five-stage model to plastic surgery. His “creativity” appears similar to the concept of sudden enlightenment (sudden cultivation) in Buddhism (subitism, 頓悟頓修). However, I think otherwise. Even after reaching enlightenment, gradual practice with patience is needed (頓悟漸修).

To echo the words of Joseph Murray (Fig. 11.3), scientists should have three important stages of creativity: curiosity, imagination, and persistence (Fig. 11.4) [9]. Curiosity is an emotion related to natural inquisitive behavior such as exploration, investigation, and learning. We can have curiosity regarding a basic research question or surgical procedure. Imagination is the ability to form mental images, sensations, and concepts, in a moment when they are not perceived through sight, hearing, or the other senses. Denis Diderot (1713–1784), who edited the Encyclopédie (1772), believed the imagination is essential to “adorn and crown” the truth, while reason and philosophy unveil the truth [9]. Lastly, persistence is the determination to do something even though it is difficult or other people oppose it [10].

Fig. 11.4

Creative process of the artist and plastic surgeon

Through curiosity, imagination, and persistence over the course of the centuries, physicians and surgeons made many scientific advances, and these advances are still continuing through their patient work. On the basis of these advances, plastic surgeons have become able to translate legends into reality.

11.4 How Can Facial Deformity Stimulate the Creativity of an Artist and a Plastic Surgeon?

To give a body and a perfect form to one’s thought, this—and only this—is to be an artist.—Jacques-Louis David (1748–1825)

Creativity, understood as the ability to produce or use original and unusual ideas, is a phenomenon whereby something new and valuable is formed. Creativity is necessary not only for artists but also for surgeons—especially for plastic surgeons.

According to Dr. Colp, there are seven emotional factors that stimulate creativity: (1) tension, (2) personality disorder, (3) bipolar disorder, (4) observation of death, (5) physical disability or deformity, (6) sadness and dissatisfaction for the past, and (7) the Oedipus complex [11].

An example of an artist who was motivated by his physical deformity is Jacques-Louis David (1748–1825). We all know his famous painting entitled Napoleon at the Saint-Bernard Pass. He was a founder of the neoclassical school of art. In his death mask, we can easily see his crooked nose and markedly asymmetrical mandible, which lead us to make the diagnosis of hemifacial microsomia. The fact that both nasolabial folds are relatively intact (not erased unilaterally) excludes unilateral facial palsy (Fig. 11.5). Despite his facial deformity, which he even expressed in his self-portrait, all the portraits he made were symmetrical and never had any facial deformities. David compensated for his deformity by painting portraits that were smooth, even, and symmetrical [12].

Fig. 11.5

Death mask of Jacques-Louis David (1748–1825). Available at https://commons.wikimedia.org/wiki/File:Death_mask_of_Jacques-Louis_David,_1825.JPG

From his case, we learn that feelings about bodily deformity and incompleteness can stimulate fantasies of rebirth and auto-reconstruction, generating creativity in the artist. Then, how can we plastic surgeons stimulate creativity in our operations?

Harold Gillies, the pioneering plastic surgeon, performed more than 11,000 operations for 5000 soldiers with facial injuries from 1917 to 1925. His experiences with head and facial injuries became the basis of craniofacial surgery, and his advances were also applied to congenital craniofacial malformations. Through treating severely injured faces, he accumulated surgical experiences with the face that ultimately led to the development of aesthetic surgery [13].

Much like an artist who has a deformity, a plastic surgeon is motivated by the body deformity or disability of the patients that he or she tries to improve. The more a surgeon operates, the more his or her accumulated experiences stimulate fantasies of reconstructing patients with deformities.

Most of the principles of modern facial plastic surgery were developed during the 20 years between World War I and World War II. As such, plastic surgery aims for humanity before beauty.

11.5 The Borromean Rings of Plastic Surgery: Science, Art, and Skill

Plastic surgeons are now sometimes referred to as “half artists.” Surgeons are generally happy to be viewed in these terms and are eager to exploit this trend. Artists often find useful means of artistic expression from scientific fields. In this respect, science and art share a common denominator in their evolving relationship. Science is a systematic and theoretical construction of knowledge, which is acquired through measurable methods. Science consists of a body of knowledge of scientific experiments based on empiricism and methodological naturalism. Science is logical and analytical; in contrast, the arts tend to encourage intuition and imagination. Science demands predictable processes and results; the arts promote creative destruction with a tint of romanticism opposed to rationality. Over time, they have run parallel, crossed over, and separated from each other [14].

In plastic surgery, patients want to simultaneously achieve scientifically predictable results and artistic perfection. At this point, a symbol representing Trinity is coming to my mind: Borromean rings. Borromean rings or knots are 3 simple closed curves in three-dimensional space. These are topologically linked and cannot be separated from each other, but they break apart into two unknotted and unlinked loops when any one of the three is cut or removed. Thereafter, scientifically predictable results and artistic perfection compose two of the Borromean rings in plastic surgery.

A skill is a learned ability to perform an action with predictable results and good execution, often within a given amount of time, energy, or both. Plastic surgery requires personal skills as well as surgical knowledge or special technical dexterity. However, this niche surgical specialty is not very well covered in the curricula of many medical schools. Therefore, upon graduation, most junior doctors have had very limited or no exposure to common plastic surgery procedures. Recently, some courses have focused on fundamental plastic surgery skills required to perform key index operating procedures for entry into higher specialist surgical training [15]. There are also international fellowship programs teaching the essential personal skills needed in modern plastic surgery [16]. Without established personal surgical skills, it is very difficult to achieve an improved quality of life and satisfying outcomes for patients. Thereafter, surgical skill comprises the third Borromean ring.

To be an academic plastic surgeon, one must have a sound knowledge of anatomy, physiology, pathology, and pharmacology. These fields of scientific knowledge consist of a ring of plastic surgery. To be an artistic cosmetic surgeon, one must have a keen eye with an artistic viewpoint and imagination. This artistic eye comprises another ring of plastic surgery. To be a real plastic surgeon, good surgical skills for operations are needed. These skills are essential and comprise the other ring of plastic surgery.

Good skills are taught by our teacher plastic surgeons. Dr. Converse reminds Dr. Kazanjian as a good teacher. “Imaginative and resourceful, Dr. Kazanjian taught to improvise new methods rather than follow the conventional. ‘Do it just right,’ he would say, meaning in his laconic way (he preferred action to talk) that each patient’s problem required an individual solution. Never did I hear him denigrate a colleague’s work. His kindness, warmth, and modesty are legendary [17].”

As Lacan’s three registers of human experience (the symbolic, imaginary, and real) are only conceivable when considered together, plastic surgery consists of scientific knowledge (science), an artistic view (art), and surgical skill (skill) [18]. Just as Lacan’s three registers are linked as in a Borromean knot of three inextricably tied rings, science, art, and skill are linked as three inseparable rings (Fig. 11.6).

Fig. 11.6

Borromean rings of plastic surgery consisted of science, art, and skill

11.6 The Poet-Physician’s Note and the Plastic Surgeon’s Note

You lethargic, waiting upon me, waiting for the fire and I attendant upon you, shaken by your beauty. Shaken by your beauty. Shaken.—Paterson by William Carlos Williams

I recently enjoyed watching a movie entitled “Paterson” (starring Adam Driver, directed by Jim Jarmusch). A bus driver, whose name is Paterson, works in the city of Paterson in New Jersey. During pauses, he writes poems in a notebook (Fig. 11.7). His wife, Laura, loves his poems and tries to persuade him to publish them or at least make copies. He finally promises to make copies of the poems, but their dog rips up his notebook, destroying his poems. Sad and depressed, he goes for a walk and sits down at Great Falls, his favorite site. There, a Japanese man sits beside him, and they talk about poetry after Paterson notices that the man is reading the poem Paterson written by William Carlos Williams. Although the driver Paterson denies it, the Japanese man thinks that Paterson himself is a poet and gives him an empty notebook as a gift. Paterson begins to write a poem in his new notebook.

Fig. 11.7

Paterson, a bus driver writes poems in a notebook in a movie “Paterson” (starring Adam Driver, directed by Jim Jarmusch, 2016)

After enjoying the movie “Paterson,” I turned to the book-length poem Paterson and learned about the poet William Carlos Williams (1883–1963). He was a Puerto Rican-American poet, writer, and physician. His primary occupation was a general physician and a pediatrician; however, he was a successful poet as well as a painter. He practiced medicine by day and wrote at night.

People asked him: “Do you have time to write while continuing your treatment? You must be a superman with at least two energies.” He replied: “The two are two parts of one, not each of the other. The two complement each other. When one part wears me out, the other part makes me rest” [19]. For him, medicine was a leap forward to becoming a poet, and at the same time, poetry was the driving force of his role as a doctor, as exemplified by his confession stating “I cannot practice medicine without poetry.”

The poet-physician’s Autobiography brought me to the topic of plastic surgeons’ notes.

When I visited the Hunterian Museum in London, I had the chance to see some relics belonging to Thomas Pomfret Kilner (1890–1964), who established the V-Y pushback palatoplasty (Wardill-Kilner-Veau method) in 1937. The BAPRAS (British Association of Plastic, Reconstructive, and Aesthetic Surgeons) archive room of the Royal College of Surgeons had Kilner’s drafts of papers, pictures of the patients he operated upon, schemas submitted to journals, and his handwritten notes. Only one drawing of palatoplasty was drawn by pencil. Interestingly, it was not made in an ordinary notebook but was drawn on the reverse side of a letter envelope from the Queen’s Hotel, Birmingham. It is therefore thought that Dr. Kilner got an idea when he was staying at that hotel. Before the vivid idea went away, he sketched a schema on the nearest paper, the letter envelope [20].

Since my training period, which started 35 years ago, I have written my operative records myself or at least reviewed those that my residents make before I sign them. Alongside the official operative records, I have empty note papers upon which I write or draw to prepare for operations that I think will involve complicated procedures. Just after surgery, I fill the space with the steps of procedures I did and my regrets regarding the operation. When such operative notes are collected, they can be the basis of case reports, idea and innovation reports, case series, or even original articles.

The human brain is like molten bronze that should be poured into a mold. When inspired, ideas should be written or drawn before they disappear. This is why Dr. Williams and Dr. Kilner seized their ideas in a moment.

11.7 The Dresser and Stage Director: Scrub Nurses and Chief Residents

Recently, I enjoyed a play, entitled “The Dresser,” at Jeongdong Theater in central Seoul. Song Seung-hwan, an actor who graduated from the same high school as me, played the role of a protagonist named “Sir.” The very next day, I searched and watched a drama film (1983) of the same name in which Albert Finney and Tom Courtenay star as “Sir” and “Norman,” respectively (Fig. 11.8).

Fig. 11.8

Norman (Tom Courtenay) is putting a triple crown on “Sir” (Albert Finney) in “The Dresser” (1983)

This play, written by Ronald Harwood (1934–2020), explores the relationship between “Sir,” an aging, tyrannical actor and troupe leader with a monstrous ego and delusions of grandeur, and Norman, his faithful dresser, ego-masseur, and shield from reality. The play is set in World War II, with themes of struggle and survival, emphasizing that everyone is simply struggling to survive as their world shifts and crumbles around them.

A particularly memorable scene was inside of the actor’s room in the theater, where there was a desk and chair for make-up, an armchair for rest, and a hanger with many costumes. When the actor (Sir), who was wearing only underwear, raised his arms, the dresser (Norman) helped the actor put on his costume, including a triple crown.

When the actor was preparing (applying make-up and putting on a costume), the stage director (Madge) notified him of the time remaining until the opening of the curtain. When the opening was ready, the actor moved from his room to the curtain. Between the acts and intermission, the actor returned to his room and took a rest or nap on his couch, or took a bath in a tub.

In the last act of “King Lear,” the entire troupe made frantic attempts to create the storm scene for Sir. However, he was not satisfied and berated them for making a noise no bigger than “farting flies.”

The actor took an interest in a new actress not because she was young and pretty but because she looked lean and lighter to carry in Act V of “King Lear.”

Just before his last performance as an actor, Sir talked to Madge, who had been working for him for 20 years.

Were you happy with your work? Was it worth it?

“No, I haven’t been happy. Yes, it’s been worth it.” She replied.

Then, Sir said: “Talk about me sometimes. Actors exist only in the memory of the others. The most beautiful thing is to be remembered by somebody.”

After the curtain call, Sir came back to his room, lay down on the couch, and then breathed his last breath. Only the dresser closed his eyes. In the preface of the uncompleted long-awaited autobiography, however, Sir did not mention the dresser or the stage director, who had worked for a long time.

Just as the actor plays in a theater, the surgeon works in the operating theater. Like the actor stays in the actors’ room, the surgeon stays in the locker room to change clothes and rest. Usually, the chief resident or circulating nurse notifies me of the exact time I should arrive at the theater.

When the patient is anesthetized and draped, I wash my hands and open the door using my foot and then raise my arms like an actor. The scrub nurse gives me hands to fit into the aseptic surgical gown. Between operations, the surgeon returns to the locker room and takes a rest, enjoys a cup of tea, or takes a shower to remove blood from the operation.

During the important procedures of each operation, I usually need a larger visual field. Thereafter, I ask my assistants to pull the retractor tightly or the circulating nurse to adjust the lightening. As I become older, I do not berate them—instead, I say, “Thank you!”

I do not prefer pretty or young residents or physician’s assistants; rather, I prefer those with strong arms and agile hands who provide me a good visual field during the operation.

I wish to be remembered by my team as a good surgeon. I sincerely hope that my pupils have been happy working with me and feel their efforts were worthwhile. As actors exist only in the memory of the audience, I believe that surgeons exist only in the postoperative results of their patients.

This play reminded me of a novel, The Atheist’s Mass, written by Honoré de Balzac (1799–1850). He defined the glory of a surgeon [21]. “The glory of a surgeon is like that of an actor: they live only so long as they are alive, and their talent leaves no trace when they are gone. Actors and surgeons, like great singers too, like the executants who by their performance increase the power of music tenfold, are all the heroes of a moment.”

As the actor passed away just after the curtain call, I would like to continue performing surgery as long as my health permits. However, unlike the character of Sir in the play, if I have a chance to write my autobiography, I certainly will dedicate it to my pupils and scrub nurses who worked with me.

11.8 Making a Narrow Path, Then a Road, through the Snow

If they were to walk directly behind the first man, the second group would make a clearly defined but barely passable narrow path, and not a road.—Varlam Shalamov

This Sunday morning, we had a heavy snow in my province. Walking along the road, I was reminded of Kolyma Tales, written by the Russian author Varlam Shalamov (1907–1982) about labor camp life in the USSR [22]. It contains six collections of short stories, with a prologue entitled “Through the Snow.”

In this preface, he explains how to make a road through the virgin snow.

“One person walks ahead, sweating, swearing, and barely moving his feet. He keeps getting stuck in the loose, deep snow. He goes far ahead, marking his path with uneven black pits” (Fig. 11.9). When totally exhausted, he selects points in the snow’s infinity to orient himself—a cliff, a tall tree. Then, followers (5–6 men) weave along the track of the first man in a shoulder-to-shoulder scrum.

Fig. 11.9

Making a road through the virgin snow. Available at: http://2.bp.blogspot.com/-2KYjwhrJm8k/VXTbHx_X00I/AAAAAAAACxU/aQPcgH7wa6Y/s1600/khylov__kolyma_tales__shalamov__through_the_snow.jpg

The followers walk beside the first man’s path but not along it. “When they reach a predetermined spot, they turn back and tramp down the clean virgin snow which has not yet felt the foot of man.” “The road is tramped down. It can be used by people, sleighs, tractors.”

In plastic surgery and craniofacial surgery, conducting novel research or developing an innovative surgical method is like making a small path in the virgin snow. The first researcher works toward his purpose, carries out experiments, obtains the results, and then submits a paper. If the paper is easily accepted, he is happy. If rejected by several journals, he feels exhausted and enters a slump, as if the first man mentioned by Shalamov were to lie down on the snow and light a homemade cigarette, after which the tobacco smoke would hang suspended above the white, gleaming snow like a blue cloud. If the paper is published, a small path is made for the followers, the second group who will cite the first man’s paper. However, this is not yet sufficient for the findings to be recommended to the surgeons who are readers of the journal.

When the men described by Shalamov reach a predetermined spot, “they turn back and tramp down the clean virgin snow which has not yet felt the foot of man.” If the second group of roadmakers walked directly behind the first man, they would make a clearly defined but barely passable narrow path, not a road. Likewise, if the second group of authors wrote papers very similar to the first one—that is, “me-too papers”—they would hardly transform the narrow path carved out by the first paper into a road suitable for the readership of surgeons. Instead of just applying or repeating the first researcher’s method, they should critique the first paper, finding its strengths and weaknesses and then modifying it if they can.

In roadmaking in the snow, the first man has the hardest task, and when he is exhausted, another man from the group of five takes his place.

When writing a paper, surgeons or researchers should not simply follow the path laid down by a previous paper; as Shalamov, a writer who spent years in the Gulag camps of the USSR, emphasized: “Each of them—even the smallest and weakest—must beat down a section of virgin snow, and not simply follow in another’s footsteps.”

He closed the prologue by saying “Later will come tractors and horses driven by readers, instead of authors and poets.”

11.9 Aging in Mathematics and in Surgery

We can use the wisdom of the old horse.—Guan Zhong

Recently, I enjoyed the film entitled A Man Who Knew Infinity, directed by Matt Brown. It is the story of the life and academic career of the pioneer Indian mathematician, Srinivasa Ramanujan (1887–1920), and his friendship with his mentor, Professor Godfrey Harold Hardy (1877–1947).

The name of Hardy was familiar to me since I remember the Hardy–Weinberg principle, stating that allele and genotype frequencies in a population will remain constant from generation to generation in the absence of other evolutionary influences: [(p + q)² = p² + 2pq + q² = 1, where q = 1 − p].

After coming home, I read Hardy’s famous book, A Mathematician’s Apology, and learned about some interesting aspects of his character. In 1896, Hardy entered Trinity College, Cambridge, where he eventually graduated.

He could not bear to look at his own reflection in a mirror. It is said that, when staying in hotels, he would cover all the mirrors with towels. He engaged in this peculiar behavior because he believed his activity and skill would decline with age and denied that he was aging.

In his book, he discussed a phrase attributed to Gauss: “Mathematics is the queen of the sciences and number theory is the queen of mathematics.” He thought that mathematics is a “young man’s game,” meaning that anyone with a talent for mathematics should develop and use that talent while they are young, before their ability to create original mathematics starts to decline in middle age.

As a plastic surgeon who turned 60 this year, I have recently thought about aging. I recalled Dr. Harold Delf Gillies (1882–1960) (Fig. 11.10). D.r Gillies, 5 years younger than Professor Hardy, studied medicine at Gonville and Caius College, Cambridge University. Gillies suffered a slight cerebral thrombosis while undertaking a major operation at the age of 78 on the damaged leg of an 18-year-old girl.

Fig. 11.10

Sir Harold Delf Gillies by Harry Furniss. Pen and ink, 1910s, 390 mm × 320 mm. Licensed from National Portrait Gallery, London

As exemplified by Dr. Gillies, aging makes plastic surgeons more experienced and wiser than when they were young. An episode in ancient Chinese history illustrates this point: A king (Qi Huanong) and his troops embarked on a conquest in spring against a nearby nation. On their way home in winter, they lost their path. A general (Guan Zhong) said: “We can use the wisdom of the old horse.” They released an old horse in front of the line of soldiers, the soldiers followed it, and they finally found their way.

Similarly to Gauss, I think that plastic surgery is the queen of surgery, and craniofacial surgery is the queen of plastic surgery.

11.10 Bamboo Back-Scratcher

If I have seen further, it is by standing on the shoulders of giants.—Isaac Newton (1642–1726)

My life will be successful if someone in the future can remember me as a bamboo back-scratcher that scratched an itch.—Kun Hwang (1957–)

During my stay in London, I had a comfortable arrangement in my flat, since I had a washing machine and could cook easily. Free phone calls were available, and I did not feel like I was far away from my wife and my hometown.

The only discomfort was that I had nobody to scratch my back for me when it itched. I missed my bamboo back-scratcher, which I had not brought with me.

When searching references, periodicals are easy to find, but it can be difficult to find books. If the library does not have a book I am looking for, I usually order it online, but if Amazon does not have the book I need, it is similar to feeling my back itch but not being able to scratch it with my hand.

On a rainy day, I visited the British Library to look for books that were out of stock on Amazon. I walked from the King’s Cross Station, famous as a location in Harry Potter, to the British Library. I was able to register as a user and find Grabb’s “Cleft Lip and Palate: Surgical, Dental, and Speech Aspects” (1971), from which I copied a chapter written by James Calnan.

On my way out, there was a very large sculpture in front of the library, standing on a pedestal taller than a man. A man was wearing glasses, sitting on a square chair without a backrest, bending forward and holding a compass in his left hand, and measuring something under his feet. When I got close to the nameplate, I realized that the sculpture was “NEWTON” (1995) made by Sir Eduardo Paolozzi (1924–2005). It was written that the original painting “Newton” was created by William Blake (1757–1827). On my way back to my flat, I visited Tate Britain and saw Blake’s original painting (Fig. 11.11).

Fig. 11.11

Statue and painting of Newton. Upper: “NEWTON” by Sir Eduardo Paolozzi. Lower: “Newton” drawn by William Blake. Reproduced with permission from Tate Britain

A naked man sat on a rock and measured a triangle and a circle drawn on the floor using a compass. Blake expressed Isaac Newton (1642–1726) as a divine geometer. He was sitting, but leaning forward, his shoulders tilted down to his knees. It seemed that if there was someone beside him, he could easily climb onto Newton’s shoulders and stand there. Seeing this painting, I remembered a saying of Newton in response those who praised him: “If I have seen further, it is by standing on the shoulders of giants.” I was impressed with the creative expression of the painters and sculptors who presented a compass as the symbol of this great physicist who discovered the law of gravity.

Walking out of the museum, I looked back and saw myself. What could be a symbolic object of me? What object could my fellow plastic surgeons, my students, and my children use to remember me in the distant future?

Since it was raining and chilly outside, when I came inside, I felt warm and my back became sweaty. I moved my arm behind my back and tried to scratch my back through my clothes, but I did not feel any relief. I wished I had my bamboo back-scratcher with me.

After I was trained in plastic surgery, I sought to elucidate aspects of the surgical anatomy of the human body needed for surgeons. I strove to write papers like bamboo back-scratchers that can directly reach the area that itches. However, my efforts were not enough to fully satisfy the curiosity of my fellow plastic surgeons, and fewer than 5 years remain until my retirement. Now is the time for me to bend down like Newton’s body in that sculpture so that somebody can climb onto my shoulders and stand there to see further.

Will my life be successful if someone in the future can remember me as a bamboo back-scratcher that scratched an itch? (Fig. 11.11).

11.11 A Plastic Surgeon Should Be a Good Physician First

Magic mirror in my hand, who is the fairest in the land?—Evil Queen (Fairy tale)

In my department, I have a weekly seminar meeting with residents, medical students in clerkship, and graduate students. The topic of the last meeting was “How much am I worth?”

The participants responded with several novel answers to this fanciful question. A resident computed his lifelong stipend, as we calculate patients’ disability rating using the McBride scale. A PhD. student thought that her value could be measured only with the amount of tears her acquaintances will shed, with a price equal to that of the most expensive French cognac.

This discussion induced me to ask myself: “Am I a man of worth?” and “Am I a good plastic surgeon?”

Tips for patients about choosing a good plastic surgeon have been presented by a CNN medical news correspondent [23], as well as the American Board of Cosmetic Surgeons [24]. These tips include checking whether the plastic surgeon is board certified, checking the surgeon’s record of malpractice judgments, and asking whether the surgeon has hospital privileges as part of a background check. In the United States, “Best in City X Magazine,” such as “Best in Baltimore,” is being judged by a survey sent to 10,000 physicians, who are being asked, “If your family member was in need of a plastic surgeon, for whom would you refer them personally?” Since all major cities in the United States have a local magazine for which votes “Best in City X,” this would be the best place to start.

However, fulfilling these criteria cannot guarantee that a plastic surgeon is a “good plastic surgeon.”

Patients consider a doctor to be a good doctor when they feel comfortable, safe, and human with him or her. However, from the medical perspective, good doctor is the physician or surgeon who solves the patient’s problem. A good doctor is one who correctly diagnoses patients’ illnesses, cures them with safe evidence-based procedures, and is honest to them. On the contrary, a poor doctor is generally credited with good intentions but inadequate knowledge or skills required for the job. The virtues needed for a good doctor are sound knowledge and competent skills to provide safety and comfort to patients while maintaining a good rapport with all around him.

Since surgeons treat people with knives and risky instruments and therefore are more frequently sued than other doctors, a good surgeon should be a good doctor with some extra skills: A good surgeon needs to learn how to operate, when to operate, and when not to operate [25]. In addition to thorough knowledge and practical skills, a good surgeon is also expected to have common sense, which enables him or her to make sound practical judgments [26].

In the plastic surgery field, we sometimes meet patients who expect us to be magicians who can change them from an “ugly one” to the “fairest of them all” (Fig. 11.12). More rarely, they treat us as merchants who are selling “new faces.” In this aspect, I do think that a good plastic surgeon must first be a good surgeon and that a good surgeon must first be a good doctor.

Fig. 11.12

The Evil Queen in front of the Mirror. Mirror in a 1916 illustration. Available at: https://upload.wikimedia.org/wikipedia/commons/thumb/8/8c/Illustration_at_page_201_in_Europa%27s_Fairy_Book.png/1024px-Illustration_at_page_201_in_Europa%27s_Fairy_Book.png. Accessed Jul 12, 2018

In terms of knowledge, we should understand the anatomical basis of treatment and the principles of perioperative care, including fluid and electrolyte balance. These are the values plastic surgeons must keep. Without the knowledge of anatomy and perioperative care, plastic surgeons are not different from cosmetologists. The decision of when to operate and when not to operate is essential, as well as surgical skills. Honesty and empathy for patients define the attitude of a good plastic surgeon. If artistic sense and enthusiasm are added, we might carve a “Galatea,” a perfect ivory sculpture that eventually lost its hardness.

11.12 The Aging Surgeon and the Secret of Longevity

I sit down at the piano and I don’t sing the opera, most of the time, until I know it.—Plácido Domingo

Last year, I enjoyed Verdi’s Nabucco directed by James Levine and starring Plácido Domingo at the Metropolitan Opera (Fig. 11.13). In response to the audience’s request for an encore, Levine gave an encore performance of the famous “Chorus of the Hebrew Slaves” of Act 3. This beautiful chorus starts as “Fly, thought, on golden wings.”

Fig. 11.13

Plácido Domingo sings an aria in Verdi’s Nabucco, at New York Metropolitan Opera

Among the “Three Tenors,” Luciano Pavarotti (1935–2007) passed away, and José Carreras (1946–) is not active as before. Domingo (1941–) has also had a long and beautiful career, as he himself said, but he is still active and has a beautiful voice, just as before. At the time of this performance, he was 76 years old.

I was curious how this great singer performed the “perfect aria” and how he maintained his voice in its best condition. I searched for this secret and finally found it in the following conversation among James Levine, Plácido Domingo, and Peter Gelb, the general manager of the Metropolitan Opera [27].

Levine: The art form is difficult enough. A mistake is not the end of the world…

Domingo: [To be] really, totally honest, I know exactly in my mind how to sing, but I have never been able to do it that way…though I come pretty close.

Gelb: What is, if you could say, the secret of your longevity?

Domingo: I don’t know, but I think it has helped me something. Since I was a musician, always, I sit at the piano and I was preparing my operas. I wonder how many hours of coaching I have. I sit down at the piano and I don’t sing the opera, most of the time, until I know it.

Levine: He didn’t have to waste voice learning it. That’s a brain job, not a voice job.

As a surgeon, I have asked myself whether I carry out operations exactly as planned. Although the operations are precisely designed and usually—like Domingo—I come pretty close, I have never been able to operate in exactly the same way that I conceive of it in my mind.

I recalled that Dr. Harold Gilles continued to perform surgery until the age of 78, which led me to think about the longevity of plastic surgeons.

First, we must preserve our visual acuity, as singers spare their voice. Therefore, excessive TV watching or cellphone use should be reduced. Second, we should maintain good general health. Smoking or excess alcohol use shortens the surgeon’s longevity. Lastly, the most important consideration is planning and preparing our operations. We should design our procedures carefully and make memos, schemas, or drawings while sitting at our desk, not in the operating theater. Much like opera, surgery is a brain job—not a job for the hands.

11.13 Accolade for Surgeonship

A good plastic surgeon must first be a good surgeon, and a good surgeon must first be a good doctor.—K. Hwang [2]

Recently, I happened to see an accolade for knighthood while watching Season 8 of “Game of Thrones.” Jaime Lannister bestows knighthood upon Brienne of Tarth, using the following words:

“In the name of the Warrior, I charge you to be brave. In the name of the Father, I charge you to be just. In the name of the Mother, I charge you to defend the innocent. Arise, Brienne of Tarth, a knight of the Seven Kingdoms.”

In the medieval ages, the first step in becoming a knight was to serve as a page (a term indicating a type of servant). Seven-year-old boys were turned over to the care of the castle’s lords. They were placed on an early training regimen of hunting and academic studies. Pages become assistants to older knights in battle, carrying and cleaning armor, taking care of the horses, and packing the baggage. Older pages were educated in swordsmanship, equestrianism, chivalry, warfare, and combat using wooden swords and spears. As the boys became squires at the age of 15, they continued training in combat and were allowed to have their own armor. They were required to master the prerequisite skills for knighthood while wearing armor. When squires reached the age of 21, they became eligible to be knighted.

The accolade is a ceremony to confer knighthood. Usually, the knight-elect would kneel in front of the monarch on a knighting-stool. In the ceremony, the monarch first lays the side of the sword’s blade onto the accolade’s right shoulder. The monarch then raises the sword gently just up over the apprentice’s head and places it on his left shoulder (Fig. 11.14). The new knight then stands up, and the king or queen presents him with the insignia of his new order.

Fig. 11.14

Accolade. Edmund Blair Leighton (1901)

In March, new plastic surgeons receive their board certification from the Ministry of Health and Welfare. To become a board-certified surgeon, in the Republic of Korea, a 1-year internship and a 4-year residency are mandatory after graduating medical school and obtaining a medical license.

At the commencement of medical school, students usually take the Hippocratic Oath. Upon receiving board certification, in my department, each new surgeon takes a photograph with the training staff and junior trainees. While this is to be commended, it may not be enough for a truly memorable moment.

I propose an accolade for plastic surgeonship. I would like to prepare a knife handle with a #15 blade, tap it on the shoulders of my pupil, and then say:

“In the name of the Physician, I charge you to have medical knowledge. In the name of the Surgeon, I charge you to have surgical skill. In the name of the Teacher, I charge you to have honesty and empathy to your patients. Arise, Kun of Incheon, a plastic surgeon.”