The current “economic downturn”, now almost ten years in office, has presided over a significant rise in popularity of an alternative cosmetic surgery practice model: the Minimally Invasive Cosmetic Approach, (MICA).
The minimally invasive option has always been a part of the traditional Cosmetic Plastic Surgery model, (CPS); but mostly for the purpose of polishing, the after a cosmetic operation, result, like: a facelift or liposuction, or breast surgery, and many others.
The current money stricture, however, has elevated the MICA to a more socially and economically persuasive alternative. It is no longer just the subcontractor called in to refine the result of an operation.
It has a room of its own.
The use of the MICA model even as the first option, in the approach to cosmetic surgery has always been inevitable.
The MICA comes to the dance with an impressive array of cosmetically directed tools: fillers, exfoliants, bleachers, toxins, lasers, ultrasound, peels, cannulas, light, barbs, strips, topicals, hair things, cryo machines, cooling machines, heating machines, and the like.
To varying degrees they all work!
It is a movable beast, and must be fed.
Success often breeds excess.
It’s an odd phenomenon, where success in any work, often seduces the work to reach beyond its intended limits, usually to maintain its hegemony:
Stretching of this sort – the very stuff of entrepreneuring – can take the MICA, beyond its grasp, and go where no man has gone before. In this role, the MICA is often called upon to do the heavy lifting of the plastic surgeon.
The results for the patient will either expose or expand MICA’s limitations, while playing footsy with a few dispossessed ethics.
Although legitimately highlighting the current economic disparity, the palace coup is often frustrating for the Plastic Surgeon. That frustration, has actually led to the emergence of what must be considered a new specialty by the odd name of Reconstructive Cosmetic Plastic Surgery, to address a few unfortunate results from this rocky regime change.
At the same time, and as a salutary, and not so “unintended” consequence, cosmetic plastic surgery is brought taken back to its roots and beginnings. There on the floor, with that, “I told you so” grin on its face, was this odd dysfunctional anomaly, and the point of this piece.
It seems the CSP practice model is home to an old odd logical fallacy, all done up in the requisite Latin: “Post hoc ergo propter hoc” – after the thing, therefore because of the thing.
In current practice, and on occasion, a patient may express some disappointment, following a cosmetic operation. The patient has been allowed to believe that everything after operation, from bunions to election fraud, was because of the operation.
This is the Post Hoc Annuity Tango, (PHAT).
The “Post Hoc” is the after the thing part.
The “Annuity” is in the open-ended expectation of additional work.
The “Tango” is in the confrontational dance of surgeon and patient in their negotiation.
Sure, in Western Medicine, there is always a give and take between the two, but this one is a set up.
Perhaps a little context music.
Cosmetic plastic surgery began life by a stone-in-the-shoe, relationship with traditional disease based medicine, even before there were “diseases” 2. In the mid to late 1800s, early cosmetic surgery was performed in secret, a place warmly endorsed by both surgeon and patient, each of whom, and for different reasons, feared an “outing”.
In time the CPS model evolved into a big fee-single operation enterprise, with the hash tag, “cure” implicit in that model. That meant the patient expected to be cured of face aging, or nose deformity, or puffy eyelids, or breast problems, unwanted fat, or any other cosmetic problem.
But the deck is stacked since cosmetic cure, is defined mostly by the patient, and is often a prescription for disappointment.
Enter the PHAT!
Most every physician, self interest notwithstanding, genuinely wants his/her patient to be satisfied, if not actually pleased, with the outcome of his work3.
Come the Day of the PHAT, the plastic surgeon is often hobbled by these persistent sensibilities, and wants his/her patient to actually be happy.
The ensuing “Tango” discussion can be awkward and unsatisfying, often ending in an untidy mitigation, usually favoring the force of the patient’s logic. The surgeon will likely end up doing additional work, but it is not a good scenario.
So that’s how the PHAT became the dysfunctional flaw in the single operation-big fee-cure model, at the center of the Cosmetic Plastic Surgery practice model. Ever wonder why they call it, “practice”?
Yet stay a while.
To many folks cosmetic plastic surgery is different from reconstructive plastic surgery.
Not so to the plastic sugeon.
To him, Cosmetic plastic surgery, (CPS) is really Reconstructive Plastic Surgery, (RPS), by a different name. The principles and techniques are the same – no different!
But RPS seems to have relatively little trouble with the PHAT. Although, by no means, immune, it has its own “get-out-of-jail-free” card.
It comes to the operating room, blessed with a “pre existing condition”. So you fall off your bike, or a ski lift, or have a fight, or some Darwin Award accident, and your body is injured.
You convince the plastic surgeon to do an operation to fix things. it is understood from the outset that one operation may not fix the problem in a single operation. So it’s understood there will be a next stage to finish the thing in a cosmetically pleasing manner.
So the RPS model was born as a staged enterprise, promising, not to “cure”, but to make things better – a sort of esthetic palliation.
Yet they remain the same work – cosmetic and reconstructive plastic surgery, but with two different practice models. One is a staged undertaking indicated by its pre-existing condition promising to make things better.
The indication for the other, is patient-defined, to be done in a single operation format, without the promise of a “next stage. So the cosmetic plastic surgeon may find himself in the PHAT…. Sorry about that.
It would not be unreasonable for the MICA to step into the breach left by the PHAT, and quite successfully. Yet unknown to but a few, Clark Kent is still Superman. But hey that’s for another time.
So what’s wrong with the MICA.
Well nothing really.
It does lack the element of control, so important in cosmetic plastic surgery, or any surgery for that matter. You don’t actually see the tip of the needle during injection, or the actual impact of the laser or ultrasound and other devices. In those and others is a general lack of control.
You do, however, see exactly where to place the surgical stitch, and that’s “control”, and something critical to any medical work.
So to finish this thing off, if my contention is correct, and the CPS is the same as RPS, it will be seen in the true re-operation rate following cosmetic surgery, reflecting the same rate as the “next stage” of the RPS. The number will be “true” only if it includes all indicated additional surgery whether actually performed or not.
Unhappily those official numbers are lacking, but they are known to plastic surgeon and those on the other side of the scalpel.
Obiter Dictum: additional surgery, in this setting, is not about right or wrong. It is just about name calling. The most frequently used term for this kind of additional surgery is “revision”, an annoying term redolent of failure; and should be reserved for those results needing actual revision.
The additional cosmetic surgery It’s really just the “next stage” with its aura of strategy, as in RPS model. For both It is true and exculpatory.
But this is just a speculation on the Post Hoc Annuity Tango, and the dysfunction that created it.
Thanks for listening
1. Frileck S. Surgery-on-Demand. Plast Reconstr Surg. 1997;99:852-855
2. Frileck S. Paradigms Lost. Plast Reconstr Surg. 2001;107:268-271
3. Kahneman D, Tversky A. Rational Choice and the Framing of Decisions. J of Business 2nd ser. 1986;59.4:251-78