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16 Behind-the-Scenes Secrets of Plastic Surgeons

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Our culture is pretty obsessed with what it sees in the mirror: Cosmetic procedures have risen an astounding 115 percent since 2000, with nearly 16 million procedures performed in 2015 alone. Breast augmentation, buttocks lifts, and minimally-invasive “injectables” have all conspired to literally change the shape of the male and female form.

For insight into the highly skilled hands that make these transformations possible, mental_floss spoke with several accomplished plastic surgeons about the living sculptures they create.

1. THEY SEE BEAUTY AS A MATHEMATICAL EQUATION.

Early in his career, Donald Kress, M.D., a plastic surgeon in Baltimore, Maryland, would find himself puzzled when encountering facial features he found unappealing. “I couldn’t figure out what it was,” he says, “until I’d match the face with the Golden Ratio.” The Golden Ratio, or Golden Mean, is a formula first articulated by Greek mathematician Euclid and later used to theorize that the most pleasing appearances in art and nature are created at a ratio of 1.618:1. In the 1970s, surgeon Stephen Marquardt, M.D., began to study commonly appreciated beauties like Marilyn Monroe and Sophia Loren and found the ratio applied to many seemingly universal standards of attractiveness.

Visualizing the formula using a “mask” designed by Marquardt in 1992 (above, middle) can reveal where a face is asymmetrical, though experienced surgeons can make a similar evaluation intuitively. “It comes up when you’re younger and don’t have a good eye for things,” Kress says. “After a few thousand patients, you can see it in your head.”

2. THEY HOST “BROTOX” PARTIES.

OnabotulinumtoxinA—commonly referred to by the brand name Botox—has been used for decades to paralyze muscles at a local injection site, which can prevent the contractions that cause wrinkles and frown lines. Some practices have taken to hosting the increasing number of male patients coming in by offering “Brotox parties,” where a number of friends will schedule at once to make the treatment a social event.

Z. Paul Lorenc, M.D., F.A.C.S., a plastic surgeon in New York City, says that “Brotox” is a result of men who have had a good experience recruiting their friends. “It’s kind of a support group,” he says. “They can interact in the waiting room. Men used to do this at parties, but that’s become passé. It was always a bad idea. You should never have alcohol involved.”

3. THEY’RE DRAWING LANDMARKS ON YOU.

Watch enough reality television and you’ll eventually spot a plastic surgeon taking a black marker to the bare torso of a patient. Matthew Schulman, M.D., a plastic surgeon based in Manhattan, says that surgeons are basically acting as topographers, marking areas of the body that may change shape or become less visible when a patient is lying down. “We’re drawing landmarks for ourselves because a person looks different when on the table,” he says. “I might circle where the fat is thickest, or where the nipple is while standing.” No special medical ink is used: It’s just a Sharpie.

4. BREAST IMPLANTS CAN CREATE “MOTION ARTIFACTS.”

There are several ways to insert breast implants, but Kress says that one in particular can create problems for patients who do a lot of jumping up and down. When an implant is inserted in a subpectoral incision under muscle tissue, it can give off the appearance of remaining stationary while the rest of the breast moves during physical activity, creating a visual ripple effect. “If there are big arm movements, or if they’re in front of people teaching or on television, I advise them of the potential consequences,” Kress says.

5. THEY CAN’T MAKE YOU LOOK PHOTOSHOPPED.

Schulman says that social media—especially the popularity of impeccably-proportioned Instagram models—has created a few headaches for his practice. “The problem with pictures is that they’re just a guide, but it’s not like picking a body off the shelf,” he says. “Half of the Instagram models are Photoshopped, so when you say you want to look like this, I can’t do it. I can’t give you an 18-inch waist.” Though Schulman does like having a visual reference for what patients have in mind, he prefers they understand it's a starting point, not a preview.

6. THEY DON’T WANT YOU TO LOOK GOOD ON THE TABLE.

“Everyone,” Schulman says, “looks great lying down.” But trying to achieve aesthetic perfection in the operating room is a recipe for disaster. “One of the first things we learn as plastic surgeons is that just because something looks good on the table doesn’t mean it’ll look good six months later. We want to make the result less than ideal to account for healing.” Breast implants, for example, might be placed higher than desired so they can “settle in.” Making them perfect during surgery means they’re likely to drop too low once the body recovers.

7. IT TAKES EXACTLY 90 DAYS TO GET USED TO A NEW FACE.

According to Kress, there’s a tremendous difference between a facelift and a procedure that radically alters the face. “In a facelift, you’re turning back the clock and people can adjust to it quickly,” he says. “But a new nose, a new chin, taking away a bump, you’re creating a person they’ve never seen before.” In his experience, it takes patients almost 90 days exactly to get used to the image in the mirror. “On day 87, they’ll see someone else’s chin. On day 91, it’s you. It’s freaky how accurate it is.” Kress will normally refuse to remove an implant (chin, cheeks, breasts) prior to the 90 days to account for this phenomenon.

8. MORNINGS ARE BEST FOR DETAIL WORK.

If you’re opting for cosmetic surgery and have a nose job scheduled for late in the day, you may want to reconsider. According to Kress, procedures that require fine motor skills like nose jobs, facelifts, or eyelid surgeries are best performed in the morning, while gross motor work like breast implants and liposuction can come later. “You don’t want to reverse the order because it can take between 45 minutes to an hour for fine-touch motor skills to return. I start with the most delicate surgeries first, have a good lunch, and do bodies later.”

9.  THEY CAN MAKE YOU LESS ANGRY-LOOKING.

Not all cosmetic surgery is focused on restoring the appearance of youth: Some people just want to look happier. “Many of my Botox patients coming in say that everyone thinks they’re angry all the time,” Lorenc says. “They want to correct a frown or a heavy brow.” Kress has also seen people ready to go on the job market for the first time in years who want to appear more awake—or sober. “Sometimes eyelids can make you look like you drink, or don’t get enough sleep,” he says.

10. THEY WORK WITH WITNESS PROTECTION.

That gangster-movie cliché of having to modify your face to avoid being spotted after offering damning testimony? It’s true. Kress has operated on several government witnesses, and they can forget about follow-up visits. “I’ve had Federal Marshals come in and tell me, ‘This is the only time you’re going to see this guy, so give him whatever instructions he needs,’” he says. Kress has also worked on covert military operatives who have had their name and image published in media and run the risk of being recognized. 

11. THEY HAVE SIGNATURE NOSES. (AND BUTTS.)

Many surgeons get into the cosmetic field because of an artistic impulse: They don’t want to perform cookie-cutter procedures and like to improvise. But a certain segment can also offer procedures with a dependable aesthetic outcome that becomes a kind of signature. “Some doctors are known for noses I can spot across the street,” Schulman says. “I do a lot of butt-lifts and make them look like an upside-down heart. Patients come in because they want that result.”

12. CALF IMPLANTS ARE A THING.

And not just for men, either. Lorenc regularly sees patients of both genders who want to rectify their genetic misfortune and sport shapely, powerful-looking calves. “I’m one of the few surgeons who does them,” he says. “The stereotype is that it’s only bodybuilders, but that’s not true. They make up only a percentage. Some people just can’t develop them in the gym no matter what they do.”   

13. BEING A SMOKER IS A REAL NO-NO.

One universal truth of cosmetic surgery: Operating on a smoker is never a good idea. Nicotine constricts small blood vessels, which can delay healing and open up the door for complications. “Every good plastic surgeon will require a patient stop smoking before a procedure,” Schulman says. His patients sign an agreement requiring them to cease any kind of smoking four weeks prior and for eight weeks following an operation. “They agree I can nicotine-test them [via urine] and if they’re positive, the operation is canceled and I keep their money.”

14. THEY’LL WORK ON KIDS FOR ONE REASON.

There are very few cases of surgeons electing to work on anyone under the age of 18 for purely cosmetic purposes, with one key exception: protruding ears. Kress says that ears that stick out too much can become a psychological burden and that there’s a sweet spot to get them pinned back. “Around age 5 or 6, the ear has gotten big enough to work on and see a lot of the underlying structure,” he says, “but it’s also before they get into grade school and the taunting really starts.”  

15. THEY THINK TRANSPLANTS ARE THE FUTURE.

While fat transplantation is an increasingly popular and effective alternative to artificial fillers—adipose tissue can be harvested from unwanted areas and injected into the butt or face—Schulman sees the future of plastic surgery being far more radical, and less focused on aesthetics. “I think in the next ten years, we’re no longer going to be doing reconstructive work for trauma,” he says. “If you need breast tissue after a cancer operation, it will be from a donor. Things like face transplants and hand transplants are being led by plastic surgeons, by microsurgeons. I see full limb transplants. The possibilities are endless.”

16. THEY’RE NOT REALLY STRESSED.

Lorenc finds it amusing when friends or acquaintances remark that being a surgeon must be one of the most stressful jobs you can have. “When I step into the operating room, it’s like nirvana,” he says. Barring the rare complication, no one is in critical condition, bleeding to death, or under any extreme duress. Surgeons tend to work at their own pace, sometimes with a soundtrack. “I listen to Pink Floyd, the Allman Brothers, Jimi Hendrix. Sometimes reggae.”  

All images courtesy of iStock unless otherwise credited.

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Medicine
Why Haven't We Cured Cancer Yet?
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Walkathons, fundraisers, and ribbon-shaped bumper stickers raise research dollars and boost spirits, but cancer—the dreaded disease that affects more than 14 million people and their families at any given time—still remains bereft of a cure.

Why? For starters, cancer isn't just one disease—it's more than 100 of them, with different causes. This makes it impossible to treat each one using a one-size-fits-all method. Secondly, scientists use lab-grown cell lines cultivated from human tumors to develop cancer therapies. Living masses are far more complex, so potential treatments that show promise in lab experiments often don't work on cancer patients. As for the tumors themselves, they're prone to tiny genetic mutations, so just one growth might contain multiple types of cancer cells, and even unique sub-clones of tumors. These distinct entities might not respond the same way, or at all, to the same drug.

These are just a few of the challenges that cancer researchers face—but the good news is that they're working to beat all of them, as this TED-Ed video explains below.

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Health
6 Ways Technology Can Help Mental Health Disorders
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Today is World Mental Health Day. Mental health issues affect hundreds of millions of people around the globe; according to the World Health Organization, some 300 million suffer from depression, and another 260 million grapple with anxiety disorders. While researchers haven't developed any breakthrough mental health drugs in nearly three decades, new technological innovations are helping some patients connect with a therapist, get diagnosed, track moods, manage or mitigate symptoms, and stick to treatments. Here are just a sampling of them.

1. APPS FOR EVERYTHING FROM PTSD TO ADDICTION

The "there's an app for that" slogan is now true for the complex world of mental health care. There are thousands. Some apps are targeted at users with specific conditions, such as anxiety, schizophrenia, or depression, and are designed to assuage and manage symptoms, track moods and thoughts, or help individuals stick with treatments. Others are aimed at improving memory, coping, and thinking skills, or managing stress through meditation or mindfulness. There are also apps for post-traumatic stress disorder (PTSD), eating disorders, and addiction. The list goes on.

Mental health apps have plenty of benefits, including convenience, anonymity, and a low price. But experts caution prospective users against using them as a stand-in for professional treatment, according to the National Institute of Mental Health (NIMH). Most aren't backed by peer-reviewed research or clinical trials, partially because tech development moves faster than traditional scientific testing. Confidentiality is also a major issue, as many of these apps don't adhere to standard healthcare privacy guidelines.

Yet some preliminary studies have shown that they can yield patient improvements. Vet any app you're considering with a doctor or therapist, focusing on ones that rely on evidence-based treatment such as cognitive behavior therapy. Double-check the app developer's credentials before downloading: The most trustworthy are typically affiliated with academic research institutions or government agencies, according to the American Psychological Association. And choose one with an intuitive interface; it will be easier to stick with, so you might see better outcomes.

To learn more about the pros and cons, visit the NIMH's comprehensive report on the subject.

2. ONE-ON-ONE THERAPY THROUGH VIDEO AND TEXT

With a shortage of mental health professionals in the U.S., online or mobile therapy appears to be a good solution for prospective patients who can't find an available one in their area. It's also promising for those who simply don't have the time or resources for in-person appointments, or are afraid of stigma.

Some services or platforms allow users to connect with therapists via voice or video on a computer or phone. Others are text-based and allow patients to send unlimited messages via their phones, 24/7, for a flat monthly fee.

3. BEHAVIOR TRACKERS THAT MAY INDICATE AN IMPENDING MENTAL HEALTH CRISIS

While some mental health apps are designed to deliver outcomes (an improved mood, lessened anxiety), researchers are also working to harness mobile technology to detect suicidal inclinations, burgeoning manic episodes, or depressive episodes before they manifest.

One such scientist is Dr. Thomas Insel, a psychiatrist and former head of the NIMH. After a stint with Verily, the life sciences unit of Alphabet (the parent company of Google), Insel left the tech giant to co-found a start-up called Mindstrong. Both organizations, he told CNBC, are working on apps that monitor users' smartphone behavior—with permission from the user.

For example, if a user starts typing more rapidly than normal, their syntax changes, or they indulge in impulsive shopping sprees, that might be an indicator that they're manic. If they don't respond to texts from family and friends, they might be depressed. Together, this data collection could create what Insel calls a "digital phenotype," which could be described as a personalized mental health map. This could help users or their loved ones mitigate any potential crises through preventative treatment.

This line of research is promising, but Insel noted that it's still unclear whether the approach will yield long-term outcomes for patients—or if the tech itself is fine-tuned enough to observe behavior changes.

4. SMART SOFTWARE THAT FINDS AT-RISK PATIENTS IN MEDICAL RECORDS

Some insurance companies are now using cloud-based software platforms to review electronic medical records and insurance claims data to identify patients at risk for developing mental health conditions like depression. Then, they connect them with appropriate treatments through a network of behavioral health specialists.

5. VIRTUAL-REALITY TREATMENTS

In addition to treating PTSD with medication, therapy, and exercise, some physicians use a technique called exposure therapy, which is designed to help patients relive trauma-related phenomena in a controlled, safe environment, such as a doctor's office. This helps patients get habituated to the memories so they no longer trigger flashbacks and anxiety. Scientists have tested VR as a tool for exposure therapy in clinical trials, and a handful of clinicians around the U.S. are now trained to use it in their practices.

Headsets whisk patients back in time using a combination of images and sounds. While wearing the headsets, subjects discuss past experiences with therapists until they become desensitized to the triggers before them.

Meanwhile, researchers like Yale scientist Sarah Fineberg are using computer games and VR to understand feelings of social rejection in people with borderline personality disorder (BPD), a complicated condition in which sufferers have a hard time regulating emotions, have a distorted sense of self, and are prone to extreme mood swings, especially towards the people in their lives. 

6. A GOOGLE SCREENING THAT LETS YOU KNOW IF YOU'RE DEPRESSED

Google recently teamed up with the National Alliance on Mental Illness (NAMI), a nationwide grassroots mental health advocacy group, to offer a mental health screening questionnaire to U.S. residents who search for "depression" on their mobile phones. The top result is a box called a "knowledge panel," which has information on depression, its symptoms, and potential treatments. To get screened, click the option "Check if you're clinically depressed" to take a confidential, medically backed self-assessment quiz.

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