So You Don’t Like The Way You Look?
Well, would you change your face if all it took was the price of a good stereo, a few days’ living in bandages, and some tiny scars even if your closest friends wouldn’t notice—that is, if that was all it took?
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Again the candid response seemed to satisfy Muriel. “If all this works out, I want you to fix this terrible nose that God gave to me. Give it to someone else.”
Jim took the turning of the tide as an opportunity to reassure her. We’re in this together, he told her. He was optimistic. He had every reason to want a good result in her case. For one thing, he always wanted to do his best. For another, he liked Muriel personally. “And finally,” he said, in another appeal to her pragmatism, “you’re my advertisement.”
With that, the discussion of procedures and complications proceeded anew, but on a more casual note. Incision placement and scarring were brought up, and Gilmore explained how he would hide the scars alongside the ear and in the hair When Muriel mentioned a D Magazine article about a recent spate of deaths during surgery in Fort Worth that criticized the use of nurses as anesthetists, he pointed out that in at least one of the cases the anesthetist was a doctor and that those surgeries were performed under general rather than local anesthetics. “You have to differentiate between the types of anesthetics rather than the people who administer it.” Bleeding under the skin, or hematoma—an infrequent complication—was brought up. And then facial nerve damage. “I’ve never had facial nerve paralysis,” said Jim, and he knocked on the table three times. “Permanent damage is very rare. A doctor has got to stray badly to injure the facial nerve.” Then he explained the difference between temporary numbness and serious nerve damage and discussed the 1-in-20,000 chance of visual damage during eyelid surgery.
“I think you’re prepared for it now,” Lyn said to her mother, signaling the end of the interrogation.
“I want a good job, a complete job,” said Muriel, like a speaker beginning the summary of a lengthy dissertation. “I can’t see doing it partially.”
“We won’t do it half-ass, if I may use that word,” said Gilmore.
“I use it all the time,” said Muriel, who then added a final question. “Do you think I need everything I’m having done?”
Jim brushed his hand lightly along the skin at her chin. “You need it.”
Gilmore rose then and took Muriel’s hand. “I beg you to do the best you can,” she said as he made his leave. As he walked out the door Sara swept in, a vision in silky pale gray and white skirt, blouse, hose, and matching shoes, and Muriel wrote her a check for $5250, saying the numbers out loud as she wrote them down.
Muriel on the Table
At one-thirty on the morning of her surgery Muriel awakened and decided that she was going to have only her eyes done. She was able to go back to sleep, however, and when she awoke again at five-thirty and took the prescribed ten milligrams of Valium—she had never taken Valium before—she changed her mind. Now it was seven-thirty, rain was pouring down outside, and Muriel was stretched out under the bright fluorescent lights waiting for the touch of steel on her skin. She was covered with a green plasticized-paper sterile sheet and a blanket, and she had an IV tube hooked up to her arm and her hair pulled straight back behind her head. Four color Polaroid prints of her face were taped to the wall over the cardiac monitor.
Muriel chatted spontaneously with Betty McFarling and Ann Coan, the anesthetist. “This is the first time in my life that I’ve done anything crazy like this,” she said.
“It’s not crazy,” laughed Betty, who has had her eyes done by Gilmore.
But apparently Muriel still felt the need for some personal exegesis. “I’m young at heart,” she said. “My youngest daughter is twenty-three and I have kids in and out of my house all the time. Those kids keep me young.” Then she went farther back in time. “I’ve always taken pride in my appearance,” she explained. “My father was director of the church choir, and I was the pianist. I was always in the public eye.”
Ann applied some greenish gel to a six-inch-square metal plate—the ground for the electrocoagulator—and put it under Muriel’s back. Then she hooked Muriel’s arm up to a blood pressure measuring device and mentioned the deaths in Fort Worth, which she attributed to “double and triple posting,”—the practice of having one anesthesiologist supervise two or three operations simultaneously. That was the real problem, not the use of nurses as anesthetists. A few minutes later Lyn popped in to take an Instamatic picture of her mother on the operating table, and right after that Dr. Gilmore came in and put a big plasticized smock over his blue scrub suit while Betty helped him into his pale yellow latex gloves.
“You absolutely don’t want to do the forehead today?” asked Muriel.
“Not when we’re doing your eyes,” he replied.
Jim sat down on a little stool right next to Muriel’s head, and he took out a purple felt-tip marker and began to draw lines on her face, lines that would show him not only where to make his incisions but also the boundaries beyond which he could not go without risking nerve damage. Then he warned Muriel that the injections of local anesthetic that would follow were the most painful part of the operation. “I’m really tough,” said Muriel. “I can stand whatever I have to stand.” Then she became very quiet, and Gilmore injected Kylocaine around her eyelids, her ears and cheeks, and finally her neck.
The various skin lifts that are done on and around the face are rather different in concept from a nose job. Rhinoplasty involves removal and alteration of structural materials—bone and cartilage—while a face lift, or rhytidectomy, involves only the removal of parts of the exterior shell—the skin—and perhaps some insulation—fat. A nose job is somewhat akin to architecture or structural engineering, while a face lift is more like fine tailoring. But unlike a tailor’s usual materials, the amazing waterproof, breathable, stretchable, heat-dissipating skin can also mend itself when it is cut or torn. It does this by forming scar tissue, which makes the cosmetic surgeon sweat a lot more than a tailor does. The surgeon must consider the placement of scars, and he must ensure that there is not too much tension on the skin in order to prevent widening of the scars as well as discomfort and immobility for the patient. He must also be very careful not to trim away too much skin, because he can replace it only by grafts, with horrendous scarring as a consequence. Such concerns are particularly important in the case of the eyelid lift, or blepharoplasty.
Using a small scalpel, Gilmore made a single punch in the skin near the outside corner of Muriel’s left eye. Sticking a fine pair of scissors into the incision at a point right beneath the lower lashes, he cut all the way along the lower eyelid. He pulled the flap of skin back with a picklike instrument, cauterized a few spurting blood vessels, and began peering intently into the area around the corner of the eye. He poked with scissors. He pulled with the tweezers. He frowned. After about five minutes he made his decision, pulled up a few millimeters of muscle at the corner of the eye, and sutured it into place with two quick loops. This tacking of the muscle, rather than the skin removal, would be the most important factor in eliminating the sagging in Muriel’s lower lids. Then Gilmore pulled the flap of skin up over the rim of the lower lid and spent some time patting it into place with the blunt edge of his scissors. He asked Muriel to look up, open her mouth, look down, open her mouth again. Satisfied that he had a natural, unstrained look to the lower lid—it is possible to make the eyes look like they are going to bug right out of the head by being overly aggressive at this point—Gilmore then sliced off a sliver of lower lid about an eighth of an inch wide and sutured the flap back along the line just below the lashes.
The upper lids began in the same fashion as the lower, except that this time the incision was made inside the natural fold that occurs at about the midpoint of the upper lid, and this time scissors cut through both muscle and skin. With the scissors, Jim dissected away the stringy muscle fibers from the upper flap, pulled it down over the lower flap, made a single vertical quarter-inch-long cut in the middle of the upper flap, and tacked the upper flap to the lower flap with a single suture. Moving toward the outer corner of the eye, he made another vertical cut and tacked the two flaps together in the same fashion. Then he began trimming off quarter-inch-wide sections of upper flap and suturing the shortened upper flap to the lower. After painstakingly working his way to the outer corner of the eye, he started at the middle and followed the same procedure as he headed toward the nose. When he was done, Muriel’s left eye was about three decades younger than her right eye. Her lids were disconcertingly parted so that about a third of her blue iris showed, but Jim said that this was normal. He had done a very conservative eyelid lift. Then he brought his little stool around to the right side of Muriel’s head and did the same thing to her right eye.
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