Israel’s first female Arab plastic surgeon

by Meredith Price Levitt
For 29-year-old Dr. Rania El Hativ, the distinction of being Israel’s first female Arab plastic surgeon has its downsides. “I feel a lot of responsibility. Many people have expectations of you — other doctors, patients and people in my community.”

On the surface, that may sound dramatic coming from a plastic surgeon. But El Hativ is quick to point out that despite the stereotypical aesthetic operations typically associated with her field — breast augmentations, nose jobs, tummy tucks and the like — plastic surgery goes far beyond the cosmetic.

“It’s extremely challenging work, because it includes treating people with traumas, war injuries, burns, tumors, facial reconstructions, birth defects like cleft palates and many other problems,” explained El Hativ in a phone interview. “There are so many important things that can be remedied each and every day that the work is actually very inspiring.”

Working out of the Rambam Medical Center in Haifa, El Hativ sees patients from all over the country with a vast array of problems. Unlike many other medical branches in which doctors align their treatments with textbook rules, plastic surgery requires creativity. For El Hativ, who is also an avid artist, this was one of the main attractions of her specialty.

And though she never envisioned being anything other than a doctor, she had never considered plastic surgery until she started her internship. “When I started out, I had no idea what it means to be a doctor. There are no doctors in my family, and very little is known about plastic surgery in our community,” she said. “I am slowly beginning to understand what it really means.”

As an Arab female, El Hativ is taking the initiative to bring about more education among fellow Israeli Arabs, who she says do not understand much about plastic surgery and often reject aesthetic operations on cultural or religious grounds. Although in some wealthy Arab countries plastic surgery is in vogue, that is not the case in Israel, and many Israeli Arabs either know nothing about it or consider it aberrant.

“There’s a lack of education about this field among the Arabs,” El Hativ said. “They think it’s all about aesthetics and changing lips or breasts, which is not something they find acceptable or are willing to discuss even if they do decide to do it. They don’t know that there are so many other things we can do to help change people’s lives.”

Through El Hativ, many people in her community have become more familiar with plastic surgery and its benefits. Aside from being a role model to other young Arab women, she is also a figure who legitimizes the field of plastic surgery in the eyes of fellow Arabs. For many conservative Arabs, the willingness to even consider plastic surgery is a huge step forward.

“Once people begin to see how easy surgery can be and how much it can benefit their lives, more people will be willing to do it and it will become more acceptable. It starts with education, which is something I’m striving to promote.”

To illustrate her point, El Hativ recounts a recent story. Several months ago she operated on a 3-month-old baby girl who was born with a cleft palate. When the child returned at 6 months for a checkup, El Hativ could not even discern the problem until she looked at the file. “We rarely have the opportunity to follow up with patients, so it was amazing to see this child again. I suddenly understood what I had done for her and how her life was transformed by this surgery. No one will ever even know she had a cleft palate.”

On the flip side, El Hativ is forthright about the downsides of her career choice. Although her family is extremely supportive and her parents have not pushed her to get married and start a family, others in the community are not so open-minded, and social pressure does exist. If a woman in her community has a career, then marriage can be delayed, but she will be expected to marry eventually.

Finding the time to travel, go out with friends and date in the midst of grueling days that often begin at 7 a.m. and end in the middle of the night is nearly impossible right now. “Family is very important, and I think I will be a much more successful person if I marry one day and have children of my own, but it is not a priority right now. My relatives understand that.”

Beyond the long, arduous hours, the work is also poorly remunerated within Israel. Unlike her American counterparts, it will take many years for El Hativ to open a private clinic and actually earn a good living.

“It is economically easier today than it was for my grandparents’ generation and for my parents’ generation,” she said. “I hope that with each generation it will get easier.”

There are black periods for El Hativ, when the burden of her responsibility as the first Arab female plastic surgeon in Israel seems like too much to bear, but most of the time she remains optimistic and is fulfilled by treating people of all ages and from all walks of life.

“Sometimes it seems like the work is endless, and I can’t see how I will ever have any time for myself. On the other hand, I know that what I am doing is helping people, and there is no better feeling.”

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Life with a new right hand -California’s first such transplant patient describes her journey

Emily Fennell, 26, became the first person in California to undergo a hand… (Francine Orr, Los Angeles Times)April 19, 2011|Shari RoanWhen Emily Fennell walks into a store or the hair salon, people often ask, “What happened to your hand?” She gets a kick out of their reaction when she casually replies, “I had a hand transplant.”

“They say, ‘Can they really do that?’ ” she said, glancing down at the soft brace that covers her right forearm and wrist, slender fingers and neatly trimmed fingernails peeking from the bottom.

On March 5, Fennell became the first person to undergo a hand transplant in California and the 13th nationwide to have the revolutionary surgery. At the time, the 26-year-old single mother from Yuba City wished to remain anonymous. Now, six weeks after the 14-hour operation at Ronald Reagan UCLA Medical Center, she is talking about her journey.

With long, straight hair and fashionable boots, she could pass for just another UCLA student who fell off her skateboard. But it was a car accident almost five years ago that took her right hand.

“It’s crazy how good it looks,” she said at her occupational therapy session one morning last week at UCLA, where she spends about eight hours a day working on learning how to move her new hand and fingers. “I knew the match wouldn’t be perfect, but if you didn’t know what happened, you’d think I just had some kind of orthopedic surgery.”

On June 11, 2006, Fennell was a passenger in the front seat of a car that was clipped by another vehicle and rolled over. The sunroof was open. Fennell’s hand went through the space and was caught between the car and the road. The mangled hand had to be amputated.

“About a week after the accident, my mom said, ‘You can be the kind of person who says ‘Woe is me’ and gives up, or you can say, ‘This sucks, but I’m moving on.’ I chose that one,” she said.

She learned to use her left hand to write, dress, drive a car and work in an office typing 40 words per minute. When she received a prosthetic arm six months after the accident, she had already mastered many tasks with her left hand and, after months of trying, concluded that the prosthesis wasn’t helping.

But she wanted to be able to do more for herself and her daughter, now 6. She heard about hand transplants last year from a friend who was also an amputee, and immediately began researching the surgery.

She was evaluated at UCLA and accepted into its newly formed transplant program to wait for a suitable donor hand to become available.
The complex operation required surgeons to attach 23 tendons, two bones, two arteries and at least three nerves, explains Dr. Kodi Azari, the surgical director of UCLA’s hand transplant program. In the video, he describes his delight upon examining the donor hand and realizing it was a match for Fennell.

“It was identical,” Azari says. “The color match was perfect. The size match was perfect. The blood group match was perfect.”

After the surgery, she works on her physical therapy, including an exercise stacking blocks. Eventually, she’d like to be able to put her long brown hair into a ponytail and complete other routine tasks as if they were second nature.

“That’s my goal – to just be able to function with it and not be able to think about it,” Fennell says.

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Stem Cells in Cosmetic Surgery: Facts and Future

by Schae Kane

No one can accuse Steven R. Cohen, MD, FACS, of being a slouch. He is known worldwide for his contributions to the treatment of children with facial deformities, such as cleft lip and serious craniofacial skeletal malformations. Cohen is the inventor of one of the leading internal distraction systems, the MID system, and holds a patent on the Macropore biodegradable distraction device, which is the first of its kind in the world.

In addition to helping to develop surgical techniques, Cohen has been involved in fat grafting for most of the 21 years he has been in practice. As an early clinical researcher in an IRB-approved study, he was involved in adipocyte-derived stem and regenerative cells in 2003, when he and Ralph Holmes, MD, performed the first series of injections for facial rejuvenation.

Cohen currently serves as executive director of the Cell Society, a nonprofit international organization dedicated to the advancement of the clinical applications of adult stem cell regenerative therapies. If that weren’t enough, Cohen is also an acclaimed painter and sculptor.

Unlike many physicians who have worked with stem cells in very limited applications, Cohen endeavors to incorporate new technologies in as many procedures as he can muster from his private practice—from facelift surgery to rhinoplasty to breast augmentation and tummy tucks.

PSP sat down with Cohen to gain insight into his use of fat grafting using stem cell technology.

PSP: What was it that attracted you to investigating and eventually working with stem cells in the cosmetic surgery field?

Cohen: I first became familiar with the use of fat-derived stem and regenerative cells in the early 2000s. There appeared to be significant promise that these cells would work well to reconstruct missing tissues and address aesthetic goals. We know that the body has the natural ability to repair itself in limited circumstances, such as wound healing, and as physicians and scientists it is exciting for us to find a way to harness those mechanisms, concentrate them, and use them in many ways to regenerate tissue and repair injury from a variety of diseases. There really is a lot of potential for the use of stem cells in medicine overall.

The use of the body’s own cells is theoretically appealing, and since experimentally and from preliminary clinical experience, the live cells seem to enhance the overall survival rate of fat grafts. This should increase the success of these procedures. I expect more widespread adoption to be forthcoming.

PSP: How easy or difficult is it to “sell” patients on a procedure that uses their own stem cells?

Cohen: I am not in the business of “selling” one procedure or another to my patients. As a physician, I inform the patient on the variety of available options, answer their questions, and help them come to the best decision given their personal objectives.

For example, if a patient comes to me for a facelift, usually it entails more than just repositioning of the skin and muscle and removal of tissue. To get the best result, one must address all aspects of aging—loss of elasticity, soft tissue and bony volume loss, and photoaging. To address loss of soft-tissue volume, there is usually a need to increase tissue volume in various areas of the face. So, when I present the option to increase tissue volume to a patient, I also present the available treatment techniques—fillers, conventional fat grafting, or using the patient’s fat combined with the regenerative and stem cells already in their adipose tissue.

As another example, when a patient comes to me for a liposuction procedure, they are asked if they would like to discard the fat, donate the fat for scientific study, or use the fat elsewhere. It is explained that their own fat cells can be used to augment tissue in a variety of procedures, from facelifts to buttock augmentation, body shaping, or recontouring. In younger patients, they may consider a lip augmentation, cheek enhancement, or breast enhancement using their own fat tissue.

If they express interest in fat-derived stem and regenerative cells, they are provided with a document that details the FDA’s regulations regarding the off-label use of cell-enriched autologous fat transfers.

Once the patient has the opportunity to review this document, the patient asks questions—typically, they ask why there is a difference between traditional fat grafting and fat grafts using stem and regenerative cells. Many patients already know about the use of stem cells and like the idea of using their own cells and their body’s regenerative mechanisms to help with healing.

Patients seem to be pretty educated, and are very excited about the potential. However, it is still a new area and data are being gathered. Also, it is somewhat unfortunate that the “sex appeal” is the stem cells, when really the stem cells are a small proportion of the regenerative cells that are being re-introduced. I let the patients know that enhancement of fat graft survival has been shown in pre-clinical studies, but the clinical experience is still small. And although we are seeing some amazing outcomes in radiation injuries, breast reconstruction, and breast augmentation, the clinical results are still preliminary. As a scientist and a physician, I am watching these study results closely but I am excited about the potential, as well.

PSP: In what procedures have you used the stem cell approach?

Cohen: Stem cells are applicable and appropriate in a wide range of procedures: breast augmentation, lumpectomies with radiation where some reconstruction is desired, especially in the treatment of radiation injuries where cells have died. Buttock augmentation, facial rejuvenation procedures and reconstruction, and basically any surgery where soft tissue needs to be replaced.

It is a great option for patients who may have adverse reactions to implants, such as capsular contraction. The approach can also help smooth and shape the breast in conjunction with the use of implants. When fat or fat with stem and regenerative cells is used correctly, it can give a better, more natural shape than an implant alone.

Conceivably, there are so many indications where stem and regenerative cells could be a viable option that I expect there may come a day where there is equipment for harvesting and using stem cells in every operating room in every major hospital.

PSP: Is this approach truly appropriate for all these procedures?

Cohen: Stem cells are definitely appropriate for all of these treatments you mention. In the aesthetic world, stem and regenerative cells make sense in reconstructive procedures.

Fat is considered to be a desirable reconstructive and aesthetic filler by physicians worldwide, but in some cases the fat cells aren’t able to thrive in a new environment. There are studies under way comparing the use of stem cell-augmented fat versus conventional fat grafting, and that data gathering is ongoing. Preliminary results imply that cell-enhanced fat increases the longevity of the life of the fat cells, and when used as a cell-enhanced filler their effectiveness seems to be more predictable.

It seems intuitive to me that there would be tremendous benefits from the use of stem and regenerative cells. In my experience, the fat grafts last to a greater extent and the skin appears to reap benefits, as well. However, I do not have enough data yet to fully document this impression. The skin just seems to look better.

The use of stem cells may also be indicated in procedures designed to address reduced vascularity—stem and regenerative cells can be used to improve tissue viability. For example, with pressure ulcers, diabetic wounds, or even ischemic coronary disease, stem cells may be an appropriate treatment mechanism.

PSP: Where do you see this technology and approach heading?

Cohen: There are really two fronts of development. First is fat grafting in general. How is it extracted? What is the best processing procedure? How do we know if the cells are viable? More research is under way to address these questions.

Second, how do we consistently deliver viable stem and regenerative cells, and what techniques and technology work the best? The scientific community is working on ways to standardize the process so that it is safe and effective, no matter what the application. And there are delivery systems in development that look promising for the future.

Comprehensive patient screening is also an important consideration. For example, when we consider that one in seven women will get breast cancer at some point in their life, it becomes apparent that every patient undergoing a breast-related procedure should be screened to ensure there are no pre-existing issues to address. In my practice, I screen patients using mammograms and preferably MRI.

The majority of studies in animals and humans have shown no significant statistical correlation between autogenous fat grafts with and without stem and regenerative cells and an increased risk of cancer. In fact, there is some evidence that fat might bind to estrogen receptors and reduce tumor growth in estrogen-positive breast cancer. Preliminary studies in humans with fat and with cell-enhanced fat grafting have not demonstrated an increase in breast cancer. It is critical that this information be collected, since researchers estimate that a population of 100,000 to 200,000 women will be needed to determine if the frequency of breast cancer is decreased, increased, or unchanged. Somehow, I personally think it is hard to imagine how the frequency of breast cancer will be changed using the body’s own tissues, but it is necessary to have a frank discussion with patients so they thoroughly understand that we do not have definitive information at this point. I am extremely candid with these points.

The main reason regenerative cell therapy is trending so strongly in cosmetic surgery, in particular, is that the process is all completed at the point of care. Nothing needs to be sent off to a lab or processed outside of the treatment facility at the time of the procedure itself. It is easy for the patient, and the materials are part of the patient’s own body. There is less chemistry and more transfer of natural body materials to achieve a particular result. This is appealing to a wide variety of patients.

PSP: What do you think has to happen before the approach is adopted more widely?

Cohen: The FDA is currently evaluating the use of fat-derived stem cells, and once their guidelines are completed then physicians will have clear direction on their appropriate use using stem cell technology.

For now, adipocyte-derived stem and regenerative cells are being utilized in an off-label environment by a number of surgeons, but that limits their availability on a more comprehensive basis. Unfortunately, there isn’t a real way to know when those guidelines will be finalized. The FDA looks at regenerative medicine as a promising new frontier, and they are managing its investigation appropriately. They are responsible for making sure patients aren’t duped into getting expensive “cure-all” treatments that don’t produce any real results.

As physicians, we need to continuously learn more about the conditions required to treat patients effectively using stem and regenerative cell technology. I foresee a time when this equipment will be a mainstream instrument in all hospitals. Its potential for use in such a wide range of treatments makes it something we can’t ignore. Everything from breast augmentation, facial reconstruction, body contouring to wound healing and even possibly in the treatment of myocardial infarction, chronic myocardial ischemia to conditions such as urinary incontinence and shock. The limits have yet to be defined.

Meet plastic surgeon Dr. Arie Benchetrit

Interviewed by Emily Shore

Recently I had the pleasure of sitting down with one of Montreal’s finest plastic surgeons,

Dr. Arie Benchetrit. In our conversation it became evident why Dr. Benchetrit is truly one of the best in this field – after twenty years of practice he is still intrigued by cosmetic surgery. I have to admit, aside from what I have seen on the medical drama shows I watch every week, I am not too well versed in the world of Plastics. And yet, after about an hour of sitting down and getting to know Dr. Benchetrit I felt I had more of an idea of what it takes to not only be a plastic surgeon, but what it takes to succeed as one. So move over Grey’s Anatomy’s “McSteamy”, because you have nothing on Dr. Benchetrit.

Here Dr. Benchetrit helps us demystify some of the glamour that accompanies cosmetic surgery, as well as discussing the art of plastic surgery, the Hollywood craze, where he believes the specialty is heading in the future, and of course, his most favourite procedures.

 

Where are you from? Tell us a little bit about your background.

I was born in Morocco, and moved to Canada when I was four and grew up in Laval. I went to Vanier Cegep, then I went to McGill undergrad for 1 year, then to University of Montreal for Medical School. And then I did my General Surgery at McGill and Plastic Surgery residency at McGill….

 

It’s a long residency, isn’t it?

Yes, seven years. One of the longest!

 

Did you always know you wanted to be a doctor?

No. I was very young. I actually finished high school when I was 14…I was a bit precocious…and of course at 14 you have no idea what you want to do. In those days you basically went into Health Science, Pure and Applied Science or Law. Those were pretty much the three choices. So Health Science seemed the most obvious to me, for no particular reason, and then once you’re in Health Science you keep going and in Cegep I finished Health Sciences and then I applied to a Bachelor’s in Anatomy at McGill, and then during that year I decided if I’m going to do Science I might as well go into Medicine – it seemed like a good way to use my science background and so I applied to Medicine…and the rest is history….

 

…is History. And you liked it all the way through?

I’ve always liked the science of medicine. I’ve always been interested in the functioning of the human body, the interaction of the body with the environment and drugs and things like that. I’ve always been fascinated by that. The actual practice of medicine within Quebec is a lot different than you imagine it to be, especially when you’re a student – there are a lot of restrictions and a lot of rules and a lot of regulations that don’t exist elsewhere. All that being said, I have no regrets. To me it was a very good choice; a very good way to marry an interest in science with a practical way to use that science knowledge. And then veering into Plastic Surgery, it’s also allowed me to add a creative element, which I didn’t even know it was there when I was 14. My family’s a family of artists – my father’s an artist, my sister’s an artist. That’s my sister’s, that’s my dad’s – (Dr. Benchetrit points to two paintings displayed on the wall of his office) – so we have a lot of artists in the family, and so I never get a chance to express my art on paper, on canvas; and so this is in a sense a way…

 

It is! It is one of the medical specialties that is very artistic.

That’s correct. And so you need an artistic eye, you need a good sense of symmetry, of judgment, and so that helps. All of those interests make for a nice confluence and so it was a good career choice for me.

 

Do you ever do – art? Or no, you leave that to them?

I’ve dabbled but not really. It’s not a passion for them like it is for my family.

 

Right…

Is there a difference between Plastic Surgery and Cosmetic Surgery?

Yes, it gets confusing semantics especially for the public and a lot of doctors, unfortunately, play on that confusion to mesmerize the public, but uh, plastic surgery is a surgical specialty recognized by the Royal College of Surgeons of Canada and recognized by the American Board of Medical Specialties so it is a specialty onto itself. Within Plastic Surgery there’s basically two branches – there’s reconstructive surgery and there’s cosmetic or aesthetic surgery. So aesthetic surgery per se is not a specialty, aesthetic surgery could be practiced by any doctor, it doesn’t have to be a plastic surgeon – it just means, doing surgery for the purposes of aesthetics. However, while many doctors, including GPs, offer aesthetic surgery to the public, only plastic surgeons have the training to perform all of the various aesthetic procedures. Therefore, there is an ongoing debate about whether non plastic surgeons should be allowed to perform aesthetic surgery which, in Quebec, they presently are legally able to do. To be a certified plastic surgeon you have to be trained, have done a residency, and have been certified either in Canada or in the US or elsewhere as a Plastic Surgeon. Once you become a Plastic Surgeon you can have a mixed practice, which is the case for most, where you can have some reconstructive and some cosmetic, and some plastic surgeons choose to do mostly cosmetic or mostly reconstructive – you really have the chance to skew your practice according to your own interest.

 

And what type of practice do you have – are you a mélange of both?

Well when I started my practice 20 years ago it was all reconstructive because my main interest was surgery of the hand, that’s what led me to Plastic Surgery.

 

So you would do accident victims?

Accident victims, patients with congenital deformities in the hand, arthritic patients, peripheral neuropathies like Carpal Tunnel Syndrome, there’s a lot of surgeries for the hand and I really enjoyed it. It’s a very meticulous, very precise surgery and that was really in my nature, I’m a very meticulous and detailed person, so for the first five years of my practice I did almost all reconstructive surgery but the realities of community plastic surgery in Quebec hit after a few years, where a community practice is very different than an academic practice – I was trained in a university and to me, Plastic Surgery meant all kinds of big complex cases – replants, microsurgery – but you just don’t see those cases in the community, so after seeing the same small variety of cases basically over and over and over again it became clear that as long as I stayed in the community that would be the nature of my practice forever. And so I started to gradually incorporate some cosmetic surgery into my practice and then as it turned out I was good at it and developed a large patient through word of mouth referrals, and it grew and grew until now – it’s about 90% of my practice.

 

Ok, so there’s a lot of demand for cosmetic surgery within the community practice.

Um no. I would say that most community plastic surgeons do mostly reconstructive. In  fact, if you look at most plastic surgeons here in Qc the majority of it is reconstructive, cosmetic is actually a small portion, but I would say 90% of the cosmetic surgery is done by 20% of the plastic surgeons, so it’s a fairly small pool and we do the bulk of it, I guess. Because we tend to specialize in it; and, of course, Plastic Surgery is based on word-of-mouth referrals and so as you tend to specialize in it you get better at it, you do more, and that’s how you build a practice.

 

But you said 90% of your practice now is Cosmetic. Well that’s transformed –

It’s changed completely.

 

…over the past twenty years.

Exactly, it went from fully reconstructive to nearly fully cosmetic.

 

Do you miss the reconstructive?

I still do some, I still do skin cancer, I still do some hand surgery, I still do some facial fractures, you know I’m affiliated with Lakeshore Hospital, I take call there. So obviously  anything that comes into the Emergency Room that is plastic surgery related I will see. So I still enjoy it, but again, it’s the same limitations. In terms of elective reconstructive surgery in the community, it’s not a very varied pool of cases and so I’m glad I made the choices I made.

 

So Plastics is pretty much, I think, the “sexy specialty” to have – although I’m sure Grey’s Anatomy is completely unrealistic…do you watch it?

No, I never really watch Nip/Tuck, I never watch Grey’s Anatomy, I never usually watch TV, but I try to stay away from medical shows because I have enough medicine during the day.

 

Right. Do you find it to be like the public views it? Because it does have that “sexy specialty” connotation or it’s built around that this McSteamy type of thing. Has it changed – I mean your practice has changed over the past 20 years – do you find that it’s changed? The public is very focused on looks…

Well I think the public has always been focused on their appearance. I mean cave men and women used animal blood to paint their faces and apply primitive make-up and so I think it’s just part of the make-up of the human being, is to try to appear our best – to look our best – obviously what looks good changes with each generation and the standards for beauty, for fashion change dramatically. But the desire for humans to look their best has not really changed. The difference is now we have procedures, technology, chemical procedures, Dr. Joe, that make the achievement of a better more youthful appearance easier and safer than its used to be – and that’s been the main change in cosmetic ‘medicine’, I would call it, (rather than plastic surgery), cosmetic ‘medicine’ most of the procedures we do now to enhance somebody’s appearance are non-surgical, whereas 25 years ago really surgery was the only way to go.

Right. You now don’t need to go ‘under the knife.’

Absolutely not, in fact according to the American Society of Aesthetic Plastic Surgery statistics cosmetic surgical procedures in the last 14 years have pretty much doubled where as the non-surgical procedures have gone up almost 800%. So there’s been a huge shift towards the non-surgical/non-invasive procedures.

 

So that’s what I was going to ask you, because I was looking at your website – so explain the difference between the surgical and the non-surgical. I mean one obviously means you’re under anesthesia and ‘under the knife’ but what type is rhinoplasty – and what is that?

Well surgery means that somebody is using a scalpel on you basically, surgery involves a scalpel. It could be a small incision, it could be a large incision but it involves a scalpel, it involves a cut of some sort. And more and more surgical procedures and plastic surgery involves shorter and shorter scars, I mean, liposuction now has scars that are 3mm long.

Some of the eyelid procedures we do are called ‘scarless’ because the scars themselves are hidden so the scars have gotten shorter but it’s still surgery, it’s still an invasive procedure; you’re going through the skin, you’re going through the body’s barriers. And that’s what defines it as ‘surgery.’ Non-surgical involves no scalpel. The most common non-surgical procedure that everybody knows are Botox injections, filler injections for lip augmentations  or for wrinkles, the lasers are very popular – whether it’s laser hair removal –

 

That’s considered also cosmetic?

Oh sure. Wanting to be ‘hairless’ is again to enhance your appearance, especially if you’re very hairy…Lasers for wrinkles, what we call resurfacing lasers, we now have machines like the Ultra Shape that can dissolve fat non-invasively with using ultrasound –

 

That’s using only ultrasound?

Yes, only ultrasound. And again, non-invasively, as in it doesn’t break the skin.

 

Right.

There are machines that can tighten the skin non-invasively like Thermage, which is a radio frequency device, we also use ultrasound on the face for skin tightening. So there’s a whole slew of technological advancements that have made it easier to, again, non-invasively improve somebody’s appearance. And as well the pharma companies have been busy =putting out products – injectable products – that we can use for the same purpose.

 

So would you say that, because of the pharma companies, and the use of all these non-invasive procedures the public is more aware?

I would say that yes, with all these procedures the public is more aware, certainly it’s much less of a taboo, much less of a restricted topic than it was 30 years ago, where if you had a facelift or a nose job you sort of kept it to yourself and your family and nobody really talked about it, well now it’s in every magazine it’s in every talk show like you said, some of the most popular drama shows are about cosmetic surgery it’s definitely all over the internet, it’s very easy to find information – in fact, you’re pretty much bombarded with it so I think it’s a much more open issue or open subject, and so I think more people talk about it more.  Not always positively but at least people talk about it more.

 

I was reading about the Ultra Shape procedure. How does that work? I’m curious

to know how that works! How much does something like that cost?

Basically the machine is an Israeli machine, developed by an Israeli plastic surgeon and engineer. By the way, Israel is the source of almost all cosmetic lasers and most of it  comes from military technology. With all the military experience they have there, they’ve used a lot of it to develop a lot of the machines we now use to look better – it’s sort of a paradox. In any case, this machine was developed in Israel about 8 or 9 years ago and it’s been used in Europe for about 7 or 8 years, and it’s been available in Canada since 2007, and it basically generates focused ultrasound – waves that are focused like if you would focus the sun’s beams with a magnifying glass when you’re trying burn a hole through a paper, so the machine basically focuses the ultrasound down to a fine beam and sends these waves into the fat at the surface of the body and the ultrasound basically blows up the fat cells, the adipocytes, at a fixed level – 1.5 cm below the surface of the skin, that’s where they’re focused. So there’s no heat involved with this machine so it doesn’t hurt, it’s just cavitation makes the fat cells vibrate so fast that they “pop” and you do a whole area it pops a lot of cells. The fat then gets transported by your bloodstream and your lymphatics to the liver and it’s metabolized like any other fat you would eat.

 

That is amazing!

Yes, what’s really great about it is fat cells don’t reproduce, they don’t come back , they’re destroyed for good. And so for most patients, results are long-term or permanent. It’s a great invention for patients who are surgery averse. Because there is a large segment of the population that – no matter how much they want to look better – will never ever agree to have any kind of surgery even liposuction, which is a fairly minimal surgery. So for patients waiting on the sideline for something non-surgical to come out, we’ve had a lot of patients asking for that.

 

But what about if you have an unhealthy lifestyle? You can still generate Adipose tissue, right?

No you won’t generate new cells but the current cells that you do have can get larger. It’s

not a weight-loss procedure, we’re not doing it to take 10-20 pounds off of someone, what we’re doing is re-contouring an area, most people have areas of “stubborn fat” – areas of fat that just won’t go away – whether it’s the love handles, the thighs, or the tummy – and that fat often resists diet and exercise, it’s also gender specific and race specific, so for those kind of areas that’s usually what we go to with liposuctions – we can do this now with Ultra Shape. It’s not as aggressive as liposuction, predictable or thorough. But it’s what we call the “muffin top” procedure, it will basically flatten that muffin top. We’ve treated over 300 patients with it, I’ve published our data and presented it at conferences all over the world – Europe, Asia – so far the data shows that an average person will lose 4. 5 centimetres in circumference, about 2 inches, after 3 treatments in the area that was treated. Significant enough for most patients to go down at least one pant size.

 

How much does the 3 treatments cost?

It varies depending on the size of the areas we treat. But, on average, about $1,000 per treatment.

 

What are some procedures you like doing most? Do you have a favourite?

I love doing rhinoplastys [nose reconstruction]. To me that is true art, because you are literally sculpting right on somebody’s face. And if you’re someone like me who wants to see the results right away there’s nothing better – because you see what you’re doing as you’re doing it. There’s no waiting to see the result. It is very delicate, very precise surgery. You have to be very meticulous, and that’s my personality. I also really enjoy other facial surgeries as well – eyelid lifts, brow lifts, neck lifts – all of those are similar. They’re all meticulous and deliberate type of surgeries.

 

Has anyone asked for a surgery that was really novel to you – a ‘can you do this’ type of procedure?

There are very few things that aren’t available. I don’t do every kind of surgery. I don’t do pec implants or calf implants, for example, which some surgeons do – especially in California – I don’t do penis elongation. So there’s things I don’t do that I do get requests for. But I don’t think I’ve ever been asked about a surgery that simply doesn’t exist.

 

What are some of the criteria to have certain surgeries done?

People talk about cosmetic surgery as if it’s a certain ‘fashion’ or ‘fad’ but it is medicine. The same criteria apply to this type of surgery like other surgeries. You are still dealing with the health of a human being. The first thing you look at is their health status. Obviously we’re not going to do elective surgery on somebody who’s very ill. So the first thing I do is look at their health survey that we have them fill out. Are they on any medication, their history – diabetes – any conditions that could affect the outcome. There is also a bit of a psychological screening that goes on during the consultation. We want to make sure the patient is doing the surgery for the right reasons, that they don’t just look at the benefits but understand the risks and possible complications, the consequences of the surgery. Part of the consultation is to understand that we don’t perform ‘magic’ here we are performing surgery, and there are consequences. So I haven’t left my medical training behind, it’s part and parcel of what I do.

 

People talk about cosmetic surgery as if it’s not a big deal these days, it’s easy to forget that it is ‘medical’ surgery.

That’s right, there is anaesthesia involved. You can have complications from this surgery, even death. The advantage that we do have in cosmetic surgery is that we are mainly dealing with healthy patients. We’re lucky that we’re dealing with the healthiest segment of our population. But just the same, we have to be careful with how we’re operating.

 

Have you refused doing a surgery because someone is motivated for the wrong reasons?

Absolutely. I’ve refused people for wrong motivations, unrealistic expectations, people who I feel are unfit for surgery or I think the risk level is too high – they may be fit for some type of surgeries but not cosmetic surgery.

 

What are your most popular surgeries?

In my practice I would say tummy tucks, breast augmentation.

 

Is breast augmentation and breast enlargement different?

No, breast augmentation is just another way of saying breast implants. Augmentation is you’re making them bigger. Breast augmentation, enhancements, enlargements is just  the same thing. To confuse you further you can do a breast augmentation and a breast lift at the same time, where you lift and make them bigger. Younger patients usually come in for augmentation, and older patients usually for the breast lift with or without augmentation.

And on women, obviously.

Well I haven’t done many breast augmentations on men, but I have done a couple on men wanting trans-gender surgery in the process of becoming women. I don’t see many transgender patients – that’s another niche of cosmetic surgery – there are some surgeons who specialize in that and they see the bulk of the cross-gender population. I see a few, but I don’t do the genital surgery – that’s a very complex specialized surgery.

 

And that is done here in Montreal?

Oh yes, in fact Montreal is one of the world centers for trans-gender surgery. There’s a surgeon here who’s known throughout the world for that.

 

So some of the Hollywood stories – Heidi Montag, from The Hills – in 2007 she had a breast augmentation, rinoplasty, Botox injections. She had 10 plastic surgeries in one day – browlifts, ear pinnings, chin reduction, a second rinoplasty, a second breast augmentation. And she says she almost died from too much Demerol, but she says it was worth it. A year later, in In Style magazine, she said, ‘it’s not what I signed up for; I should have been way more informed. Doctors should have really walk through all aspects of it, not just the glamorous side.’ She then goes on to say how it has ruined all aspects of her career and personal life, and how she wishes she could ‘jump into a time machine and take it all back.’

 

Do you think Hollywood and Heidi has glamorized plastic surgery, and put so much focus on the aesthetic…idolizing perfection?

I think Hollywood has made cosmetic/ plastic surgery look like a drive-through procedure. They’ve done it with cop shows, war movies, and they’ve done it in the last few years with cosmetic surgery. Shows like Extreme Makeover, which basically took patients who were down on their looks and did everything to them – surgery, hair make-up, whatever – and then by the end of the show, within the hour, the patient went from the Ugly duckling to the beautiful swan. It reinforced the notion that plastic surgery is somehow magical. That you can walk in the office and walk out a few hours later as a different person. What they don’t show you is that the surgeries take a long time, that there’s a healing process, there’s risks and there’s scars. So they swept all that aside and just show you the final product. When that show was on I used to get emails from patients all the time saying ‘will you just take me on as a project, I’ve been unhappy my whole life. ‘Then shows like Nip/Tuck, it just falsely glamorizes the world of plastic surgery. And then there’s Heidi Montag, and people talking about it. It’s taking cosmetic surgery and removing it from the realm of medicine and I think that is wrong. It is still a medical procedure. It’s a double-edged sword, it popularized surgeries but on the other hand, it made our lives (plastic surgeons) a little bit difficult because we had to manage expectations a lot more. You don’t get your surgery one day and then go to a gala the next. There’s recovery time. You have to manage expectations. Although now with the Internet, I have to say people are a little bit more informed and realistic. So the pendulum is swinging back a little bit, but you’ll still get the Heidi Montag’s and the Michael Jacksons’s, what I call the caricature of plastic surgery, not the real thing.

 

So what are some things that we could be looking for [on the market] to use where we’re not spending $1,000 on cosmetic surgeries?

The easiest and probably the least expensive is to buy a good bottle of SPF 60 and slather it on. Even in the Winter, because you’re getting ultra-violet rays. There’s three things that make you age. One is genetics, which you have absolutely no control over; two is smoking, which will age you prematurely, and three, the sun, which you don’t have to completely avoid, just use a good sun screen. A good part of my practice is reversing sun damage to the skin So the number one easiest thing, sunscreen. Two a good healthy lifestyle. Eating properly, drinking water, exercising, not letting your weight yo-yo because that has an effect on your skin (it will lose elasticity). And then there’s also skin care, good skin cream, Skin hydration is important. It has no long-term effect, no benefit on wrinkles, but it keeps the skin looking better. Even a $6.00 basic skin cream will do the job.. Of course, getting a good night’s sleep and limiting the stress in your life is good too.

Where do you see the future of cosmetic surgery?

I see the trend of the non-surgical expanding and growing. There are things that we can do today that weren’t available five years ago. It’s amazing, just the last five years with the amount of technology…. But there are three things, in my view, that will be the big movers and shakers. On the surgical side, one is robotic surgery, which has already made its entrance into Urology and other surgical specialties. They’re already using a robot to do microsurgery in the US and it’s a matter of time before robots will perform cosmetic surgery. Of course, these robotic devices are still controlled by human hands but who knows, one day…

Two is tissue engineering, which has been going on for many years. They can now grow

complex tissues in a petri dish – collagen, bone – but they’re not quite at the stage yet where they can create a multi-tissue organ .

So what would you then do with that?

Well if someone loses an ear in an accident, we now have to reconstruct it with skin from another part of the body, cartilage taken from the ribs etc. But if you can grow skin and cartilage in a petri dish then you can literally grow somebody’s ear and graft it on. We have been doing it awhile with skin, for skin grafts. But now we’re getting into more complex tissues. This isn’t only restricted to plastic or cosmetic surgery, Imagine if you can grow a liver or a kidney in a lab. But one of the most exciting developments, and it’s already being used, is stem cells. Because one of the things we didn’t know before is that fat is one of the richest source of stem cells. Adipocytes stem cells are phenomenal. And we’ve been using fat injections for a long time, to make lips bigger, to fill in wrinkles and scars etc. so fat grafts have been around for 25-30 years. But what some people have observed that if you graft below a scar it will improve and nearly disappear in some cases, and no one really figured out why. It’s now hypothesized that it’s the stem cells in the fat that are differentiating into new dermal cells and so minimizing the scar. We can now isolate the stem cells from the fat and inject them into any site . If you do liposuction, for example, instead of throwing all this extra fat away you can put it into a machine and it separates out the stem cells. You then take these concentrated stem cells and you put them back into the fat, inject this super charged fat into an area and not only get a better cosmetic result, through better survival of the fat graft, but the stem cells can perhaps differentiate to improve the quality of the skin in the area. So scars are one thing but the potential for this is amazing. Imagine stem cells that differentiate into cardiac tissue when injected in the muscle of a defective heart, or that differentiate into bone or cartilage or other needed tissues. We ‘re not quite there yet but that’s where we’re going.

 

And this is an element for cosmetic surgery?

Well it applies to cosmetic surgery because we use fat grafts anyways. For example in

Europe, and in some trials in North America, they’re already doing fat grafts for breast augmentations instead of using implants. You’re taking a patient’s own fat and injecting it

into the breast.

 

You’re recycling. Instead of using a silicone implant.

Yes, you are recycling. So for some patients who don’t want to use implants this may become an option. So the issue now is getting the stem cells to differentiate into the different tissues that we need like the bone, the heart, the muscle or intestine. So to me that’s a really exciting aspect of plastic surgery and medicine in general. And it’s ongoing right now; it’s not a pipe dream.

 

Well Dr. Benchetrit I thank you very much! This was all very interesting and I can now say I fully understand the intricacies of cosmetic surgery.

Thank you.

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