Plastic Surgery: Q&A with Robert Cohen, M.D., F.A.C.S.

Plastic Surgery: Q&A with Robert Cohen, M.D., F.A.C.S.Q: Why did you decide to get into the field of plastic surgery?
A:
I always had an aptitude in art, and I was drawn to professions (such as architecture and graphic design) that utilized artistic ability. I also really enjoyed science courses and visual subjects like geometry. As a high school student, I saw a television program about plastic surgery, and it seemed to combine the best of art and science into one incredible career path. By my junior year in high school, I decided that I wanted to be a plastic surgeon, and each step of my career (college, medical school, residency, fellowship and private practice) only reinforced my commitment to plastic surgery.

Q: What do you feel attracts patients to your practice?
A:
My goal is to provide the most caring, safe and professional environment possible to my patients. This patient care philosophy is evident to patients from the first time they call my office, and continues long after they have had their surgery. Operating on people is a tremendous privilege and responsibility, especially in the case of elective surgery, and I do everything I possibly can to make each patient's experience safe and enjoyable. To ensure this, I am personally involved with the entire process, and I spend a lot of one-on-one time with every patient - not just prior to surgery, but with follow-ups as well. A large part of my practice is word-of-mouth referrals from other happy patients.

Q: How many years have you been in practice in Arizona?
A:
I established my private practice in Paradise Valley in 2005 after finishing a full plastic surgery residency at Dartmouth and a cosmetic surgery fellowship in Los Angeles.

Q: What is the most common misconception that the general public has about your specialty?
A:
The most common misconception is that all plastic surgery is cosmetic surgery. Plastic surgeons are rigorously trained to operate on all parts of the body, literally from scalp to toes, in order to correct a huge range of problems. No other surgical specialty covers the same range and depth of anatomy. We treat congenital facial defects, and we reconstruct faces, breasts, abdomens, chest walls and limbs disfigured by trauma and cancers. No plastic surgeon can finish a residency without becoming proficient in microsurgery as well. The skill set and understanding of anatomy from reconstructive surgery is what allows plastic surgeons to truly refine their skills in cosmetic surgery, which is the most visible aspect of our specialty. I think people often do not realize the years of training and critical surgical judgment that are required to become a board-certified plastic surgeon.

Q: What is the most common misconception that the medical community has about your specialty?
A:
I think that some medical professionals tend to view plastic surgery as something frivolous or vain, because the specialty focuses more on changing appearances than curing diseases. What the medical community underestimates is the incredible impact self-image can have on people's quality of life. I have literally seen some of my patients' lives change as a result of their surgery when they experience a transformation in their body image and self-esteem. On a less dramatic level, I also find that the visible improvement of cosmetic surgery often motivates patients to develop healthier lifestyles. Many of my patients improve their diet and exercise habits, and stop smoking in order to undergo surgery or maintain their new appearance.

Q: Why should patients seek out board-certified plastic surgeons?
A:
Board certification by the American Board of Plastic Surgery is the only objective way to ensure that a plastic surgeon has completed a full residency in an accredited academic program, has passed a rigorous written exam and has passed an oral exam by presenting his/her own actual cases in front of the specialty's premier surgeons. There are a lot of medical boards out there, but the American Board of Plastic Surgery is the only board for plastic surgeons recognized by the American Board of Medical Specialties.

Q: Describe a procedure or technique that you employ that is unique to you or your practice (i.e., a variation on a traditional breast lift/tummy tuck, etc.).
A:
I can't take credit for inventing any new techniques, as there have been many great plastic surgeon "pioneers" who have forged the way for the rest of us. What I do feel is rare with regards to my practice is the range of breast surgery techniques I utilize. Because I have had the opportunity to work with some of the best breast surgeons in the country, I have mastered a huge range of techniques that I customize to each of my patients' unique needs. For example, in some cases, I will use a circumareolar (around the areola), tightening suture to avoid scars beyond the edge of the areola during a breast augmentation/mastopexy surgery. Sometimes, I will use a laser for skin de-epithelialization during breast reductions or breast lifts. When necessary, I can correct drooping or inverted nipples at the same time as I improve the breast itself. I feel that the level of detail and artistry that I apply to my breast surgery is something my patients recognize and appreciate.

Q: Who is your typical patient?
A:
I see a large range of patients, both female and male, ranging in age from college students to retirees, and coming from all different types of backgrounds. Most commonly, I tend to treat women in their 20s to 40s who are generally well adjusted, often are married with children and look like they could be your next door neighbor. If someone walked in my office right now and I had to guess what they looked like and what they were interested in, I would visualize a pleasant "soccer mom" in her mid-30s, interested in very natural looking breast and abdominal surgery to return her body to her pre-pregnancy appearance.

Q: How do you help to ensure that your patients have realistic expectations regarding their surgeries?
A:
Providing realistic expectations to patients and being able to deliver what you promise is crucial to having a successful plastic surgery practice. I spend a great deal of time with each patient trying to understand what their specific goals are, evaluating each unique aspect of their face or body, and presenting a realistic explanation of how surgery can (or cannot) achieve their goals. I often use drawings or pictures of other cases I have done to clarify my points.

Q: What is the best way for a surgeon such as yourself to deal with patients' unrealistic expectations?
A:
After I realistically describe what surgery can accomplish for a patient, I spend more time making sure that my explanations came across clearly. I tend to underplay what I can accomplish rather than oversell myself to ensure the highest likelihood of a happy patient. If, after a lengthy discussion, I still feel that the patient has unrealistic expectations for surgery, I will politely choose not to operate on that patient. Not every patient is a good candidate for elective surgery, and learning this early saves plastic surgeons (and their patients) a lot of anguish and disappointment.

Q: Who is not a good candidate for cosmetic surgery?
A:
Because cosmetic surgery is elective surgery, I believe plastic surgeons have the obligation to control and minimize every risk possible to protect the safety of their patients. As a result, I will never operate on someone who is in poor health, or has known psychological issues such as an eating disorder, major depression or body dysmorphic disorder. Anyone who has significant health risks (a history of heart disease or significant asthma, for example) would need to have clearance from their primary physician before I would consider operating. Smokers and tobacco users are also at high risk for wound-healing problems, so I mandate that they quit three to four weeks prior to surgery and I check a carboxyhemoglobin to ensure they did not cheat.

Q: Give an example of a situation where the risks of a procedure outweigh the benefit to the patient?
A:
If a patient was a smoker and wanted a breast reduction, you might be able to get away with the surgery without a complication. You also might lose the nipples and areolas due to poor oxygen carrying capacity from carbon monoxide in the cigarettes. For me, taking this risk would be unacceptable when it is possible to have the patient stop smoking prior to the procedure. Complications can still occur even when you do everything right, but the surgeon should prevent any risks within his or her control.

Q: What types of procedures do you refer out to other plastic surgeons?
A:
My personal philosophy is that I will not perform a procedure unless I feel that I can truly offer the patient an excellent result based on my skill and experience. I don't experiment on my patients, and I have no ego problems referring patients to other surgeons if I feel they will provide the best care for a particular problem. For example, one operation I do not perform is a buttock augmentation, so when patients call with interest in that procedure, I refer them to other surgeons. Also, if someone has had multiple prior rhinoplasties and wants a third or fourth revision, I will usually refer them to someone who specializes in revision rhinoplasties. I love performing primary and even secondary rhinoplasty surgery, but for tertiary rhinoplasty and beyond, the work is often best left to those who do this surgery on a daily basis.

Q: What is your favorite procedure to perform?
A:
One of the things I enjoy most about plastic surgery is the variety. However, if I had to choose, my favorite surgery for the body is what I call the "mommy makeover," which generally involves breast surgery (usually an augmentation mastopexy) combined with abdominoplasty and liposuction. While this is a fairly extensive surgery, the results can be extremely dramatic and the patients are usually thrilled with the results. With regards to the face, my favorite procedure is a rhinoplasty because I enjoy the focus on details and the artistic vision necessary to aesthetically reshape a nose.

Q: What type of referring physician practice values your services the most?
A:
It seems that more and more patients are looking to their primary care physicians for referrals to safe, reputable plastic surgeons. I find that many of my physician referrals come from internists and OB/GYNs.

Q: Describe one or more examples of a case in which you changed patients' overall quality of life through a surgery or a series of surgeries.
A:
Recently, I saw two patients who literally told me that my surgery had completely changed their lives in a positive way. One patient was a female fitness trainerwhose breasts had completely deflated after having children. She felt like they looked like two socks on her chest. This affected her confidence in public, as well as how she felt sexually with her husband. After a breast augmentation with a circumareolar mastopexy, her chest had a normal, aesthetic appearance and she told me this completely improved her confidence and enjoyment of her sex life and of life in general. A second recent patient was a man who, when I first met him, was overweight, depressed and had poor self-esteem. He had excess fat and loose skin on his chest and abdomen, and had never felt comfortable shirtless. In order to be a good surgical candidate, I asked him to eat better and exercise more. He began to work out, and six months after his first consult, he returned to my office over 40 pounds lighter. After this weight loss, I performed liposuction and skin tightening for gynecomastia, and an abdominoplasty with liposuction of the flanks. I saw this patient last week after he returned from vacation. He had a huge smile, looked fantastic and said that for the first time in his life, he was able to. run around on the beach shirtless without feeling self-conscious about his body.

Q: What people most influenced your career choice and training?
A:
The first plastic surgeon I ever spent time with (during high school) was Martin Johnson, M.D., who is a board certified plastic surgeon in Paradise Valley. Dr. Johnson is a wonderful person and an exceptional plastic surgeon, and he solidified my early interest in the specialty and continues to be a great colleague, mentor and friend to me. During my residency at Dartmouth, I had a wide range of excellent instructors, but Christopher Demas, M.D., was the one most responsible for teaching me the nuances and perfectionism necessary to be a skilled aesthetic plastic surgeon. Finally, my cosmetic fellowship year with Grant Stevens, M.D., (in Marina del Rey, CA) was unbelievably valuable, and he not only honed my skills in cosmetic surgery, but also taught me how to run a truly first-class medical office. I am extremely thankful that I had such wonderful teachers and mentors, and without them, I certainly would not be where I am today.

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