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The Plastic Surgeon: Artist or Scientist?

Swanson, Eric M.D.

Plastic and Reconstructive Surgery: January 2013 - Volume 131 - Issue 1 - p 182–184
doi: 10.1097/PRS.0b013e318272a0f3
Editorials
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Leawood, Kan.

From the Swanson Center.

Received for publication July 17, 2012; accepted July 30, 2012.

Disclosure: The author has no financial interest to declare in relation to the content of this editorial. No outside funding was received.

  • Artist: “One, such as a painter, sculptor, or writer, who is able by virtue of imagination and talent or skill to create works of aesthetic value, especially in the fine arts.”1
  • Scientist: “One engaging in a systematic activity to acquire knowledge. In a more restricted sense, a scientist is an individual who uses the scientific method.”2

It is almost taken for granted today that plastic surgeons are artists. Our patients want us to be artists, and many surgeons are willing to accommodate this preference.3 Our textbooks are often titled some variation of The Art of Plastic Surgery. Our offices can resemble fine art galleries. A recent editorial asks plastic surgeons, which type of artist are you, Michelangelo or Da Vinci?4

In reality, the mindsets of these Renaissance artists might not have been well-suited for surgery, which is an empirically based discipline with little use for Neo-Platonism. Few of us would choose a surgeon who believed that he or she was uniquely touched by genius, divinely inspired, or imagined that he or she was liberating an imprisoned entity by chipping away at the tissues. Being one with a universal force is of limited practical use when it comes to deciding how far to undermine a flap or how much fat to inject. No doubt these legends of their times would have lacked humility, a quality bestowed by the hard experience of surgery, which imposes its own set of limitations and unpredictability on the outcome.

Importantly, neither Michelangelo nor Da Vinci was trained in the scientific method. Galileo, a century later, would separate religion from science, famously saying that God would not have given him the capacity for reason if not for him to use it. In doing so, he helped create the scientific method. Remarkably, Galileo had the insight to reject institutional authority, the humility to subject his ideas to experiments, the diligence to see them through, and the courage to risk his life defending unorthodox findings. He was a Renaissance original truly worthy of emulation.

Da Vinci's ventures into flight serve to contrast art and science. His intricate drawings remain inspirational today, but liftoff failed because of a lack of knowledge of aerodynamic principles. If Da Vinci tinkered, it was because he had no scientific guidance. Surgical dithering derives from a lack of understanding, not a lack of inspiration. Writer's block is usually a creative breach. If surgeons are not “creating,” but rather operating, they are unlikely to suffer such a gap. Experienced surgeons seldom tinker because they understand the objectives, their capabilities, and their limitations.

In plastic surgery, it is difficult to predict the three-dimensional outcome because we do not control all the variables. Unlike marble, human tissues are dynamic, and the price of failure is incomparable. Our efforts are subject to the realities of wound healing. We must wait until the swelling goes down, the scars have matured, and the tissues have settled to see the result. We are never entirely certain how it will turn out, which is part of the fascination of surgery. With experience, surgeons learn how the passage of time affects the result and to appreciate this fourth dimension.

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HONORING OUR SCIENTIFIC PEDIGREE

Turning to one's inner psyche for guidance in surgery is dangerous and in fact bound to fail, as humans are inherently imperfect. We need the scientific method to guide the way. Just as we want our pilots to have good instincts, we also want them to have an altimeter. It is sobering to review our literature and consider how many surgical techniques that were conceived in creative bursts remain grounded because of a lack of scientific validation. In mammaplasty, the number exceeds 100.5

Art and science may not be mutually exclusive, but there is an essential difference. An artist uses a medium as a form of self-expression. A scientist seeks to uncover knowledge (and arguably beauty) that already exists while imparting none of his or her own prejudices regarding what that should be. Which discipline is more important in surgery? Is the human body truly a canvas to be manipulated into a form conceived by another human? Or is that form already created for us, and we seek to either rebuild it (reconstructive surgery), reshape it to resemble an accepted norm (rhinoplasty), or return it to its improved, youthful condition (cosmetic surgery)? Most of us would prefer our surgeon to be respectful of the innate beauty of the human form and not to be inspired to stamp his or her signature on it. Few people would like their nose to be recognized as the work of a particular surgeon.

If the human body may be likened to the ceiling of the Sistine Chapel, we are at best renovating it, not creating it. We may have more in common with the (highly skilled, mind you) craftsmen on the scaffolds working to restore the luster of the original masterpiece than with Michelangelo. “Liposculpture” might imply too much. What we are really doing is suctioning fat and injecting it elsewhere. Liposuction serves to better reveal the (essentially beautiful) human form, not to create it. Breast tissue is too malleable to hold its shape well; pedicle dissection does not constitute sculpting.

Although science and art may be essentially different, beauty can attach to both. Many scientists find beauty in science. Einstein found beauty in an elegant equation.6 When his relativity theory was proven, he reportedly experienced palpitations.

Artists rely on their intuition as a guide. Scientists are trained to question it, aware that the road to ruin is paved with good intuitions. It may be intuitive that manipulating breast tissue can improve upper pole fullness. It may be intuitive that superwet liposuction is virtually bloodless. Ultimately, intuition must give way to the facts.

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THE CONSEQUENCES OF SCIENTIFIC APATHY

Apathy toward science, or a willingness to let the science be outsourced, has real consequences. One recent study conducted by obesity researchers concluded that fat returns after liposuction,7 but not in the same places, invoking a mystical fat redistribution mechanism and discouraging prospective patients. A commentator remarked that plastic surgeons are fond of inventing operations but uninterested in rigorous studies.8 Fortunately, scientific evaluation reveals that patients after liposuction look more proportionate, not less.9 However, we must admit some responsibility for this previous knowledge deficiency, a consequence of not proving for ourselves years ago that fat reduction takes place without redistribution. We allowed misinformation to fill the scientific vacuum.

As a product of creativity and imagination, innovation is celebrated.10 New or repopularized techniques find an audience at meetings. So what is missing? Measurements. Innovation starts the race, but measurements propel us across the finish line. Without measurements, no rejuvenation concept is ever proved and none is disproved either, which is a sort of therapeutic purgatory. Remarkably, although face lifts have been performed for a century, only recently has any form of facial rejuvenation, surgical or otherwise, been evaluated objectively to confirm its efficacy.11 Saying that numerous techniques can deliver the same result is a familiar throwaway line at meetings. As scientists, we do not really believe that, do we? Perhaps it is more accurate to say that without measurements there is no way to ever know. Often, the less scientific merit for a claim, the more passionate the proponent. Such claims often follow the lead-in, “I'm a firm believer that.…”

Some plastic surgeons suggest that our specialty is too subjective to permit scientific evaluation.12 However, there is always a way of measuring if one puts one's mind to it. Claiming that plastic surgery is an art is no excuse for not measuring. The old axiom applies: what we measure, we improve (and the opposite is true too). Fortunately, computer imaging has made photographic standardization and measurements easy to perform. Gillies, who reportedly said that the camera was the most important advance in the history of plastic surgery,13 might feel the same way about the computer if he were with us today. Examining one's consecutive, standardized photographs is an educational experience for which there is no substitute. After doing so, plastic surgeons might be less inclined to promote a two-decade difference in apparent age after a 1-hour minilift, or advocate a “natural breast implant.”

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PLASTIC SURGERY IS A MEDICAL SPECIALTY

Indeed, innovation gives us a competitive advantage.10 However, so does our professionalism. A commitment to the truth and a resistance to marketing pressures help distinguish us from the wannabes. If we insist on being artists, we risk distancing ourselves further from the medical mainstream.14 No, it is not time to reconsider plastic surgery as a fine art. Cross-training is fine; the importance of an appreciation for aesthetics is unquestioned, but let us not forget our medical foundation. Scientific study is needed to confirm claims that we have made for decades,9,11 and only science informs us when the facts do not support our beliefs.5,15 When our patient or inner child asks, “Does this really work?” we can respond with conviction. Nothing gives one as much confidence as the facts.

Eric Swanson, M.D.

Swanson Center

11413 Ash Street

Leawood, Kan. 66211

eswanson@swansoncenter.com

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REFERENCES

1. Yahoo, Inc. Artist. In: Yahoo! Education, Dictionary. Available at: http://education.yahoo.com/reference/dictionary/entry/artist. Accessed July 15, 2012.
2. Wikipedia. Scientist. Available at: http://en.wikipedia.org/wiki/Scientist. Accessed July 15, 2012.
3. Goldwyn RM. The plastic surgeon as an artist. Plast Reconstr Surg. 2003;112:327.
4. Rohrich RJ, Sullivan D. So you want to be like Leonardo da Vinci or Michelangelo? Which one are you? Plast Reconstr Surg. 2011;128:1309–1311.
5. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.
6. Isaacson W. Einstein: His Life and Universe. New York: Simon & Schuster; 2007.
7. Hernandez TL, Kittelson JM, Law CK, et al.. Fat redistribution following suction lipectomy: Defense of body fat and patterns of restoration. Obesity (Silver Spring) 2011;19:1388–1395.
8. Kolata G. With liposuction, the belly finds what the thighs lose. The New York Times. , 2011. Available at: http://www.nytimes.com/2011/05/01/weekinreview/01kolata.html?_r=2. Accessed July 16, 2012.
9. Swanson E. Photographic measurements in 301 cases of liposuction and abdominoplasty reveal fat reduction without redistribution. Plast Reconstr Surg. 2012;130:311e–322e.
10. Longaker MT, Rohrich RJ. Innovation: A sustainable competitive advantage for plastic and reconstructive surgery. Plast Reconstr Surg. 2005;115:2135–2136.
11. Swanson E. Objective assessment of change in apparent age after facial rejuvenation surgery. J Plast Reconstr Aesthet Surg. 2011;64:1124–1131.
12. Alpert BS, Baker DC, Hamra ST, Owsley JQ, Ramirez O. Identical twin face lifts with differing techniques: A 10-year follow-up. Plast Reconstr Surg. 2009;123:1025–1033; discussion 1034–1036.
13. Guy C, Guy RJ, Zook EG. Standards of photography (Discussion). Plast Reconstr Surg. 1984;74:145–146.
14. Tanna N, Patel NJ, Azhar H, Granzow JW. Professional perceptions of plastic and reconstructive surgery: What primary care physicians think. Plast Reconstr Surg. 2010;123:643–650; discussion 651–652.
15. Swanson E. Prospective study of lidocaine, bupivacaine and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702–722.
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Contribute to Plastic Surgery History

The Journal seeks to publish historical photographs that pertain to plastic and reconstructive surgery. We are interested in the following subject areas:

  • Departmental photographs
  • Key historical people
  • Meetings/gatherings of plastic surgeons
  • Photographs of operations/early surgical procedures
  • Early surgical instruments and devices

Please send your high-resolution photographs, along with a brief picture caption, via email to the Journal Editorial Office (ds_prs@plasticsurgery.org). Photographs will be chosen and published at the Editor-in-Chief's discretion.

©2013American Society of Plastic Surgeons