Fakhr Alkhairy
Posted: 2007-12-14 by Prof. Dr. Fakhr Alkhairy [send email]
ProF.Fakhr Alkhairy
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Prof. Dr.Fakhr Alkhairy
Pakistan
www.cosmeticreality.com

asrar shaikh was under my care for facial rejuvenation. He had mini-facelift couple of years ago. He was happy with the result. Then he asked me for rhinoplasty because he was happy with the mini facelift. He opted for rhinoplasty. If he had any doubt about my surgical skill he would not have asked for rhinoplasty. There was a big gap between the two operations. Mini facelift usually lasts for a year. He turned back for further enhancement. His full facelift including skin, SMAS stretch and liposuction of the face was done. No major complication was observed. Even the commonest complication "Haematoma" was not observed in his case. Scar was well involuted. No skin necrosis and no nerve injury were noticed. After his first surgery he used to oblige me with fresh fish because his profession was related to fishery. In fact once or twice he supplied himself cooked fish which was very delicious. This fisherman actually trapped me in the sense that I was compelled not to charge him for my actual professional fee. In fact his second major surgery was done with meager amount of money, which covered hardly the hospital and medicinal charges. His two subsequent minor surgical procedures were done without any charge. He was never charged for follow-ups. The greatest mistake on my part was not to charge him because he bribed me with few kilos of fresh fish. ( The total cost may not be more than three thousand rupee ) If I had charged him probably he would have valued it very much. This phenomenon is common in cosmetic surgery.

If a person who comes for facial rejuvenation in middle & late fifties particularly in this part of the world one can very well visualize what aesthetic deficiencies a person may have. Usually they require Blepharoplasty, facelift, Forehead lift, and neck lift. They can all be done in one stage or in different stages. Some people have prominent aging signs in upper part of the face and some may have in lower part of the face. There are many where aging signs are all over the face. Liposuction of the neck and face is an added procedure to further enhance the aesthetic result, which may or may not be required. Depending on the patient’s requirement and self-consciousness a surgeon plans to achieve the desirous result. In Asrar case Facelift, neck lift, Bleparoplasty and nose job were done in different stages. Many of these patients who come to plastic surgeons have self-consciousness of aging (Disproportionate anatomy). Which may be mild or deeply rooted depending on the lifestyle and personality. Induction of self-consciousness is caused either by the natural process of self-comparison with the appearances of others or comparing own different photographs of different ages or by the experience of others criticizing the abnormally appearing feature. (David Harris 1987) Once the self-consciousness is inducted the patient develops a defensive mechanism or adapts corrective methods. Defensive mechanism leads to Camouflage technique (such as applying cosmetic, or hiding the defects with hair style or cloths), restriction to the patient’s lifestyle (Occupational, social, domestic, and recreational) and artificial pattern of behavior. The corrective method brings him to a surgeon for surgical correction. The difficulty arises when there is conflicting concept of success. As evidenced by research finding, patients with slight defects tend to assess these defects as being more conspicuous than they are. Such patients are also apt to be the most demanding (Macgregor 1967) additionally, the smaller the defect that troubles the patients, the more likely he is to focus on minute details and post operatively to magnify any residual imperfection. Cursory, consultation with such patients seldom exposes their underlying motives. In case of any complaint on the part of such patients require realistic evaluation by the psychiatrist as well as a group of Plastic Surgeons for objective assessment without being subjectively biased. Overall most of the people who seek cosmetic surgery suffer from Somato-psychic problems. To the best of my knowledge he is suffering from BDD. details of BDD is as follows:-
Body Dysmorphic Disorder
(BDD)


* What is body dysmorphic disorder (BDD)?
* What are the symptoms of body dysmorphic disorder?
* What is the treatment for body dysmorphic disorder?

What is body dysmorphic disorder (BDD)?

Body dysmorphic disorder (BDD) is a serious illness when a person is preoccupied with minor or imaginary physical flaws, usually of the skin, hair, and nose. A person with BDD tends to have cosmetic surgery, and even if the surgeries are successful, does not think they are and is unhappy with the outcomes.

What are the symptoms of BDD?

* Being preoccupied with minor or imaginary physical flaws, usually of the skin, hair, and nose, such as acne, scarring, facial lines, marks, pale skin, thinning hair, excessive body hair, large nose, or crooked nose.


* Having a lot of anxiety and stress about the perceived flaw and spending a lot of time focusing on it, such as frequently picking at skin, excessively checking appearance in a mirror, hiding the imperfection, comparing appearance with others, excessively grooming, seeking reassurance from others about how they look, and getting cosmetic surgery.

Getting cosmetic surgery can make BDD worse. They are often not happy with the outcome of the surgery. If they are, they may start to focus attention on another body area and become preoccupied trying to fix the new "defect." In this case, some patients with BDD become angry at the surgeon for making their appearance worse and may even become violent towards the surgeon.

What is the treatment for BDD?

* Medications. Serotonin reuptake inhibitors or SSRIs are antidepressants that decrease the obsessive and compulsive behaviors.


* Cognitive behavioral therapy. This is a type of therapy with several steps:


1. The therapist asks the patient to enter social situations without covering up her "defect."


2. The therapist helps the patient stop doing the compulsive behaviors to check the defect or cover it up. This may include removing mirrors, covering skin areas that the patient picks, or not using make-up.


3. The therapist helps the patient change their false beliefs about their appearance.


Being the President of Pakistan Association of Plastic Surgeons I would like to constitute a Medical Board comprising two psychiatrists and four plastic surgeons of this country for objective assessment and evaluation on this patient.

At present he has two very small areas which are lumpy and required infiltration of Kenacort. I already gave him a shot, which reduced his lump, which he admitted on the phone. This is something, which is one of the known sequels of liposuction if not managed properly. Small bore cannula for liposuction and compression of the area for couple of weeks is the key to avoid this known complication. On very second day he came in his Pajero Jeep without suspension & without facial support and took out his dressings at home by himself. He was so obsessed that he wanted to see the result on the very second day of surgery, which is far from the truth in aesthetic plastic surgery. His compliance as a patient was very poor. Generally the compliance in male is poor in facial surgery because of two reasons. They are outgoing as compared to female particularly in this part of the world and they have to use shaver, or blade for shaving. Facial support in liposuction of the neck area is essential to minimize contour defects. All my patients who have undergone this procedure had very good compliance even some of the celebrities in showbiz such as “Nighat Choudhry” never had any such complication. asrar shaikh has not the slightest idea about Aesthetic Plastic Surgery in this region. He does not know that a patient expired during face lifting in this very city in a well-known hospital. One of the elite trained plastic surgeons was involved in it. He does not know that many patients were crippled because of facial nerve injuries in facelift operations in this region.

After a lapse of many months his preoperative and postoperative Photographs were compared. There was a significant improvement in his appearance. I wish to paste these photograph for the viewers on website. Viewer can also watch other videos, http://www.youtube.com/watch?v=Av-KwkXfsrk http://www.youtube.com/watch?v=FpyVS9yUUPE on facelift done by me.
http://www.cosmeticsurgery.com.pk/video.php
His entry to my clinic was deliberately banned because he started coming to my clinic without appointment, which was very disturbing for me and for my patients. Since he was never charged for follow-ups so he took the advantage of it. In his last procedure he promised in front of my theatre staff to provide me “ Jumbo Prawn “ as a fee for the operation, which he never did because his fishing boat already sank into the sea. His entry to my clinic was also banned so that he should come out of the vicious cycle of “Obsessive Neurosis” which he definitely suffers from.

His lifestyle tells me that he is a disturbed man. Lives alone, unmarried, ” Basically Sharif “spends most of the time at home, and doing renovation all the time. It looks as if he is waiting to receive some one. Very few friends. (Related to FIA) His profession is related to fishery. Recently his fishing boat sank in the sea while fishing. He tried several times to recover the boat from the sea bottom but disappointed. While touring London he had some grievances (regarding camera) with someone and lodged complaints with London Police and spent more money than what he wanted to recover He told this story to me. He scanned hundreds of present and ten to fifteen years old pictures for comparison. He sent me many photographs in mail and some were shaded deliberately to highlight his point of view. His aging process is more rapid than a normal person. He is in late fifties and wishes to get married according to one of his companions. In fact his companion proposed my beautiful receptionist for him after his first operation i.e. mini-face-lift. This simple fact shows his confidence building and trust in himself after face-lift. His opinion about his own face changes rapidly. What looks good today becomes bad in a couple of weeks and what look bad becomes good in short span of time.


In one of his letters he wrote me “In the end I request U to think over the matter seriously and tell me what I should do. I am determined to get it corrected from anywhere. Better if U do it seriously as it is your responsibility ethically and according to your professional norms and it is my preference to get it corrected by you.”

This is a typical love and hate story. Several times I told him to take second opinion from someone who is tuned to this type of surgery. He is advising me to follow ethics but he does not follow the ethics of business.

I am ready to take him back provided he should abide the rules of the games. He should take the appointment first before he lands in my clinic. He should follow instructions strictly. He should provide “Jumbo Prawn “as a fee of my last surgery which will cover the hospital expenses only. This is his way of paying surgeon & hospital’s fee. Over all he is my patient. I will always like him to feel good. The entire exercise of these operations is to reduce the self-consciousness and meet the mind image of the aesthetic candidate. Basically his minor imperfection even if corrected is not the real issue. His issues are others, deep rooted, which compels him for repeated surgery for further enhancement. Here they do not understand the limits of aesthetic plastic surgery. They keep on pushing the surgeons to make them more beautiful. They think that face beauty is the only thing, which can solve their social problems. Most of these who come in this category have a very few other potentials for attraction. Most of this patient requires thorough counseling. Surgeons have to stop this ongoing process at certain level to minimize their miseries whether the surgery is paid or unpaid. I have showed him a video of actual operative procedure of one of my patients so that he understands the surgical limits of removal of excessive redundant skin and SMAS and how this operation is done. But somehow he believes that enough skin was not removed. Why he thinks so I do not understand. At the moment he has no redundant skin on his face to be removed. But I am sure if he keeps on coming to me eventually he will ask me to remove more skin from his face. This is typical of his approach. He keeps on lingering the insignificant minor issue until he finds some loosening of skin and ask the surgeon for surgical correction. At that moment he gives less stress to any minor issue and get corrected other things without paying any penny. Either he is very shroud or has deep rooted problem. His aging process is accelerated one there is no doubt in it but not to this extend that he keeps on pushing the surgeon for skin removal again and again. There is no need of it for a couple of years. I have never motivated him for any surgery. My professional approach was most scientific and most modern. I am enclosing his postoperative photographs for evaluation

Facial rejuvenation can turn the clock back for the time being but aging continues. One cannot beat aging permanently and cosmetic surgery is not the solution of all social problems. Cosmetic Surgery is not even hundred percent. It does not ensure hundred percent perfection. Realistic expectation with stable personality without much social pressure is prerequisite for Aesthetic candidate for Aesthetic Plastic Surgery. I do not think asrar fits in these criteria.
.
Prof. Fakhr Alkhairy M.D., F.I.C.S., F.A.C.S.Specialist
Certification in Plastic Surgery (Belgium)
Formerly Assistant Professor of Plastic Surgery
Dow Medical College Karachi.
Consultant Plastic Surgeon, Cosmetic Surgery Centers, Alkhairys Hospital, Taj Medical Complex & Karachi Adventists Hospital. www.cosmeticsurgery.com.pk, www.plasticsurgery.com.pk
Formerly National Secretary of the International Society for Aesthetic Plastic Surgery,
Faculty Member for Aesthetic Surgery for Postgraduates (Bombay Hospital) International Academy for Aesthetic Plastic Surgery http://www.iaaps.com/Mumbai07.htm
http://www.aestheticsurgerycmeseries.com/pastevent/faculty.htm

Member Editorial Board, representing Asia, International Journal of Cosmetic Surgery
http://www.ijcs.org/about/editor.php

President Pakistan Association of Plastic Surgeons
www.papscon.com www.paps.com.pk


References: -
1- Cosmetic Facial Surgery (1973)
Thomas D. Rees, M.D., F.A.C.S
Donald Wood-Smith. M.D., F.R.C.S (Ed)
2- Transaction 9th International Congress of Plastic (IPRAS-1987) And Reconstructive Surgery- page 476
David Harris. M.S. F.R.C.S.
3- Macgregor F.C.: Social and cultural components in
The motivation of persons seeking plastic surgery of the nose J. Health. Soc. Behav, 8:125-135, 1967