Part 2: Body Image in Excess – The Sense of Entitlement

Featured image above: Dr. Luis Bueso Larios with mother and young patient

Part 2, Body Image 101: Entitlement, Stakeholder, miracle of plastic surgery

Body Image when over-praised

I, and we, the audience, have often wondered what the outcome of Tomas Dominguez has been over the last decade or two.  Hypothetically, let’s say you help somebody and a thought may enter the equation: does that help benefit the world? Or does simply giving things away to people do them harm? Harm is common and unintentional. For example, there is harm in giving money to children; giving money in a will or bequest to people who have not worked for it; or seen in my blog about doing surgery on a person who is not a stakeholder in obtaining that surgery. Your help might not be appreciated and, in fact, we all know instances in which the unearned is misused.

An excessive dose of praise may produce a harmful result when the young person becomes an adult. The “Street of Over- praising” as a child may lead to house a mild case of a sense of entitlement. Tomas’ recovery was miraculous and his peers hailed him as a hero. But was Tomás overpraised? Perhaps he was.

Now in Tomas’ case I believe that he acted according to his own situation. I’m not going to say his culture. But he acted according to a young, extroverted, able Mexican of alpha characteristic. He was interested in upward mobility, as we all are, and if you have the abilities of what Tomas had with his wonderful personality you could naturally turn to being a narcotraficante – selling drugs for money. It’s hard to blame him. He was surrounded by  poor role models. He didn’t have any real training in ethics and morality, except how to get ahead for himself. And he was starting not at ground zero but at negative 200; he began his climb from the very bottom because he had a physical disability.

I called Henry Alfaro, who had adopted him in a way. But he has lost track of him. Now they did have a little fight because Henry thought that Tomas did not have the right goals, ideas or role models. And he said, “Tomas, this is not the right thing to go for, such as new clothes, shoes – materialism.”

I said, “What did you expect?  You’ve got to have good parents, which he didn’t.” He had a nice mother but he was separated from her when he was growing up. He had spent 8 years having surgery, much of the time with us.

So this continues the philosophical thought on why there is little return on investment for giving help or money away. Scandals appear in industry startups, like Solyndra – that received 500 million with the promise of delivering solar energy to Americans and they went broke. They did not have a real good product and could not compete with the Chinese.  Now did they think they were going to be a huge success? THEY WERE OVERPRAISED. I don’t blame Obama. He didn’t see it, but he wanted to encourage a good alternative energy industry; and as a good salesman he could sell it to those people in Washington.

Social return on investment (dubbed “SROI”) follows along the same lines as financial return, but human nature produces more positive results as shown by the way Interplast worked. In the instance of Interplast, et al. performing gratis surgeries on 60,000 people around the world, do the patients in turn get the spirit of reciprocating these gracious services to other people? Yes!   Instances where that occurs are frequent enough.Scott Corlew, M.D., M.P.H., the former medical director of Interplast, once did a study on the social return on investment in terms of wages and money earned when you change a person from being disabled to a working, contributing member of society. He found a huge return.

Unfortunately, sometimes a gift can be a curse, rather than a blessing if the recipient develops a sense of entitlement. When a third party heaps praise on an individual, telling him or her that they are the greatest, as in the professional athlete whose income is a hundred million U.S. dollars, then that person may automatically feel more productive and superior because they are paid more. In consequence, it seems to be in our human nature to become loose and cocky. This is a reversal of the “hungry mentality,” one that resembles that of the Great Depression, displayed by lower level players who hustle, scramble, and struggle to survive and climb the ranks to success. Productivity may drop sharply or these top-earning players may suffer from a high dose of entitlement, which reduces their incentive for “life or death” effort, and in effect to contribute to the good of the whole. If your Body image has been constructed merely by the words of others or hype, it may not be helpful in the long run.   Receiving too much praise, like eating too many sweets, can have unwanted consequences.

Barry Zito

Now in as far as the athlete is concerned, it’s common that when the salary increases by a factor of 10, production decreases by a factor of 10. Why is that? It must be something inherent in human psychology. When athletes are paid $200 million, they receive absolute proof that they are better than other players. So they begin to lose their incentive or what’s called the “depression mentality.” Rookies have to scrimp and scramble, and work hard to get ahead. But because athletes paid well feel they are already ahead, they don’t have to struggle like it’s life or death every time they are at bat.

The San Francisco Giants increased the salary of two players by huge amounts: the best pitcher in baseball, Barry Zito, brought from the Oakland A’s; and what SF Giants thought was the key to winning, a superstar: Barry Bonds. I’ve said enough already that you can figure out about Barry Bonds, who was paid a lot but he also did a lot himself. He figured out how to build muscle and how to get home runs by taking a certain concoction of chemicals.

Many athletes want to get ahead, and in order to get ahead they find out what they can do. Sometimes they misstep and use a little different thing, like a type of steroid to boost their performance. In my mind I really can’t blame them for following the societal wolf pack: a bunch of individuals moving ahead equipped with a lot of brains and balls; however, they stumble sometimes. To have a defeat is important because lots of defeats along the line lead to greatness. Stress can have a positive bodily reaction that leads to increased strength and an enhanced biological defense system. In fact entrepreneurs wear a badge of achievement in Silicon Valley for how many times they have gone bankrupt in the dot com era. Because they still have brains (and experience) they truly have not gone bankrupt.

Phil Helmuth, poker champion

Now in order to avert a similar failure, the coach of the 49ers, Jim Harbaugh, felt that players should not receive huge salaries. Instead, they should keep the mentality more blue collar rather than being spoiled like a prince. So he calls his players “blue collars.” At the start of each season, he puts in everyone’s lockers a blue collared shirt with their name on it.  He invites accomplished people to come and give lectures for his players. One of the persons invited recently to talk to the 49ers was a man named Phil Helmuth, who is famous as a card playing poker champion, and he runs Poker Brat Clothing Company and makes $200 million a year – a lot of money. “If you keep your heads up listening to NFL Network and Warren Sapp, then you’ll buy into being ‘great’ and get sloppy,” he told them, “instead, keep your heads down and your bodies in the right place at the right time; no jumping routes.”

So to prevent getting sloppy – the human reaction to over-praising, over-evaluating, and over-paying – you have to keep your hands dirty in the ground solid with a realistic goal.  And you have to keep it up or you go downhill. This is important in evaluating social return on investment, where the recipient must be a stakeholder in the situation.

Another example of this is the Romans, whose highest achievement is to win in battle. A general who leads his army to a victorious conquest of a foreign country was feted by the public on return to Rome. Several thousand people would line the streets, cheering and he would ride a golden chariot, pulled by three horses. In Roman culture, the shift between human and god is fluid and indiscernible. It was easy to crossover in their mind because the Roman general, adorned with a crown, looked like a half-human and half-god. Even he was thinking he was party god or immortal. But there was a slave hired to ride on the chariot and whisper in the general’s ear: You will die, you are mortal. You will die in a future battle. You didn’t die in this battle, thank goodness. But you will die in another battle. It’s postponed. It’s not gone. Memento Mori. (Remember you are mortal.) And he repeated this warning to the general.

Concurrently, we all know that mild to moderate stress strengthens almost every biological system. On the basis of these two theories, we should pay attention to the nuances of the body image theory, which have been developed in the plastic surgery discipline. Both praise and encouragement, and mild to moderate stress in the form of “do better” must be administered in just the optimal mix. Analogies of this axiom run through almost all fields of endeavor. But in plastic surgery, 50% of our theory and 50% of our practice revolves about our understanding of body image and its nurturing. And your participation in it.


The reason why we make a consultation with a plastic surgeon is to seek improvement in our body. We expect, as a sure consequence of that change in body, an improvement in our life. The desire for improvement in our life is not usually well verbalized by the patient to the physician, and usually does not come up during open discussion with the surgeon. But early in a plastic surgeon’s career, the physician has already acquired sufficient wisdom to help in this exact situation. The Plastic Surgeon’s training equips him or her with a repertoire of social skills and theory, which has been acquired from behavioral science and specific psychiatric training, and from the school of hard knocks.[1]* This Wisdom is helpful in interpreting the nature of the patient’s non-verbalized agenda. The surgeon grasps well the importance of being aware of the patient’s desire for improvement in life, but in many cases it is given little verbal attention by either patient or surgeon.

Visualize this aspect of plastic and reconstructive surgery as a second triangle, below; it relates to the importance of the person in the success of the surgery. The goal of each individual surgery and of each individual case is success, and success means achieving the patient’s request. Both the written and unwritten agendas require satisfaction.

[1]  “School of hard knocks” refers to street smarts associated with multiple interactions with a cross section of society.

This triangle exemplifies a superior method in patient management compared to the advice in some textbook pages. Theoretical information learned in textbooks does not sync well with a patient’s unrealistic expectations. Despite a high level of training in a particular technique, the doctor’s capabilities cannot consistently deliver the optimal result because the patient many times has different expectations for their body and their life. Perfection in a surgical result will satisfy the verbalized agenda, but perfection in a physical surgery result may often be insufficient to obtain a successful result. The verbalized agenda alone allows you to easily arrive at a decision regarding surgery or no surgery. On the other hand the unwritten agenda may require time and a little friendship with the patient in order to understand their goal in life. To find and understand an unrealistic and unwritten request is the surgeon’s job, señor.

Whenever the patient’s expectation in life is unreasonable but the expected anatomical result is perfectly reasonable, many times it is helpful to actually PUT THE UNWRITTENEN AGENDA (THE PATIENT’S PREREQUISITE) IN ORDER TO BE SCHEDULED FOR SURGERY. Achieve the patient’s life agenda prior to surgery. Achievement of the unwritten agenda is more easily obtained when it is made a pre-requisite for the decision to do the surgery. Picture a fictional character who will serve as our example – a pushy, unpleasant, almost obnoxious 40-year-old used-car salesman who is an ex-boxer, and who had sustained a fractured nose some years ago and a resulting bump on the dorsum. The salesman requests an operation to improve the appearance of his nasal dorsum because he believes it affects his car sales. This operation can be 100% successful anatomically, but the man’s deeply ingrained obnoxious personality might continue to be present after surgery, and continue to interfere with success in sales. The theory states that preoperative evaluation of the social aspects of his personality would have been important.

The man told the physician he couldn’t make his sales with such a bump on the nose. Note carefully that he said “can’t make sales” rather than saying “Doctor, remove this bump.” If the surgery is 100% successful from the anatomic and aesthetic point of view[2], but the obnoxious personality persists. If his car sales do not improve, the surgery will be considered by the patient to be a failure. Indeed, on many occasions, the patient will be so disappointed after surgery that they will not comprehend the “Why?” He may have “psychological pain” in the incision.

On the other hand, if the approach is yes, great let’s do it! In fact enroll in the “How to be successful in the used car market” or marketing class and achieve an”A” grade. Then complete successful sales of three autos, and we’ll go forward with the operation, which is step 2.

Conversely at a certain level the patient expectation becomes so great that there may be corresponding difficulty in accomplishing the anatomic surgery itself. There’s trouble when the preoperative expectation exceeds the possible postoperative result.

[2]  A handsome, perfect nose with yet a little character to it.

This is an example of “The Gorney Equation.”[3] The graph below show how the more difficult the surgery, patient expectation is higher. When the stakes are high, there is bound to be trouble because different factors intervene to make matters worse.

Green line– patient with big mole who shares their dissatisfaction, “ As soon as I come into the room, people stare at me. They think a fly has landed on my face or that it is the mark of the devil. People do not listen to me. They don’t understand my value to them. They whisper behind my back ‘Oh the girl with the black mole on her face. I forget her name.’ She has the “always a victim” syndrome. But it important as a surgeon not to be flippant towards a seemingly easy case. Because she may easily get fixated on another body part to blame for lack of success in life. Rather “let’s both together do every detail perfectly. We must be meticulous and after surgery, you must promise to go out in public without any bandage (a crutch).

Blue – This can be easy or difficult. This can be an ingrown toenail (close to origin) or treatment of a scratch; making a black person white (Michael Jackson) or sex change surgery or making a wing. This is the easiest situation for the surgeon because simple or complicated cases put you on exactly the same page as the patient. And the patient understands the relative risk of the complication (0.001% to 90%). The patient and you have the same mind, and work together as a unit to solve the problem.

Purple – complex case. Like the removal of big internal cancer. The patient won’t be aware of a significant life change or bodily change, but the surgery may carry a risk of losing the patient’s life or cause disability. It requires management skills, which have been learned the hard way by making mistakes with the previous cases.

[3]  Mark Gorney, demonstration and lecture, plastic surgery grand rounds on, March 31, 1972, Stanford University School of Medicine, R212, Surgical Library, given to plastic surgery faculty.

The patient may complain of pain at the operative site, a psychologically induced pain. Sure, one can almost always find a small imperfection, but accompanying that will be a large dose of dissatisfaction. The dissatisfaction is expressed to the surgeon, and in turn the surgeon will not understand that the patient expected that his unwritten agenda would be completely fulfilled. The surgeon may operate again (on the nose, not his life) in an attempt to satisfy the patient, but the patient will be dissatisfied again.

Three plastic surgeons have been shot as a result of this scenario—each by a dissatisfied male rhinoplasty patient.

I learned this lesson clearly and easily in the field of transsexual surgery. In transsexual surgery, many times the patient carries an additional diagnosis, which is “always-the-victim” syndrome. Through no fault of their own they were given a really bad deal in life. In this syndrome, self-starting ability is stifled because the alibi – “I am not able to help myself very much” – is so easily at hand. The physician would have been so much better off to diagnose the ratio of the expectation with the likely result, to not be a hundred percent, but to have a significantly lower correlation or P-value. The physician would be better off to recognize the disparity between the result expected (the unwritten agenda) and the likely actual result. The solution is for the surgeon to satisfy himself/herself that any unwritten agenda has been drawn out from the patient. It was not my gender anatomically but what I really want is acceptance as a human being, to be a normal human person.

In the marginal cases, this is best done in the pre-operative phase. The hitherto unwritten objective must be understood by both parties prior to surgery, such as being an actor, being a good salesman, winning an election. The surgeon may say, “My dear, a prerequisite to scheduling your surgery is for you to go to a class on how to be pleasant, how to be polite, how to be of service to others. Go to a class on ‘How to Treat the Customer Very Well.’ And oh yes, be sure to use this new knowledge and skill to sell eight cars before you return to schedule the surgery. Then after we perform the surgery, I will assign some tasks that you are to perform religiously, such as putting on ice packs, keeping your head elevated, refraining from sexual activity, and abstaining from alcohol.”

This of course brings up another point. The patient will have become a stakeholder in the operation, having participated in the preop requisites, the lab work, and the postop work. The patient who is given free surgery as a professional courtesy, for example a psychiatrist’s wife, will almost always be dissatisfied with a correlation value of 1 (100%) with the free surgery because she was not a stakeholder in the process. In fact, most non-stakeholders start to complain as they are waking up from anesthesia.

[4]  In “always-the-victim” syndrome the patient has the conviction that all his life problems are caused by his condition. Every piece of bad luck in life is a result traced back to the bad luck that the patient was cheated by a greater power, who designed him or her imperfectly; for example, with a female mind and male body.

Post Op

Another problem is the big bandage. Because seeing the big bandage may cause an attitudinal change, the patient may imagine that the operation was very difficult, that there may be huge amounts of blood leaking out, or there may be an expectation of correspondingly big pain. Therefore the patient, almost every patient, must be informed immediately that the surgery was successful. So after every operation which I perform, I write a note to the patient in cursive saying “Dear Joe, Surgery was a success. There was no complication.” I usually add a bit more detail, such as “The eyebrow elevation presented no problem; we elevated it 1.5 cm and fixed it to a firm place higher on the scalp.” I also usually mention two or three sub-points in my note to make the story cohesive and which relate to success and/or problems during the course of the surgery. Furthermore, the nurse should not show concern over blood in the drain or about any normal pain. No serious looks allowed. Have a big smile.

Here’s another case that shows what not to do. A resident did a successful full-thickness skin graft on the neck of a patient, a child. A newly healing full-thickness skin graft looks awful just at about one week after surgery. That’s normal. But a relatively inexperienced resident was changing the bandage and upon seeing the healing graft in its sad state exclaimed, “Oh shit!” This naturally frightened the child and the parent and significant repercussions resulted; troubleshooting was necessary and was successful. And additional point to keep in mind: Never say “Oops” when the patient is under local anesthesia. The patient will think ‘Dr. Oops is not a successful surgeon.’

Despite all the possible risks and nuances, surgery can bring unbelievable results that can transform lives.  The miracle of surgery is dramatic, permanent, and immediate.

Entrance into the Human Race

The entrance into the human race via a series of body image changes through surgery is always a fantastic gift. The improvement in craniofacial anomaly surgery is many times of miraculous proportion, transforming from a sort of grotesque situation to that of merely ugly – not to truly attractive or handsome standards, but enough to enhance body image. An ugly person can then undergo additional cosmetic surgery to look more beautiful.

When a citizen in the middle of the bell-shaped curve seeks and attains a body image change to handsome, or to really attractive or lovely, an unusual increase in self-confidence occurs. The difference in the style of change – that is whether the surgery was cosmetic or reconstructive – does not lead to abuse, according to our present level of theorization. Both changes are the same psychologically and are based in reality; and both have substance to back up the feelings of moving up the ladder. The cosmetic patient and reconstructive patient both suffer significantly, believe it or not.

I would like to present a few cases that show the miracle of plastic surgery.

Rosario Rosaria Villegas

Rosario Rosaria Villegas is an 11 year old girl with a severe bilateral cleft lip and palate from Navajo Sonora Mexico. She was brought up here as part of the Interplast domestic surgery program at Stanford and had a close to perfect result from surgery by Dr. Ernie Kaplan. Rosaria was identified by our pilot who had brought us in private plate down to Sonora one morning for a weekend of surgery. The pilot was essentially “dead-headed” – he had to wait around till Sunday night before we returned to our home base. He was a nice Dutch immigrant who was gregarious and socially-minded and went about town in our interest. Sort of as our ambassador for external affairs, he was in process of asking persons if they had ever seen kids with cleft lips and was directed to a home just off the highway south of town at a subsistence farm. At that place the mother told Milhoan that the cleft lip patient was “out in back”. “Out in back” was a where the pigs were kept in a pen.

He found Rosario in the actual pig sty, naked without clothes, being raised as an animal. This may be a little exaggeration on our part about being raised as an animal; she did have a name, but she did not have a birth certificate. In my estimation she had not yet entered the human race. This is a severe disability when you have not able to enter the human race. This is severe prejudice to be less than human and be denied all human rights – not denied, never been offered any human rights. Of course, who knew human rights at that time. I mean this wasn’t in any of our vocabulary in 1974.

Before & After image of Rosario Rosaria Villegas

Anyway, I became excited with this case and I recruited our gracious and competent social worker Amy Laden to please obtain parents’ permission and have the patient brought up across the border as an outpatient or inpatient staying with a foster family here in Los Altos Hills to have surgery. I saw the patient in clinic with Ernie 24 hours after her plane landed at San Jose airport. She, of course, was quite happy in anticipation of this flight courtesy of PSA airlines to the United States where everything would be perfect in her mind. Here was salvation; it was like coming to heaven I think. At the airport in San Jose she went to the bathroom, which she had never experienced. On coming out of the bathroom (all being a wonderful experience up to that point, she came face to face with a peer, an 11 year old American child who saw Rosario with a double cleft lip and screamed, “AHHHHH!”

So life as a patient is like a trampoline – you can be down at the bottom in a pig sty or up in the air with PSA airline coming to a heavenly experience, like a Nirvana. Well, she went down again when she was “evaluated” by the 11 year old American “peer” and began to cry loudly. I mean severely. And when I saw her the next day at clinic, she was still crying. This was a terrible experience for us. Well, she did calm down with the new family. They told her how to use the bathroom, how to do all these different things. She entered the human race. She looked beautiful and was successfully rehabilitated despite obstacles.

Dr. Larios

Dr. Larios was a tall and talented thoracic surgeon working in the next door operating room, donated by TB foundation, in San Pedro Sula, Honduras. On Sunday Dr. Larios was on horseback in the forests of Honduras hunting deer. He came across a child sitting with his back to him along a small creek. Coming around in front he saw a bilateral cleft lip in a five year old boy. Asking his name, he was unable to understand him because of his cleft palate speech. He did converse. The child was brought up to his saddle and they visited his parents.

Dr. Larios obtained permission to bring him to us for surgery rehabilitation. The child had never seen a paved road. In order to admit him to the hospital and place him on the surgery schedule he required a name and a birthday. We provided both. We all thought it was a great adventure. We took each of us and put together our names: Dr. Laub, Dr. Bueso, and Dr. Larios. Donaldo Larios Bueso Laub was entered into the hospital and operated successfully. The social history for this newly named patient has been lost in the labyrinth of patient records of Leonardo Martinez hospital and in Interplast archives. I have depicted the situation in a sketch above. This child was shy. He was a typical of a rural upbringing. However, he was the favorite of Dr. Bernado Larios (thoracic surgeon), Dr. Luis Bueso Arias, Dr. Donaldo Laub and the entire hospital.

I frequently see him in virtual life and in dreams; he seems to be a normal body during glimpses.

In summary:

1. Different surgery goals. A patient’s request to change the body via plastic and reconstructive surgery (PRS) is distinct from general surgery’s removal of a significant pathology, such as a tumor or a diseased gallbladder. That is, in general surgery you remove the cancer or the diseased gallbladder. The patient may recover fully, or perhaps evidence is found that the patient’s life may be shortened. On the other hand, although requests for PRS may be verbalized as diseases, in many instances these surgeries are methods to improve life and body from normal  to better than normal. And again, the goal may be verbalized as removal of a disease, but the real goal is in life.

2. Person to person. In research science, or biotech executive training, or in most CEO work, the individual is not part of the equation. The interaction which includes the one person is the sole province of the physician, and especially the reconstructive plastic surgeon, who has the opportunity to deal with the one person, to receive Psychic Income, which is best received from one person, the patient. This surgeon can enter into the life of people from a complete cross-section of society. Only by practicing medicine with Hippocrates’ method of considering the one person’s welfare as your primary concern do you find this key to heavy doses of real happiness.

3. Be sure the patient is a stakeholder in the success of the operation. They should contribute with tasks, such as advance weight loss, reading, careful skin preparation, dressing changes, application of ice, and payment that is personally earned (not through a third party). To actually acquire the unwritten agenda prior to the written agenda and prior to the surgery itself is not a trick of the trade. This technique is part of life and it is in all life and work. It negates the sense of entitlement that many children acquire as a result of over-praise as a child. Identify the more difficult unwritten agenda before surgery, and make it a prerequisite to the surgery; the patient will then perceive the operation itself was the key to achieving the goal.

4. Teach this to PRS students. Each such patient increases the input into your instincts and increases the joy of life. This methodology builds the body of knowledge of PRS theory, and we should remember to pass it on to our students. Teach the students, in so doing, this is an act for the betterment of the world. These students will grasp these tidbits of knowledge and multiply them in their careers, through the patients they serve who will tell others, and will become teachers themselves. This multiplication is in one career: 10,000 patients who will contact (family, parties, committee meetings) 10,000 more, at least. If they teach, the multiplication is logarithmic. You improve your own knowledge and skill in the process of teaching. Not only do you provide for your own succession, but you enrich your life in the process of interchanging thoughts and concepts.


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