The wOw Interview: An Insider’s Look at Cosmetic Surgery, With Dr. Haideh Hirmand

Dr. Haideh Hirmand

Plastic Surgeon Dr. Haideh Hirmand joins Joni Evans for a frank discussion about plastic surgery – how to find the right doctor, how hush-hush you can really keep it and other ifs, whens and how much

JONI: Well, welcome to wowOwow. I’m delighted to have this particular, spectacular guest actually, Dr. Haideh Hirmand, who I will confess I met about a week or two ago, and she’s absolutely gorgeous.

HAIDEH:
Thank you, Joni. It’s a pleasure to be here.

JONI: We’ve heard about you for years and now to have you on the show is wonderful. I should say to our audience that Dr. Hirmand is in private practice right here in New York City. She is clinical assistant professor of surgery at the Weill-Cornell Medical College. She is a member of the attending staff at the plastic surgery departments of New York Hospital/Cornell Medical Center, Manhattan Eye, Ear and Throat, and Lenox Hill Hospitals. Her practice focuses on what is known as aesthetic plastic surgery, especially specializing in eyes and facial rejuvenation – something our audience has no interest in, Dr. Hirmand! So we hate to bother you.

HAIDEH: Oh, my gosh. I think that everybody this day and age is interested in that topic.

JONI: You’re absolutely right. Let me ask you, how did you get into this business? I happen to know that you were the valedictorian of your class. I don’t know whether it was at Harvard or whether it was the JFK School of Government.

HAIDEH: It was actually at the University of California.

JONI: And you were studying molecular biology as a major?

HAIDEH: Yes, that was my undergraduate degree.

JONI: And then what brought you to Harvard?

HAIDEH: I did my medical degree at Harvard, and I did my Master’s degree at Harvard’s Kennedy School of Government in international health development-related issues; it’s a Master’s in public administration.

JONI: How spectacular. So how does this happen to end up in plastic surgery?

HAIDEH: This is a great question and actually many people wonder about that and ask me. The short answer is that I’ve had a love for surgery, for aesthetics and for international health issues, especially as they relate to women, independently. And so in plastic surgery I found a way to really combine them. That’s the short answer. The long answer is my parents are both physicians. My mom comes from a very long line of doctors. In fact she’s now 82 and she was the first woman who became a gynecologic surgeon, or doctor or surgeon in her family. But most of her brothers and uncles and great uncles and great, great uncles were physicians. So I sort of grew up with medicine and sciences and I had a love for it as a child. I also loved clinical medicine and patients because, again, I sort of grew up around it. My father was really involved in international health and health policy, which is where that sort of background came in.

I happened to have had a very, very bad accident when I was about 13 years old and I had a very bad head injury. I should have decidedly died, and I lived, which is already a miracle. But I had a very disfiguring injury to my face at that time. And at a very young age I experienced the traumatic effect of looking in a mirror and really looking like someone else – not looking like yourself. And I remember this distinctly. Of course, I never knew at that time that it had affected me consciously or subconsciously. It was very disturbing and is something that I needed surgery for, and I had several surgeries for it.

Today I don’t think there is a real big visible mark of that injury, but I think, and I know, that subconsciously it affected my decision making down the line. When I decided to go into sciences and then eventually into the clinical side of sciences and to bring that research side, the interest I had in technology and biology, into my clinical practice, I did a number of years of research in immunology and transplant tissue rejection during my training as a surgeon. And then when I was looking for a specialty within surgery where I could combine new technology, research, clinical practice, ability to work in the international arena and make a difference, but at the same time, you know, entertained this idea (I guess it was maybe a subconscious idea) of how form and function can be restored and what is the importance of that for a person, I think plastic surgery just brought it all together without me even really looking for it. It just was there, I experienced it and it just gave me the opportunity to really combine all these varied interests. So that’s really the long answer. But that’s how it happened.

JONI: Well, it’s fascinating and it’s really almost like it was meant to be because you’ve had the sensitivity, the personal experience – it’s just an amazing story.

HAIDEH: Yes. I sometimes think that. Sometimes I actually think, “Gosh, this was just meant to be.” I always loved aesthetics. I always had deep thoughts about the importance of aesthetics and life; why it is that it’s boundless and it’s just across cultures, across time. Why is it that people are drawn to it? Why is it that functionality and the form are so inter-related? But I think that it just came together, and sometimes I think, “Yes, it was just meant to be. That’s just the way life works.”

JONI: Exactly. It’s a rare profession in any case, is it not, for a woman? How many women are plastic surgeons? What kind of percentages?

HAIDEH: Definitely surgery is not a profession where you find a lot of women. Now, plastic surgery – it’s about ten percent women. The last documented data is from 2001, that was actually measured – and it was seven percent then. Now it’s a little bit more than that and it’s probably around ten percent. That’s not a huge number.

JONI: Do you think it’s about the physical strength one needs?

HAIDEH: I think there are a few reasons actually. The training is quite long. My combined training in medical school was five years. I then did a year of cancer research, so that’s six years. And then I did another seven years additional to that in surgery, general surgery and plastic surgery. So if you add all those up, it’s probably about 18 years. It’s a long training.

JONI: Oh, my God, that certainly is.

HAIDEH: It’s long. It takes many, many years. And also surgical training is quite demanding. It’s by nature demanding – it’s physically demanding and it’s psychologically demanding, and it does take a certain kind of personality. So I think traditionally – and this is changing over time – traditionally those elements have not made it necessarily a friendly specialty to women.

JONI: I see.

HAIDEH: And that’s across the board in surgery, and plastic surgery being a surgical sub-specialty falls into that. I think that’s slowly changing, and especially in plastic surgery we are seeing more young women go into the field, which is delightful, which is great.

JONI: What about the subjects themselves? I’ve always had the impression that 90 percent of people who are engaged in plastic surgery are women; that women are the ones who really want plastic surgery, more than men.

HAIDEH: In fact, the numbers are exactly flipped – ten percent of plastic surgery patients are men, 90 percent are women. Whereas the providers are 90 percent men and ten percent women.

JONI: I wonder if there’s any other profession with statistics like that. That’s amazing.

HAIDEH: It’s really quite amazing. In our own practice, the numbers are a little higher for men. We have probably around 15 percent, and the numbers are increasing, which I find fascinating.

JONI: Well, that’s a whole other subject we should get to at some point. We’d love to know what the men are wanting versus what women are wanting.

HAIDEH: Right. Exactly.

JONI: As I said before, you specialize in eyelids, facial surgery – why that in particular? Is there a particular reason?

HAIDEH: You know, I’ve always been a very detail-oriented person and I just really, really enjoy details and I enjoy fine surgery. I found in eyelid surgery and in facial surgery that it’s really all about being meticulous and paying attention to those details; and it also allows me that artistic expression. The expression of aesthetics takes meaning in these kinds of procedures in my view. Also, I always conceptually found that the eyes are the centerpiece of the face. And they are where all changes in most people start. And to really focus on what’s happening in that area and how to treat it, or not treat it, is really where it’s all happening. So that was just, again, one of my loves from the very beginning within plastic surgery. And so when it came down to further sub-specializing, it was an obvious choice. I did train in cranial-facial and in oculoplastic surgery, which is eyelid surgery, and I do a lot of facial procedures – both surgical and non-surgical. A lot of my writing and teaching is focused on the eyes. However, I do other kinds of surgery as well. We do FDA trials for a new liposuction technology. I do quite a bit of breast surgery, especially revisions. I did train in cranial-facial and in osteoplastic, which is eyelid surgery, and I do a lot of facial procedures – both surgical and non-surgical – and I love it. It’s great.

JONI: Are there many advances? Have you seen, over the last 10, 15 years, complete changes in such surgery?

HAIDEH: Yes. This is one area where technology has just been moving very rapidly. As you remember, I think it may have all started with the explosion of Botox onto the scene as a nonsurgical alternative around a decade ago. It had been in use since the 1970s but really the cosmetic indications started then, and then it got FDA approved for it – and since then it’s been nonstop. It’s been new fillers; it’s been new laser technologies. Basically the technology and the demand and everything has moved at a very fast pace. But it also has been really prompted by our understanding. Our understanding of facial aging is in a completely different place; it has improved so much. In the old times we didn’t really understand, or we didn’t actually study it scientifically at all – what happens with aging? So if something looked good, if we pulled something and it seemed to look better, we just did that. This is the old time. And then around the same time we started looking at, well, what happens with aging? And we devised actual scientific studies to understand it. So that’s how that whole idea of volume came about.

We looked at patients – women, men – aging and saw that they were actually getting thinner in their face; that there was a uniformity into the aging process on certain levels. And so the tightening wasn’t the only prescription, it wasn’t enough. It was good; it was making them better. But sometimes it wasn’t what was needed. And then we started doing work with fat, because that’s the filler we had available back then, and looking at how volume fit into the equation. And that’s kind of how it evolved. And now we have so many fillers … we have so much more knowledge, and we’re still doing these longitudinal studies looking at aging, and we still don’t understand all aspects of aging – either clinical aging or molecular aging, as you know genetic aging. If we could crack that, my God, that would be just the most amazing part of this whole equation. And now we have all these technologies that address some of these issues that we’ve been able to understand. So, yes, again the short answer to your question is, absolutely. It’s just been fantastic. It’s been very exciting to be in this field at this particular juncture.

JONI: Well is it a cliché – do I have this wrong that there’s a moment where Restylane and Botox, all these fillers, can no longer help and you really do eventually go into some form of surgery? Or are we saying that surgery is really not necessary, finally? Or will eventually not be necessary?

HAIDEH: I can’t say that one day surgery will not be necessary. I doubt it. I think what the new technology has allowed us, it’s not about substituting surgery. It’s actually about allowing us to combine the right things for the right reasons to get the best results. So if the volume loss is an issue, just doing surgery doesn’t give you volume back. It can reposition, it can tighten, it can rejuvenate that way. But then you add the volume, before or after surgery, at an appropriate moment, and now you get the best results. So my philosophy is – we see this in practice – if you use Botox and fillers to an extreme to try to substitute for something that that can’t accomplish, but surgery can, it actually starts deforming the face.

JONI: OK.

HAIDEH: Whereas if you try to do too much surgery when the issue is something else – either too much muscle motion or lines that have to be filled, to be softened, or volume that has been lost that surgery can’t give back – then you just look like an older, tighter face as opposed to a fresher face.

JONI: I see.

HAIDEH: So the key is, how do we combine these modalities, be it surgical or nonsurgical, for the particular person to give them the best results? And that … again, for me it’s exciting because I don’t look at a person with their concerns and say, “Gosh, what surgery suits them?” I look at the whole gamut: “What is it that I can combine to address their concerns?” And sometimes it’s surgery, sometimes it is not surgery.

JONI: And what do you say to the people who say, “Let’s just stay natural”? Is this changing the values of the world, everyone has to look younger? What if one wants to just stay the way they are? Is there a philosophical response to that?

HAIDEH: I think there is. Honestly, this is such an important question. I’m so glad that this was on your mind. This is my own personal philosophy – there are different parts to this answer. One is that I’m totally respectful of those who do not believe in dabbling in the “course of nature,” and they just want to stay natural. I have total respect for that. And the reason for that is I really believe that everyone has to find their own definition of physical aging.

JONI: I found mine very early.

HAIDEH: They have to feel comfortable with it, and not do it because a friend did it, or because of this or that. For some people that may mean doing nothing. And for some other people it may mean that they want to look fresher. Now, I also have to say, I think to me it’s not about a person who is 60 years old looking like they’re 20, because I don’t think you can ever accomplish that in a realistic manner. And secondly, if you try to, it will just have a ridiculous outcome. So I think it’s more about not necessarily looking younger; it’s more about looking youthful or vital, or looking one’s best. Different people age differently. Some of us age more elegantly, we don’t have our neck hanging down to our chest. And some of us don’t. And so I really believe it’s a personal decision. I’m very respectful. I have friends who don’t believe in necessarily treating signs of aging; it doesn’t bother them. They’re very comfortable with the way they are, and I think it’s a personal decision. I happen not to be that way personally, and I don’t have any problems discussing that. But I really think it’s something that everybody has to come to terms with themselves individually.

JONI: Right.

HAIDEH: Now, I have to admit to you, I’ve also recommended to some people that they not do anything. There are certain individuals – and most of these individuals happen also to be individuals who age really beautifully, and maybe their brand or who they are or their public persona really depends on how they look and how they age naturally, or maybe the product they have or whatever their life is all about is about not doing anything to themselves. Now for those people it’s not even appropriate to do something, and it has come up a good several times in my practice with certain people and I’ve said, “No, I don’t think you should do anything, you know, even though we could improve it physically, but you won’t be better off for having done it. And that’s the key point, and I think if we’re going to take one thing away from this philosophically, it’s not necessarily about just looking better, it’s about feeling better. We want to look better because it makes us feel better. And so that’s why I’m very, very adamant about the fact that every individual has to find his or her own definition of aging that they feel comfortable with.

JONI: That’s a fabulous answer to that question. Let me get direct and say – I’ve already answered the question – I am totally unhappy with aging. And I have had, just as an example, I think it’s called Restylane, in that area between the nose and the mouth.

HAIDEH: Sure. The nasolabial fold.

JONI: Right, which made a huge difference and everybody thinks I’m just as young as can be because of that, and I go something like every six months and get those fillers injected. I went to this fabulous doctor, and now am addicted to this procedure.  Do most patients ask, “What would you do?” Or do you ask what is bothering them? Do you ever venture into, “You really should fix that”? What advice do you have for a person such as me who would do almost anything to look great.

HAIDEH: I always ask what the concern is before I actually examine the patient or voice my opinion.

JONI: Just in case they don’t know they look terrible?

HAIDEH: Well, no. Not at all, because I think we all view ourselves differently.

JONI: OK.

HAIDEH: And it’s very important for me, as a plastic surgeon, as a specialist in aesthetics, if you will, to find out how my patient views himself or herself. What is of issue to them? Remember, we have so much now that we can offer. We can literally address every little sign of aging on the face – not that we should, but we have things we can do to it. So to start a conversation it is important to find out what is on the mind of the person: What do they see in the mirror? What is bothering them? And beyond that, what is their motivation? Who is this person? What do they do in life? Where are they trying to get to? What is their goal – the bigger picture goal? I think once you start a conversation from the physical to the psychological, then you get a good picture of what is motivating the person. And then I will come back and make suggestions. Now, if it’s something that a person hasn’t mentioned but is somewhat relevant or has bearing to the issue, I’m going to raise it. But if it’s something completely irrelevant it’s probably not necessary to raise it, certainly not right away, and you want to address what is at hand. And that’s been my philosophy.

JONI: OK.

HAIDEH: I’ll give you an example. I see a lot of people who are very focused on that nasolabial fold – and it is an issue, it’s very rejuvenating when you fill it. But oftentimes, one of the reasons that fold gets very heavy after the initial stage, if you will, is because some other part of the face above it – the cheek, the mid-face – is actually flattening and falling and deflating. Now if I just keep putting filler into the fold and never mention anything about the other part, which is really causing the problem, I’m doing my patient a disservice. So in that case I would say, “You know, we should really think about the proportions of your face and I want you to pay attention to this area above the fold; that’s what’s causing the fold.” Sometimes it actually takes a conversation and education, and really looking at their photos from when they were younger and really simulating the results, to understand that something they don’t see at all is actually causing the issue.

JONI: I see.

HAIDEH: If it’s relevant I think it’s worth bringing up. And, to be honest, some people just do come and say, “You know what? I’m not the kind of person who looks in the mirror, focuses on myself. I just have noticed I’m tired, a busy person. You look at me, tell me what you think is going on, what I should do, and then I’ll decide.”

JONI: Right.

HAIDEH: And if they give me those parameters I will also follow their instructions. And I will do that. So everybody is different. And part of the fun of doing this is figuring out the person, because it’s a relationship. It’s a journey; you sort of go on this journey with the person.

JONI: What do you find are the biggest mistakes your patients make? What are their misconceptions?

HAIDEH: I’ve come to the conclusion that the biggest mistake people make, in general, all of us – probably myself included – is that we think if a little is good, a lot is better.

JONI: Ah.

HAIDEH: And that has just been a recurrent theme that has caught my attention. More than once I have seen that something is just softened, and it looks great, looks completely natural; it is invisible, fantastic and maybe it’s not perfectly correct, but maybe it shouldn’t be perfectly corrected for it to be natural. It’s not true that if a little bit, or some, is great, then more is even greater. It’s just not true.

JONI: That is so interesting. That’s why we get those big, fat lips on so many women walking down the street. Don’t they know?

HAIDEH: Maybe – it’s the biggest mystery, right?

JONI: Is surgery always detectable? When somebody comes into your office, can a trained surgeon such as yourself tell? Is it always detectable that someone’s had fillers, or somebody’s had Botox, or somebody’s had surgery, to the trained eye?

HAIDEH: No! A trained eye is, of course, better equipped to pick up on work. So I definitely will notice subtle things, subtle signs, things that will tell me that something has been done – probably much more than a person who’s not in this field. So that’s definitely true. That having been said, good plastic surgery, a well-done aesthetic procedure, should be invisible. So once you can tell that something has been done that game has been lost. Now, on a technical level, surgery always leaves a scar of some sort. It could be a minimal scar – if I look, if there’s been a face-lift or an eye-lift, there’s always a scar. It may have healed very well, it may have been endoscopic so it’s tiny; but if surgery was done there’s always a scar. For the newer procedures, for the nonsurgical options, of course there is no scar, and sometimes it is invisible. If, for example, some volume restoration is done, and it’s done beautifully, keeping the proportions in place and really doing it appropriate to the person’s age and the stage – no. Sometimes even the most trained eye is not going to necessarily pick it up.

JONI: This is encouraging, but this brings up the problem that my girlfriends and the wOw women often talk about, which is how we do this without telling our husbands. I know getting just a filler doesn’t sound like it takes a lot of time, but having an eye-lift or a face-lift takes many weeks. How long do these procedures take if you want to keep them secret?

HAIDEH: It really depends on the procedure. Let’s talk about small surgical procedures you can get over, in about a week. Having a bigger procedure like a face-lift will require a ten-day to two-week time period to recover. It’s best to discuss it with the physician and then come up with a plan, based on individual lifestyles and circumstances. The nonsurgical procedures can also have bruising and swelling. Generally you don’t need to take time off, and you can cover it up. But, especially the first time something is done, it’s wise to be cognizant of possible swelling and bruising. I always think of Alex Kuczynski’s book, Beauty Junkies, and the time when she gets these injections for the first time in her lip and she’s supposed to go give a talk at someone’s funeral service and she can’t go because her lip is blown up.

It was a sad, funny part of this book and I just thought, “Wow.” You never want to do something for the first time before a big event, even if it’s not surgery, because there’s some minimal downtime. So I want to say there’s no one answer to that. It really depends on what is being done.

JONI: I would imagine a lot of this depends on the skill of a doctor. Are there any caveats of knowing you have a good doctor? Recommendations are the best thing, I suppose. But is there anything about which to be careful?

HAIDEH: It’s important to check the physician’s credentials in general – that the person is well credentialed. In my field, of course, No. 1 is being board certified by the American Board of Plastic Surgeons; being a member of the American Society of Plastic Surgeons; being a member of the American Society of Aesthetic Plastic Surgeons. These organizations are national, they have really rigorous criteria and, of course, board certification in a real board specialty is very important. Beyond that is how the referral comes to you, which is what you mentioned. Is it your physician who referred you? Is it word of mouth? Is it something that’s reliable? And is this the right person for you? If your doctor does not listen to you and you are concerned, then that may not be the best match. You have to be cognizant when meeting an aesthetic specialist, a plastic surgeon. Is the doctor listening to your concerns and really addressing them? And is there a match between your aesthetic goals and your sense and their approach?

JONI: How expensive are these procedures? I know they must vary, but getting Restylane, getting Botox, that kind of thing – are they wildly expensive? Is there a big range in cost here?

HAIDEH: It depends. Even when you talk about something like Botox, it depends on what areas you’re treating. So there’s just no one number. There’s also a huge variation depending on where you’re located. And even if you use the same material, filler, it depends because no two people are alike. So one person might only need a certain amount of treatment and their friend may need three times as much to get them to the same baseline. I think it’s best to discuss that at the time of consultation and plan from there. It’s best to have a consultation before you plan.

JONI: You can’t really know whether one patient absorbs all of it in a month, or maybe it lasts must longer. That can’t be predetermined, right?

HAIDEH: It can’t, but it depends on the kind of material as well. If you’re talking about the nonsurgical stuff, there is some ability to predict – we can have many discussions in the future that are more focused on different categories and fillers and treatments. But the newer fillers in general can last six months to nine months or even a year. If you have done a layering procedure they can last more than a year. One thing I can address is that there is a misconception with some who think that some of these nonsurgical treatments you have to do all the time – and that’s actually not true. And by the same token, the results of surgery don’t last forever either. So that myth we can do away with. Some of these fillers turn on your body’s mechanism to produce collagen. Some of the results last a very long time.

I saw a patient of mine today who I had seen over four years ago, and we had treated her in an area around her eye, around the tear trough. And this person still had most of the effect, and we, both of us, were just astonished. I said, “Oh, my God, you still don’t need any more in that area.” This is actually unusual. Usually it’s about a year, maybe two. But not four and a half years.

JONI: Oh, it’s that long? Oh, my.

HAIDEH: It was that long, and the effects of it, or whatever new collagen synthesis had happened in that particular area, which doesn’t move very much was still there. I meet those who say, “You know, I just don’t want any of this new stuff because I’m not into maintenance. I just want to do one thing and to be done with it because I don’t want to be in here every other month.” Well that’s not the case, necessarily. If it’s done right and if you take well to it, it can be a year, maybe longer,

JONI: Really? It’s fascinating. Well, this is fascinating and there are about 100 other questions I plan to ask you next time. You have such an interesting and personal way of looking at this. It becomes sensible for the first time. So no further questions except: When can I have an appointment? But we will follow up and on our website we’re going to ask our audience for their own questions – so there’ll be plenty more to come. And I so enjoyed this conversation. I really appreciate it.

HAIDEH: Absolutely. It’s been my pleasure.

Editor’s Note: Dr. Haideh Hirmand is a noted plastic surgeon, academic and thought leader in the aesthetic and beauty arenas. She completed her Doctorate in Medicine at Harvard and is Clinical Assistant Professor of surgery at the The New York Hospital/Cornell-Weill Medical Center. She specializes in eyelid and facial rejuvenation, secondary breast surgery, body contouring and is recognized nationally as a pioneer in injection techniques.

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