Dr. Leon Goldstein is the founder of Coastal Plastic Surgery Center. He performs procedures including breast augmentation, liposuction, facelift, eyelid surgery and nonsurgical cosmetic treatments from offices in Madison, Connecticut, and Providence, Rhode Island. Dr. Goldstein graduated in 1978 from Albany Medical College at Union University. He attained certification by the American Board of Plastic Surgery in 1987.

How did you get into plastic surgery?

When you go through medical school and then you go through seven years of residency, a total of eleven years before you are finally practicing, you go through a lot of different possible changes. You think that you are going to be doing this or that. I started off thinking I would be in internal medicine, then I thought about being in cardiac surgery, and then over time I realized I really like the complexity and the uniqueness of plastic surgery. By that I mean that it’s not stylized in the way that general surgery is, or even cardiac surgery. [In] those types of surgeries you have to have everything the same way so that things go as smoothly as possible and much of the anatomy doesn’t change much. I was lucky enough to go in and experience what plastic surgeons do and that’s what I really liked. Plastic surgery is not stylized, it is absolutely different for each patient. You are presented with problems particularly of the reconstructive type or even cosmetic type that are unique to that individual. You really bring in all the expertise and all the different disciplines of surgery that you’ve been trained in. You really need to put together a plan for that individual that is different from the previous one.

A lot of people don’t understand what the term plastic means. It comes from the greek word plastikos, which means to form, to change, and that’s exactly what plastic surgeons do. They change, they form, they recreate limbs and other anatomical parts for people who have had trauma– that’s reconstructive surgery. They also take people and improve on what is normal and that would be considered cosmetic. All that entails the change from one state to another.

Would you say there is an element of creativity you have to bring to each patient?

Absolutely. You have to have some sort of plan and even with that plan, whatever the objective may be, in the middle of the procedure, there may have to be some changes. A lot of it is flying by the seat of your pants. Obviously you are not uninformed, you are not naive, you have expertise that you can use. It just means that all of a sudden, I have to do this as opposed to that. It’s unnerving for a lot of people. A lot of physicians don’t like that. A lot of nurses don’t like that. They know that they’re going to be in and out of the room a thousand times getting things that they never thought they needed to get. They like things to be the same. Nurses in the OR always have cards on their surgeons and cards on some specific procedure that they do. They go crazy when all of a sudden, [something is] not on your card, but it’s a different patient and a different problem. I like that.

How long is the process between someone coming into your office and saying that they want a procedure done to the actual operation?

I want to make sure that the person understands what they are getting themselves into, understands the procedure, the possible options, and understands what the postoperative course is going to be like or can be, and whether they are willing to go through that to get where they want to be. The other aspect is that they have to be physically prepared for it: their hemodynamic status is O.K., they are not taking tons of aspirin, vitamin E, any herbal medicines which will cause bleeding, or they are not taking some strange fat loss product that can interfere with anesthesia. Then you can go ahead and proceed. Usually the time between consultation and surgery can be anywhere from four to six weeks or even longer. I usually see people at least twice to make sure we are both on the same page.

What are some trends in plastic surgery right now?

[Sigh] That was a deep sigh because the trends do change. I have been around long enough to see a bunch of different trends come and go. Some last a decade and others last six months to a year. The trend has been “non-invasive” aesthetic procedures when we are talking about cosmetic. People want minimally invasive procedures, non-invasive procedures, which is fine. The problem there, which I think is a fad that I think will fade in a short period of time, to use a well known phrase– you can’t make an omelette without breaking an egg. There is a limit to what you can do without surgery. They are not equal- injecting fillers into the face to plump it out and make it more youthful is not the same as performing a face lift. They don’t give you the same results. They don’t give you the same lasting results, either. There is an element where someone could use both. A lot of people like to equate the non-invasive procedures such as botox, fillers, attempts made to reduce fat with machines that tend to freeze the fat from the outside. You have to be a little sceptical about that stuff, as to how well it works. Even if it does work, and I am skeptical as to whether or not some of them do, you have to quantify it. You don’t know to what degree have you been successful in doing that. For instance, you can tighten skin with certain IPLs (intense pulse light treatments) that heat up the skin, and tighten the skin to some degree. Is that tightness the same as a necklift? Of course not, but people do tend to think that one is as good as the other. It’s not, so they do get some improvement, but they are going to be invariably disappointed and they wind up doing what they should have done the first time. That’s not to say that these modalities don’t have a place. For instance, laser resurfacing started out with carbon dioxide lasers and now we are using erbium YAG lasers that smooth out the skin, improve the texture of the skin. Ten year old kids have bright, shining faces not because they wash them, but because their skin is smooth. Light bounces off their skin. As we get older, our skin gets a little bit more cracked and light comes in and doesn’t get out.

What laser resurfacing does is it smoothes the skin and gives us the texture we had when we were younger. Your skin goes from the smoothness of an apple to the coarseness of an orange and so the laser gets back the skin that we had to a large degree. Laser resurfacing, done appropriately, which usually takes more than one treatment, can take about ten years off someone’s face. I can’t improve the texture of someone’s face with my surgery. I can put things back where they were if they dropped, where they anatomically should be, but the actual surface of a skin, like a road, ages, but I don’t have the technique to improve that except for chemical peels or lasers.

I don’t like chemical peels because they’re not specific enough. It depends on the concentration of the chemical you are using, how long you apply it, and how you apply it to the skin. It usually causes a lot of skin color loss, and it’s not permanent, but a lot of people still like the spas and the chemical peels. The laser is much more specific because you can dial it down to how deep you want to go. If people only have one or two days of down time, we don’t go very deep, we can repeat that treatment four weeks later, and eventually get to the point where the patient wants to be without too much downtime. That’s one of the big trends now–having minimally noninvasive procedures as opposed to surgery. How’s that for an answer?

It’s wonderful!

Another thing that is really important. There is this gut reaction that people have when you mention surgery, right? “Oh my god, not surgery.” In reality, surgery causes a lot less physical trauma to a body than a pill. You take a pill and it goes to every system in your body and even affects every system in your body. Even aspirin can cause problems, as you can imagine. When I take a knife and make a cut on your arm or some place, the only area that is injured is that cut on your arm, and each cell on either side of the cut has not been touched. There is much less injury with surgery. People feel that popping pills is safer and not a problem, when indeed, they can cause a lot more damage than you can with surgery.

Why do you think we have this stigma that surgery is so much more dangerous?

I think it stems back to prehistoric times, just the idea that your skin is cut. You see blood and you equate it to one of the most horrible things that could happen to you. Obviously it depends how deep the trauma is. There is a visible, visceral experience when it comes to surgery. Whereas with popping a pill, it is a black box. You have no idea where it goes and what it does. [If it is] not seen, [it is] not a concern.

Who is dictating the trends in surgery?

I think a trend coming up in reconstructive surgery is replanting not just fingers but hands and arms. We are doing facial transplants for people who have been horribly mangled, taking donor faces and transplanting them and having them work and mimic almost normal activity. In cosmetic, gosh, it’s hard to tell. A lot of the trends are someone coming up with a new wheel. It’s reinventing the wheel. It’s the same stuff proposed in a different container packed differently. The important word, and I think that’s when the media takes over, is new. People like to hear that there is a new way of tightening skin, a new way of making my eyes look younger, so automatically new means better. That’s not necessarily the case, but we jump on that stuff right away. It is difficult to predict in the aesthetic arena, but at the same time, there aren’t too many things that can be done at the present time.

The best way to fix issues with aging and gravity is with surgery, and I think that there will be a return to surgery when people get disappointed or tired of having semi-adequate results. The other aspect is that we will get back to procedures that actually work– neuromuscular blockers like botox and xiemen do really work. Those two neuromuscular blockers, for instance, when used appropriately on a forehead have eliminated a forehead lift. If they are used on a regular basis, over time, the effects will seem to last longer and longer, so I think that’s a big advancement. Also, laser resurfacing is a big advancement because not only does it smooth out the skin by improving the texture, it takes care of some of the melasma, the uneven skin color that people have, gives them a much more even tone, helps with acne, and rosacea. Those are things that are going to be applied more and more, but people have to come to the realization that there has to be some downtime. There’s going to be some discomfort and there’s going to be some downtime. If neither one exists, then nothing was done to your body. That’s us. We are an organic entity. In order to affect the change, there is going to be some sort of a reaction to it. You can’t avoid that. You can’t saw the legs down on a chair without causing some sort of bust if you want to change the height of the chair. The same goes for the body. The organic, biological reaction is inflammation and then healing. But Facebook, social media, and websites trump science because people want to hear that there is magic.

I watched a few videos from your web series.

Oh, jeez.

They are great! It’s evident that you care a lot about the well-being your patients. You mentioned in one of your videos that being a doctor is one of the few professions where a personal relationship is so important with the patient. How can doctors excel at giving patient care?

You have to know your particular area and consider yourself an expert. You have to be comfortable and comfortable enough to say, “I don’t know, I’ll find out,” or “I don’t know, this isn’t my area, but I’ll find someone whose area that it is.” They appreciate that and [it] makes them feel like, “my, he is telling the truth.” This isn’t something you can pass off to some other machine. You have to do it yourself, and that is what people really want.

You don’t stare at the computer the whole time. You look at your patient, you look at the situation, you are there, involved. I don’t have a nurse that takes out my sutures. I could, but I’d rather do it myself, because it gives me a little bit of extra time with the person to find out how they are really doing, what concerns they have, and that gives them an opportunity to ask me questions they probably wouldn’t ask otherwise. If they have any concerns about what we did or something else, that really gives a chance for them to communicate, and that is the important thing. You have to be able to communicate with your patients. People shouldn’t be afraid to be with people. Future physicians need to take a look at themselves and really evaluate what they are comfortable with. As long as you do what you are comfortable with, I think you will be ok, as long as you are happy with what you are doing. If you wake up in the morning feeling good about doing something you like, I think that’s what’s important. I know it sounds like a cliche, but I think it’s true.

You touch on body dysmorphic disorder (BDD). How can doctors or patients know if the changes they are looking to make stem from BDD?

In reality, I think BDD is actually a spectrum. I believe that yes, even people who are completely sane and normal can be looking for a change in how they look. Someone may say, “why are you doing that? Aren’t you happy with who you are?” There is a small element of your body believing there is a perspective that people are missing. You have to be honest with yourself and you have to figure out, “O.K., I don’t like my nose, here’s what I can do, and then you have to decide whether or not that’s going to be acceptable. If someone says, “I can make your nose look smaller, but it will be yours, not to the scale of a small Scandinavian boy,” and then you don’t understand that and you are not happy with the result, that’s an indication of BDD. You don’t understand that there is a limit to what can be done and that it’s not going to be perfection.

Often times patients may transfer other more serious issues of life over to their physical appearance. My interviews are at least half an hour. You can tell a lot about a person based on how they perceive their problem. How much they perseverate on that. It’s also easier to see when you are the third person they are coming to after they have had two other procedures with different doctors. That shows red flags into the situation. It’s very difficult. Once you have decided this person has serious problems, another operation is not going to help. Then you have to diplomatically say that you don’t think you can help them with what they are looking for. You have to be able to say that.

When you are dealing with cosmetic surgery, it can be a controversial topic, especially as people try to embrace body positivity. What would you say to people who doubt or reject these procedures?

I’ll start off by saying almost everyone likes ice cream, right? Not everybody. Some people don’t, and that’s O.K. There will be differences in [opinion in] everything you can think of. It’s not for everyone. A lot of people who are vehemently against it have some other issues, I think. There are people who would like to get it done but are too afraid to even come into my office to just talk about it. I give complimentary consultations. I don’t charge for it. Why? Because I feel that the more patients acquire knowledge, the better patients they become in the future. I’m helping people by letting them come in and talk about whatever concern they have. They’re learning, and then they can make a better judgement as to whether or not this is the right choice for them. For every person that comes into my office, there are ten people who don’t feel secure enough to come in and talk about this issue, even though they would like to have this done. They can’t wait to see their friend who got something done, and they are especially gleeful and happy when, and this happens rarely, their friend didn’t like how their procedure turned out because this confirms [their] feelings on this particular procedure. Some people, deep down inside, are afraid to come talk to me, so they are excited to hear that news. For the most part, there is always some sort of a personal reaction that people have to surgery because it raises the question of aging, not looking as good as you used to. You either put up a defensive posture or you don’t. Some people want to age gracefully. Gracefully can mean different things to different people.

Something I learned on your video series was that according to the FDA, women under the age of 22 are not allowed to get gel implants.

There is no medical reason for that. I can’t imagine how archaic the thinking is behind that, but that’s exactly what it is.

Are other forms of implants allowed?

Women can have saline implants. Probably if a young person was missing a breast or had a mastectomy done, I’m sure the FDA would be O.K with that done because they look more natural and feel more natural, but God forbid a reasonable, intelligent person who can have children, serve in the armed forces, vote, could get silicone implants.

Are there any other restrictions?

Age is always the restriction. People under the age of eighteen need to have a reason for why they need implants put in and they have to have permission from whoever is their guardian. I guess there is such a thing as being too young and not old enough to undergo certain procedures. This gets a little bit more complex due to the medical and legal climate we have in this country, which doesn’t really exist anywhere else. For instance, I can put silicon implants into a woman under the age of twenty two. They would have to sign a form that says they understand the FDA considers these “off the shelf,” meaning they are not the way they are supposed to be used according to the FDA. The problem is that the implant manufacturer who guarantees these implants in most cases will not guarantee implants for women under twenty two because that makes them complicit with what I want to do and against what the FDA ruling is. So they will not guarantee implants for women under the age of twenty two because they are afraid that somewhere down the line there is going to be a law suit. We put ourselves in these crazy binds.

Accessibility and protection of patient information seems to be a new battle for doctors. How have you approached this?

I am not a fan. First of all, HIPPA (Health Insurance Portability and Accountability Act) was designed to protect patient confidentiality, medical history, etc, or make sure that doctors, hospitals, nurses don’t tattle-tale on their patients. Why would I want to do that? That’s part of having the doctor-patient relationship– the confidentiality. The trust is stronger than the one that lawyers have for the clients. This HIPPA ruling is meant to control people who are already controlled, so that is one thing. Two– it actually inhibits the act of giving medical information from one doctor to another. You are limited now because the patient has to give their consent, and that can be a problem when there is an emergency going on. I had a personal experience with this, where my twenty five year old daughter was seizing, and I knew that she had a CT scan at the hospital. I called the hospital and told them who I was and who my daughter was, wondering if anything was able to be seen on the CT scan and have it sent over to the ER, where I was going to take my daughter and the first question they asked me was, “how old is your daughter, twenty five? Then we can’t give you that information.” The privacy is going out the window when we are putting information into computers. It’s overrun by political correctness without any thought as to whether or not it makes a real difference. I have paper records. I have a file cabinet that I keep my charts in. If someone wants to get in, they have to go through a lot of effort to look up your chart, my chart.

You don’t have any information on the computers?

I do use the computer purely for the patient’s name, address, and phone numbers, and also to coordinate office visits. I do limit it to that information and nothing else. The practical side of me says still that my patient’s records are safer, still, kept in a locked file cabinet than on the internet. Maybe in the future it will be different. I think the use of computers in medicine will find its place, and there will still be a need for written records.

If the system goes down, and they are paperless, there is nothing you can do. I think computers are great for analyzing data, transferring data, correlating data. Nothing better. But when working with patients, it slows things down. You are either going to be working with the computer, or physically taking care of the patient. One of the two, and you can take care of the computer later, but now everything needs to be done at the same time.

What encouraged you to break the wall of the doctor’s office and start a video series?

Because that’s the only thing that people listen to [laughs]. I wanted to get my two cents in. I update it on a regular basis, I like blogs. At least once a month I try to do a post on a topic that would give people more information. Youtube is a way of getting across to people who are more visual. I don’t want you to think that I don’t like computers, I just think they are sometimes not used appropriately when it comes to something as intimate as medical care.

With the power of search engines, people can look their symptoms up and self diagnose. Obviously with plastic surgery you need that doctor-patient relationship. Do you see other areas of medicine being dismissed when it comes to diagnosis and care?

That’s an important aspect of it. I think an intelligent person can go online and decipher his or her condition. I think nevertheless, these people still need to go and see someone who has the experience and knowledge. The problem is, a little bit of knowledge is dangerous. A little bit of knowledge gives you a very small perspective. A doctor with a lot of information can give you a better perspective on your situation. I think that doctors will not be replaced by webMD. In my specialty that becomes even more obvious in the sense that they read up on the topics, but I always ask, “where did you get your information? You had a friend who had this surgery. Did you talk to him or her? Did they show you what the results looked like?” If they say yes to all of that, they are at a different knowledge level than someone else who just read a few things on this or that website and I spend half of my time with them trying to correct their views or understanding of certain aspects of the procedure that they obtained just from the internet. Many times you have to give them a different view from what they read on the internet. It has nothing to do with getting them to do the surgery. I am not here to sell my wares to anybody. If someone wants to come in and talk about facelifts I will tell them what they need to know about facelifts. The actual decision is theirs, obviously. I don’t try to seduce them in any way. The seduction is just knowledge. The more they have, the better decision they can make.