The Moment of Truth - 3



I have repeated ad nauseum to my students the following advice: "Alright, you are able to do a certain operation; your hands are itching to add on more operation to your list; the patient, besides, wants to have the operation done, especially if it is cosmetic surgery, the patient is perfectly happy to spend money on the operation, but these, gentlemen, ARE NOT indications for operation. The real indication for a surgical procedure is that in the judgement of the surgeon, the operation is worthwhile and the patient understands the benefits and the shortcomings of what is recommended." If the shortcomings of the operation are not stated clearly, then the patient will harbour false hopes leading to later unhappiness. The patient has every right to say no and to seek another opinion. Who knows, another surgeon may be able to lead the patient to the mirage he is seeking! The following story may be of some interest to readers.

I had refused to do reduction mammaplasty in the early days of my practice. This would have been my first case in private practice. A young female patient came with a young man for consultation. She said she would like to have her breast size reduced. It is my usual practice to inquire exactly what it is that the patient wants—and why. The usual answer is that the breasts are too heavy, too uncomfortable, bra straps cut into the shoulders, skin in the groove below the breast often gets sore, walking, running or even bending are ungainly etc. This young lady said she wanted her breasts reduced because her fiancé (pointing to the young man) felt that they were too big. She herself did not think so. Her mother and sister had similar builds.

I examined her. She was a healthy person with rather large breasts. I pointed out to both the lady and her fiancé that they can be reduced in size and given a better shape. The method I use leaves the areolae and nipples with their natural sensation. Even though the milk-producing potential of the heavy breasts is low, she could still suckle her children. I made it clear that this was not a small operation; blood transfusion may be required. Hospitalisation for a week to ten days would be necessary. The operation would leave quite a long scar. However, if she so wished, a garment with a plunging neckline or a bikini may be worn without revealing the scar. I told the lady: "All this information is to help you to decide. I do not want you to decide in favour of an operation in haste. As matters stand today, I will not do the operation.” My statement appeared to have shocked her. I continued: "It seems that you do not want the operation. I would not subject you to it, unless you yourself want it. Reflect on the information given, then, if you still want it, come back with the following investigations.” And I listed them.

A week passed; then another, but there was no further news from the lady. One part of my mind said: "You muffed it! Your first reduction mammaplasty in private practice, and you bungled it!". Another part of my mind said: "To say 'no' was correct. Possibly she did not really want the operation. Moreover, she is a Christian, her fiancé is a Punjabi Hindu. If things do not go well for them in future, she would regret for the rest of her life what, in her opinion, was an unnecessary operation. She had not by even one word, expressed her wish to have the reduction"

She did re-appear almost three weeks after the first consultation said I had made her do a lot of soul-searching. Now she knew that she wanted the operation: "It was shyness that stopped me from saying that I want the operation. I realise now that my fiance asks me to do this or that I though I do not do all that he asks me to do”. She had a successful mammaplasty. Later they were married and lived for about in Germany before shifting to Canada. Their Christmas cards told all was well with them, for about 5 years after the operation.


The opposite procedure, to increase the size of the breasts with a prosthesis, is unfortunately very prevalent. It is a simpler operation of a much smaller magnitude and leaves behind a very short scar. It is a purely cosmetic operation. Lay people regard any operation on the breast by a plastic surgeon as a cosmetic procedure. Then the patient has difficulty in getting the claims for medical expense settled. This happened to a patient of mine who had massive, nay, gigantic breasts. She used to wear a 'tailormade' bra which was a marvel of British ingenuity (acquired at a recurring high cost). By doing a well-deserved reduction mammaplasty I had removed a little over 2.5 kg., leaving behind well-proportioned breasts. She was thrilled with the result but even more thrilled to tell me of her happiest moment-"to enter a shop to buy a bra off the shelf like any other normal person". Suddenly there was a change in her voice. This patient, who was getting on in years and was still unmarried, said: "I wish I had got it done years ago". The intonation said it all: the shame, the agony and the physical discomfort suffered over a number of years. Her claim for expenses was refused by her company as they did not reimburse cosmetic operations. I wrote to the company on my patient's behalf. I brought the following points to their attention.


*             In all the years she worked with your firm she made not a single claim for medical expenses.

*             It is true that some of the cosmetic surgical operations could be described as frivolous, non-essential procedures intended to boost misplaced vanity. This operation is not in that class. It need not be considered a cosmetic operation just because I have improved the patient's shape.

*             Please remember I have removed her disability and her deformity which cried out for surgical relief. If I had removed a mass even one tenth in weight from anywhere else, you would have paid her medical expenses.

They did!

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar