Medical Pioneers

10/12/2002

BY G. WAYNE MILLER
Journal Staff Writer

See a slideshow of Barbara Gummere's surgery

PROVIDENCE -- Barbara Gummere lay asleep on her back, the entire right side of her face dissected away from her skull. Peering into the incision, one could see clear to her neck. Bloody sponges accumulated in a steel bucket. Some three hours into this seven-and-a-quarter-hour operation, it seemed impossible that beauty could emerge from such an unsavory scene.

With a forceps, Dr. Patrick K. Sullivan, Brown Medical School professor and a leading practitioner of this type of extensive face-lift, examined a layer of tissue that he had exposed inside the incision. Comprised of muscle and fat, and sandwiched between the bone and the skin, the tissue helps cast the shape of the mid and lower face. And like other soft structures of the head, it sags with age. Gravity is indomitable.

Sullivan began cutting with an electric cautery, an instrument the size of a pencil; the tissue, yellow in color and the consistency of cottage cheese, sizzled. Sullivan proceeded deliberately, aware of the extraordinary power of his gloved hands. Face is identity.

"It's not like buying a car: when you get a lemon, you can take it back," Sullivan later said. "You only have one face and really only one chance."

Sullivan had taped preoperative photographs of Gummere to the wall behind him in this operating room in a building next to Rhode Island Hospital. They revealed an attractive, fit, tanned, blonde woman of 55 who has spent much of her life outdoors. Crow's feet extended from the corners of Gummere's eyes. The frown lines between her eyebrows ran deep. Her forehead was uniformly wrinkled. Her cheeks were beginning to hollow. Her neck was ringed with creases, and her lips, the upper one especially, had started to deflate. Sun and age are a potent affront to Caucasian skin.

Journal photo / Connie Grosch Barbara Gummere, 55, is having the facial rejuvenation surgery to eliminate the damage that came from years of sun exposure.

"As nice as you look and vivacious as you are," she later remarked, "you still look like you've got somebody else's head on."

Sullivan had started the operation shortly after 8 a.m. on this July 8, when, working with an endoscope, he had reduced the deep frown lines between Gummere's eyebrows. Now he continued fashioning the flap of tissue inside the right side of her face. He lifted it this way and that, folded it, trimmed it and trimmed it again, all the while watching how his adjustments smoothed wrinkles and changed the shape of the right side of her face from nose to jaw. This was not the face-lift of old, when the skin was sliced and tightened and that was about it. This was a "facial-rejuvenation," first successfully accomplished a quarter of a century ago and now the gold standard of the field.

Sullivan was guided by the purple markings he'd drawn on Gummere's face before she was put under -- and by the vision he'd formed in his head of how she would look when the stitches had been removed, the bruising had disappeared, and the swelling had receded.

Much of surgery is inclined toward the scientific: a new heart valve must be sewn in exactly where the old one was, a replacement knee must be attached precisely in order to properly reconnect thigh to lower leg. But plastic surgery leaves much to the doctor's imagination. Sullivan, who draws inspiration from the scuplture he studied in France, considers himself partly an artist, working in a medium of living human cells. When he evaluates a patient, he sees beyond altering the image of advancing age.

"For some (patients)," he said, "it's not just the vision of looking like they used to -- some of them want to look better."

But a younger appearance remains the chief attraction bringing patients like Gummere to doctors like Sullivan. According to the American Society of Plastic Surgeons, almost 70,000 people underwent face-lifts last year -- an increase of 74 percent in less than a decade. Other procedures, notably Botox injections, showed more dramatic increases. The baby boom rolls on.

America is a society obsessed with age. Until the promise of stem cell therapies, genetic engineering and the like is realized, the closest aging mortals will get to the Fountain of Youth -- at least facially -- remains in what the plastic surgeon can accomplish.

A DIVORCED MOTHER of two grown children who is financially independent, Gummere moved in 1994 to a distant state from Massachusetts, where she had been a tennis pro at several country clubs and the coach of the Boston University women's tennis team. Her life-long love of sports had kept her body youthful, but she had not uniformly benefitted from being an athlete. She could still wear a bikini, but when she beheld her face in the mirror, she saw an aging woman -- unquestionably attractive, just not the person she envisioned herself to be.

Time brought neither improvement nor acceptance. And Gummere did not want to follow the road that some of her contemporaries were traveling.

"There are many, many women I know," she said, "who are happy to move into matriarchy -- to be the matriarch of the family and to age gracefully or however they feel about it. And they let their hair go gray, and they start wearing Dr. Scholl's shoes, and they gather the grandchildren around their skirts. I wasn't ready to do that." She wanted to date, but not the 70-year-olds who were most attracted to her. They were all nice gentlemen and some were exceedingly well off, but Gummere believes that life should hold more excitement than an afternoon on some grandpa's yacht.

She decided that the bags under her eyes needed immediate attention. An out-of-state surgeon operated on them five years ago, but he left scars. The same surgeon also attempted to restore her breasts to the way they looked before she became a mother, but the result was painful and unshapely. Another doctor rectified that mistake shortly thereafter, but the experience left Gummere leery of further appointments with the knife.

Gummere was touring Africa three years ago when she met a woman who was 58 but looked younger. The woman had visited Sullivan's operating room, but Gummere would never have guessed she'd been lifted if the woman hadn't revealed her secret: her surgery had created what she considered a "natural" look, a high compliment to any plastic surgeon. Moreover, the woman had friends who were also patients of Sullivan and their lifts had succeeded, too.

Word-of-mouth advertising is unusually decisive with cosmetic surgery, and last year Gummere scheduled an appointment with Sullivan.

CLASSICAL MUSIC fills the waiting room of Suite 502 at the Bayside Medical Center, near Women & InfantsHospital. The magazines are all current (not a single dog-earred issue to be found), and they include Vanity Fair, Vogue, GQ, and Allure, in which Sullivan's recent study of 123 sets of ears was featured in an article entitled "Taking Years Off Ears." A scrapbook of letters from satisfied patients may be perused, and patients are welcome to any of the pamphlets describing the numerous cosmetic products and treatments that Sullivan and the seven members of his staff offer; further edification, including pre- and post-op photos, is available at www.drsullivan.com . Smoking, of course, is not allowed: like sun, it is a dire enemy of skin.

But patients may wish to avoid Sullivan's waiting room, where strangers -- or, maybe worse, acquaintances -- could lurk. So Sullivan provides a private rear entrance, marked only by a small button. On the day of her appointment last year, Gummere rang the bell and was discreetly admitted.

She was shown to the consultation room, a bright corner space with a view of the Providence skyline. The couch and two chairs are comfortable in this room, and the armoire features a full-length mirror, should one require a last-minute primping. A reproduction of Falconet's The Bather, a favorite statue of Sullivan's, sits prominently on a window ledge. A nude of a young woman (perhaps Falconet's mistress in real life), The Bather resides in The Louvre, where Sullivan has studied it first-hand. Sullivan publishes a photo of The Bather on his Web site and in some of his pamphlets. To him, it personifies beauty.

As she awaited the surgeon, Gummere watched a video of Sullivan giving a presentation at Brown. In it, Sullivan described not only the technical details, risks, recovery, and results of face-lift surgery, but also his ability to augment breasts, suction fat, move hairlines, and reshape ears, noses and necks. Patients in the audience rose to praise his work. One who bore witness was his nurse/office manager Judy O'Connor, on whom he has operated.

THE VIDEO ended and Sullivan entered the room. He is a slight, bespectacled, nattily-attired, middle-aged man with a kindly and mostly unwrinkled face. Sullivan has never had a face-lift. He benefits from good genes -- and also from Botox, which he periodically injects into himself.

Sullivan and Gummere engaged in small talk over glasses of bottled water. But all the while, Sullivan was evaluating the surface of her face and the features of the skull beneath. He was analyzing her animation patterns -- the facial changes when a person laughs, ponders, frowns, and otherwise emotes. A rough rule of thumb holds that the more expressive the person, the more pronounced the signature of age. Cosmetically, it can pay to be dull.

Although vanity compels most people to consider having their faces reconstructed, Sullivan maintains that other factors can, or should, also play a role: in such an appearance-conscious culture as ours, he maintains, an aging face can punish a person.

"We have something that we can't change," he said, "and that's that our society looks at people and makes judgments -- whether they're going to hire that person, if they're going to buy from that person, if they're going to approach that person socially. Not that it's right, but that's what happens. My goal is to give every person that comes to see me the chance to live to their maximum potential. And part of living to your maximum potential is that you'll be able to approach life with passion, that you'll be able to get to the top of your field, that you're going to be able to live your life to the fullest and not ever have your appearance hold you back."

Sullivan escorted Gummere into the more formal setting of an examination room, where, under a bright light, he scrutinized her face.

Then, as Gummere held a mirror to see for herself, Sullivan reviewed his findings and made his recommendation. It was not some fine-tuning, a nip and a tuck here and there, the piecemeal approach, but a complete facial-rejuvenation. Sullivan averages about 200 various face operations a year; some 95 percent are on women, many from out-of-state and even from overseas. Although he has rejuvenated the face of someone as young as 39 and someone in her late 70s, most of his face-lift patients are in their 40s and 50s. Sullivan didn't promise Gummere a 20-year-old appearance, but he did offer renewal.

"I can't stop the clock," he said, "but I want to start it at a new level."

Gummere left his office without scheduling the surgery.

"It scared me to death because it's [my] face," she recalled. "I said: 'Thank you, I'll think about it.' "

The months passed and what Gummere saw in the mirror continued to distress her. Finally, angst trumped fear and she visited Sullivan again this past June. Sullivan set a date of July 8 for surgery and Gummere arranged payment. Including office visits, anesthesia, and post-operative care, Sullivan charges some $13,000 to $15,000 for a facial rejuvenation. Insurers will not pay.

"Most people think that this is an extreme vanity, which it is," Gummere said. "It's also expensive, so there's that to it as well: 'Why would anyone waste their money like that, they're nuts.' I think you should do what makes you feel good."

THE YOUNGEST of nine children, Sullivan grew up in Minnesota. His mother taught school and his father worked the iron ore mines and held other blue-collar jobs. Dad had wanted to be a doctor, but he had to leave college when he could no longer afford the tuition. He hoped for better for his children.

The Sullivans valued education, and they encouraged the young boy's interest in sculpting and painting. They also encouraged curiosity. When Patrick's oldest brother came home from medical school with his freshman-year anatomy text, they let him read it -- and they allowed him, a second-grader intrigued by what is hidden beneath skin, to perform his first dissection. He dissected a fresh-killed chicken on the kitchen floor. "I was frustrated because my knives weren't good enough!" he recalled.

Sullivan majored in science but also took art and music classes at St. John's University in Collegeville, Minn., from which he graduated in 1975. He finished Mayo Medical School in 1979, then completed a general surgery residency followed by three year's study of otolaryngology and head/neck surgery at the University of Colorado. Sullivan's interests in medicine and art merged while there, and he settled on plastic and reconstructive surgery.

After completing his plastic surgery training at Brown in 1986, Sullivan trained for nine months with two of the masters of the field in Paris and Zurich. Sullivan also frequented some of the world's great museums -- such places as the Louvre and the Musee Rodin. "I probably learned just as much in art museums as I did in the operating room," said Sullivan.

A Barrington resident now, Sullivan holds the title of associate professor of surgery at Brown. He publishes regularly in scientific journals and he belongs to all manner of professional societies. As a member of the non-profit medical volunteer group Operation Smile, he regularly travels overseas to provide free reconstructive surgery and training to those in need. Beauty alone does not motivate him.

ONE DAY LAST MONTH, Sullivan spent several hours at Rhode Island Hospital reconstucting the face of a teenager who had been mutilated in a car crash. Then he drove his BMW to the Brown Medical School anatomy lab, located in the basement of an East Side building. It is down there, amongthe cadavers, the hanging skeletons and the shopworn books with titles like Surgical Anatomy of the Orbit, that he instructs young residents and conducts his research. Animal dissections and computers are of limited use to him, and experimentation on living people is -- of course -- no option.

Although plastic surgery has its roots in ancient times (doctors in India were experimenting with skin grafts for reconstructive purposes almost 3,000 years ago), the face-lift (or rhytidectomy) has modern roots. Having learned from the treatment of soldiers injured in war, surgeons as early as the first decade of the 20th century were lifting faces for cosmetic purposes. The earliest practitioners worked in great secrecy, but by the 1920s textbooks were being published. Bodies donated to science played a major role in progress.

Sullivan changed into scrubs and entered the Brown lab. Five cadavers inside five plastic bags lay on five guerneys. The smell of formaldehyde was strong, the overhead lighting stark and unforgiving. But Sullivan was in fine spirits, delighted to show a visitor his after-hours world.

Resident Dr. David P. Singer had already selected one of the cadavers and the bag was unzipped to reveal a woman's head. She appeared to be in her 60s, although the tag provided no age nor any clue as to when or how she had died. The woman's skin was a shade between cigarette tar and battleship gray, her eyes filmy and shrunken, her lips shrivelled like an old prune. "One of the problems is that tissue with formaldehyde won't act like fresh tissue," Sullivan said. But this woman would do.

The objective of the evening was to demonstrate an innovative way to alleviate puffiness under the eyes. One traditional approach requires an incision through the outside of the lower eyelid and removal of the fat beneath, but that can leave scars and remnants of the bags. The new way puts the incision on the inside of the lid -- and redistributes, not removes, the fat. The outcome is more natural-looking.

With a scalpel, Sullivan opened the inside of the lid and worked his way down to the tissue below.

"You want to make sure the plane of dissection is right here," he said. "You don't want to be digging in the muscle. Any questions about this?"

Sullivan finished one eyelid, then let his residents have the other.

When they were done, Sullivan discussed with Singer a research paper they had just completed. It described a controversial technique to remove part of a large salivary gland, the submandibular, that eventally sags as the upper neck ages. "Detractors maintain that the procedure is dangerous as it puts too many important structures at risk, notably motor nerves," the paper began. The paper went on to demonstrate a safe technique that Sullivan and Singer had pioneered working on cadavers at Brown and other medical schools.

Photographs of a woman in her mid-60s accompanied the paper, which was to be submitted for publication that very week. Unlike the cadavers in the Brown lab at the moment, this one, which the University of Texas Southwestern had made available to Sullivan and Singer, was not many days from death.

"Look at her lips," said Singer. "They're pink. She was a fresh specimen."

"Very fresh," said Sullivan.

"It's amazing."

"A lot of people want to get their hands on fresh cadavers like this because they're just incredible to dissect. The reason I got her was I was on the faculty that taught the face-lift course."

The course, in March, drew more than 100 cosmetic surgeons to Dallas. Three to a cadaver, they practiced the latest techniques.

IT WAS NEARING noon on July 8. Satisfied with how he had shaped and positioned the tissue layer inside the right side of Gummere's face, Sullivan sutured it into place.

"I put in a lot of stitches because I want it to stay up forever," he later said. He then turned his attention to the outside of her face.

Sullivan pulled the skin up toward the scalp, trimming it so the edge fit perfectly to Gummere's hairline and right ear, around which he had made the initial incision. "The edges are kissing, no tension," he said. "That is one of the keys to getting a scar that is impercetible." Sullivan sewed the skin with fine suture and the right side was finished. Even with the bruising and extensive swelling, the change was remarkable. That side was now nicely heart-shaped, the chin sharply defined. Gummere's jowls had disappeared, her cheek was fuller, and the corner of her mouth no longer puckered.

The best face-lift is the one that leaves virtually no trace of the surgeon. The worst looks like, well, a bad face-lift. The possibilities frighten. Bad jobs can leave the patient with so-called "pixie ears." They can give a patient the perpetually-surprised or wind-tunnel looks. They can leave what Sullivan calls "Frankenstein suture marks," which he illustrates by showing a photo of a woman who came to him from another surgeon. The scars behind her ears are ugly, and glaringly visible if she wears her hair up. She must surely regret her choice of physician.

But the most devastating possibility is irreversible nerve damage.

The surface of the face may appear simple, but the anatomy beneath is an intricate assemblage of muscle, gland, ligament, cartilage, fat, and blood vessels laced with a gossamer network of nerves that control movement and provide sensory input to the brain. Cut a critical nerve, and a droop will result. Permanent paralysis can ensue, the face frozen in cruel caricature of its former self. And more can go wrong. Sullivan recalls a case in which another surgeon cut nerves that later grew back, but not in proper circuit: when this patient tried to shut her eyes, her mouth closed instead. With the lessons of the anatomy lab and his residency in head/neck surgery ever in mind, Sullivan says he has never caused nerve damage in a patient that permanently paralyzed any part of a face.

Lunchtime passed, but much remained to be done.

Over the next several hours, Sullivan repeated his tissue-lift procedure on the left side of Gummere's face. Working through a tiny hole in the navel that would be invisible when he was done (she would still look fine in a bikini), he withdrew fat cells from her abdomen. Scrub nurse Lynn Thompson Adams rinsed the cells clean and Sullivan injected them into Gummere's lips, chin, the corners of her mouth, and the sides of her nose. The fat further softened wrinkles and restored her lips to youthful fullness.

More than seven hours later, he was done. He washed Gummere's face and bandaged it, then bundled her head in a cotton mesh.

Although Gummere had been unconscious the whole time and would remember nothing, she had not received general anesthesia, not been temporarily paralyzed, and not had a tube placed down her throat; the sedatives that anesthesiologist Dr. Douglas Blake had administered through an intravenous line would produce few effects when waking up. Vomitting, which general anestehsia can cause, wreaks havoc on fresh facial suturing.

Blake shut off the sedative and Gummere stirred.

"Operation's all done," Blake said. "Everything went fine."

GUMMERE SPENT the night in a private room at nearby Rhode Island Hospital, and Sullivan came by early the next morning to remove her bandages and see how she was feeling. She was feeling no pain, a tribute to the intraoperative nerve blocks that Sullivan has helped to pioneer. Later in the day, Gummere left the hospital with Teresinha Franco Taveira, a nurse on Sullivan's staff. Gummere's mother was summering in Maine, and Gummere had use of her apartment in Massachusetts. Recovery times vary greatly, from a few weeks to several months. Gummere would have to await her fate.

Taveira and a good friend of Gummere stayed with her during the first few days. Gummere mostly stayed in bed, sleeping on her back with an inclined pillow. Sullivan had attempted to undo some of the eyelid scarring from the earlier surgery, and Gummere's eyes were sensitive to light. Cold compresses helped. Otherwise, much to her delight, she remained pain-free.

Gummere did not spend much time at the mirror at first: Sullivan had warned of the vagaries of recovery, and she had no yearning to discover the gory details of the immediate aftermath of a seven-and-a-quarter-hour dissection of her own face. During that first week, Taveira removed the plastic tubes that Sullivan had placed to drain off fluids. Sullivan removed stitches which, if left too long, can exacerbate scarring.

Eventually, Gummere went to the mirror. And what she saw both pleased and alarmed her.

She was pleased because with her face still swollen and tight, every line and wrinkle seemed to have disappeared. "Whoa, that's great!" she thought. Traces of the old face would return as the swelling receded, but to be wrinkle-free at 55 was nonetheless a kick.

But she was alarmed because, as she said, "It didn't look like me." Weeks passed, and Gummere remained concerned. People complimented her, but she was still thinking: I don't recognize myself.

As the summer progressed, Gummere returned to Sullivan's office for further attention. From esthetician Pattie Priestner she received instruction in camoflage makeup, sold by a Hollywood company called Cinema Secrets and capable of hiding severe bruising. She received Botox injections and lymphatic massage, which prods the swelling to recede. Priestner also performed microdermabrasion and DermaPhoresis, to smooth, soften and brighten the skin.

By September, Gummere recognized herself in the mirror. She looked younger, but it was definitely her.

SHORTLY BEFORE returning home late last month, Gummere came by Sullivan's office. After an hour with Priestner, she saw Sullivan, who examined her in the strong daylight of his consultation room, there with the reproduction of Falconet's The Bather. The contrast of Gummere's new face to her old was dramatic. She looked much younger, and she looked very attractive. Beauty had indeed emerged from the blood-stained table.

"It looks great," Sullivan said. "I'm very happy. I love your eyebrows."

"He's an eyebrow man," Gummere said.

"I am kind of an eyebrow man, it's true!"

Gummere recounted the opposition that some in her family, especially her daughter, Sara, had voiced before the surgery. "Why can't you age naturally, Mom? What's the matter with you?" Sara had said.

And like Gummere herself, Sara had been disturbed by the initial results. She didn't think Mom looked like Mom.

"She saw me two weeks ago and I was looking pretty good, but she was horrified," Gummere told Sullivan. "But yesterday when I took her out to dinner she said, 'Well, now you look like you.' That was a great happening."

Increasingly, Gummere said, her family has trouble recalling her old face.

"That's exactly what happens," Sullivan said. "people don't remember the other face."

"As far as they're concerned, I've always looked like this."

"Perfect!"

"I looked very nice before," Gummere said, "I just looked like an older woman. I would get dressed with this body and something really great-looking on and then I would look in the mirror and I would go, 'How can I do that? This head just doesn't fit this body.' "

"Of course your head has to match your body," said Sullivan. "So this was very important."

G. Wayne Miller can be reached at gwmiller@projo.com