A Conversation With Peggy Howrigan MD  Plastic Surgery

A Conversation With Peggy Howrigan MD Plastic Surgery

Dr. Howrigan, how did you decide to be a plastic surgeon?

I knew from the time I was six years old, growing up in Vermont, that I wanted to be a doctor.  Years later, while I was in medical school, it became clear that being a surgeon was the right work for me.  I love using my hands, and have a naturally good spatial sense.  I’m also highly visual, and like to talk to people.  Plastic surgery is the perfect specialty for me.

What is your definition of beauty?

A natural appearance that suits the individual’s face and body.   Many different types of faces and bodies are attractive.  It’s a manner of balance, with each feature fitting harmoniously with the others.  You don’t look like you’ve had work done:  you just look great for your age and comfortable in your own skin.

Describe your philosophy of patient care.

I believe the best way to interact with my patients is to collaborate with them.  I am there to listen, to provide information and options, and to let my patient decide what they want to do.  This is interactive medicine. It’s not just me as a doctor telling my patients what they’re going to do.  Most of my patients are seeking elective surgery and each is unique in terms of desires, expectations, and appearance goals.  They are an integral part of the decision making process, even though I am responsible for the quality of care they receive.

What goes on during your initial consultations with your patients?

Initial consultations are a time when to develop a trusting, collaborative relationship with my patient.  I want to learn about the person sitting across from me, so I focus on listening carefully, in order to understand her concerns, the changes she is hoping for, and the expectations she has with regard to appearance goals.

During this visit, my patients sometimes tell me that they’ve had prior consultations with doctors who’ve told them what they needed to have done before the patient has even had a chance to express their presenting problem.  I don’t do that.  The relationship between my patient and me is one of mutual respect and we consider options until we’re both comfortable with the decisions made.  The consultation is a time to for my patient to ask questions, to learn about options, and to discuss pros and cons.  For me, it’s also a time to evaluate the patient, to take measurements, to consider what the best outcome will be and what I can do to achieve it.

Dr. Howrigan, you were trained at one of the most prestigious medical schools in the United States.  Has that been an advantage to you as a practicing surgeon?

Yes, Harvard Medical School gave me the opportunity to study and to learn from excellent professors, particularly during my residencies in plastic surgery.  I was able to train in the renowned teaching hospitals in the area, where I learned the best techniques from the best doctors, adopting them into my own way of performing plastic surgery procedures.  The opportunity to learn from the best continues even now, and I stay abreast of the latest advances in my specialty.

New plastic surgery procedures, new lasers, and new techniques:  the media can’t seem to get enough of these kinds of stories.  Do you find that more patients are asking for specific procedures, based on what they read and see in the media?

One of my primary goals when I see my patients in consultation is to make certain that my staff and I give them the best – and most accurate – information available.  Manufacturers of new treatments and products can directly reach consumers with TV ads and articles that encourage them to ask for this pill or that procedure.  On the one hand, it’s a positive thing for people to learn about their options and to have a hand in making decisions about their own medical care.  But just because a new surgical technique is raved about in the media – or even by certain doctors themselves-that doesn’t mean it’s always better.  The new injectable filler, a new laser…they are approved by the FDA but it is often true that over time they don’t prove themselves to be as effective as anticipated.

I am conservative about taking on the so-called “newest and greatest advance”in a surgical or non-surgical technique until it’s tried and proven over time.  I’m not an early adopter; I’m an advocate and protector of my patients’ health and wellbeing.  I want my patients to have the best procedures, using the best methods and equipment that are right for them specifically.   Patients are individuals, and each face and body is unique.  There is no one-choice-fits-all.  And the latest doesn’t always mean the best.

As a female surgeon, do you have a unique insight into the needs of female patients?

Over the years, a growing number of plastic surgery patients have chosen female surgeons and many of them find their way to my office.  I see patients from a fairly wide area: Boston, Western Massachusetts, New Hampshire, and Rhode Island – as well as those from other states who have been referred to me by my patients.  More women want a female plastic surgeon as time goes on, and it’s true I’m aware of the ways in which women think and feel about their bodies.  In the mid-80’s and up into the early 90’s, enough women had become surgeons and being a woman doctor wasn’t unusual anymore.

Being a female doctor had a neutral impact when I started out, but now it’s a definite asset.   I listen carefully to my patients in order to gain an understanding about what concerns them and what they want.  As a female myself, I understand the female sensibility, so it’s not hard for me to bond with my patients.  I know what it’s like to be a woman, and how hard it is to feel self-conscious about a part of your own body.  I also know how good women feel when they’ve sought and attained treatment for a physical flaw that has bothered them for years.  Yet, I also believe that I also relate well with my male patients.  I want what’s best for each of my patients, and strive to make sure they get it.  That’s the ongoing challenge in my work, which makes it both interesting and enjoyable.

Dr. Howrigan, will you tell us a little about some of the procedures you perform most often and how you think about them?

Of course, and I’ll start with breast augmentation, one of the most requested surgeries in my practice.  As with every consultation I do, I start by asking questions and really listening to my patient.  I want to know what bothers her, what changes are desired, what she’s looking for.

Most of my patients who choose breast enhancement are in their early 30’s through late 50’s.  Many have had their families and have seen changes in their bodies caused by pregnancies, lifestyle choices, and the passage of time.  After the last pregnancy or following a significant weight loss, breasts lose volume and appear saggy.

Many of my breast enhancement patients have waited a long time to do something for themselves, and they now have the opportunity so they tend to be pretty excited. They have the breast enhancement surgery, which fills out the breasts by restoring volume, places them in the appropriate position on the chest, and gives them an appealing appearance.  My staff and I are always delighted to see how happy they are afterwards. They have more confidence, they’re pleased with their bodies, and it’s wonderful to witness the transformation.

The majority of my patients seeking breast enhancement don’t want conspicuous changes or “statement breasts” that are coveted in certain parts of the country; rather, they want a natural look with attractive contours that let them feel good about their bodies and how they look in their clothing.  My patients are typically highly satisfied with their results, and I attribute this to the fact that I understand the female body, I learn what my patient wants and needs, and I know what goes into ensuring a smooth process and a good result.

Implants:  saline or silicone gel?

The media can’t get enough of stories on the saline vs. silicone gel implant question – and opinions vary widely and sometimes spark controversy.  But this is simplistic.  I talk with each patient about the pros and cons of both types of implants, in terms of what they want and which option will be best for them.  Patients who choose silicone gel are getting a procedure that yields a very natural feel and appearance, but women who choose silicone implants have to be willing to have periodic MRIs as required by the FDA protocols.  Saline implants – when selected carefully and placed properly – can also give an aesthetically pleasing result.

How do you optimize the recovery period after breast enhancement surgery?

My nurse specialist does great pre-operative education for my patients, so they know exactly what they need to do to support the best possible experience and result.

Implants are generally placed in the sub muscular (under the muscle) plane and my patients need to allow their bodies the short, but important time period needed to ensure a comfortable and successful recovery.  My staff and I give our patients all the information they need to hasten this process, making sure that they receive small, but important care elements that make the recovery process a positive experience.  For instance, near the end of the surgical process itself, I instill a long-acting local anesthetic that lasts up to 15 hours.  This makes a big difference in terms of my patient’s comfort on Day 1, when they need to be able to relax and rest without stress.

In addition, my staff and I teach our patients how to ice their breasts for the first 48 hours after their procedure.  This simple protocol dramatically reduces discomfort and keeps post-operative swelling down.  I also prescribe pain medication, in case my patient feels that she needs it – but I prescribe it in a formula that also contains a muscle relaxant.  These are small protocols with positive and meaningful impact.  That’s what I mean when I talk about a high standard of care.

What can you tell us about facial rejuvenation procedures and how you go about getting the best result?

The aging face shows a pattern of predictable changes that occur.  As we have grown in our understanding of that process, there’s been a paradigm shift in facial procedures in recent years.  It used to be that there was one primary way to treat the aging face: you cut and you sew.  The facelift was the answer, and patients were older when they had them done.  Now, as surgeons, we focus much more on how a face is aging, and what is needed to optimize the patient’s appearance at any given point in time.

I look at volume changes in the face, as collagen diminishes and the face loses the fullness that signifies a youthful appearance.  As we age, the soft tissue of the cheeks descends, for instance, and the lid skin loosens.  We begin to see thin eyelid skin over bone, with no fat to support it.  We also lose volume around the mouth.  The lips get thinner and longer, and the nasolabial folds (vertical creases on either side of the mouth from the lower nose downward) increase.  We also lose volume on either side of the chin, which means jowls form.  For instance, we now know that changes can even be seen in the skeleton as we age and these changes are visible in CT scans.  If you look at a young person’s face, when
the mouth is in repose (relaxed), the teeth are visible.  This is subtle sign of youth.  As we age, the upper lip gets longer and the teeth are not visible and this can give an aged appearance.

Facial rejuvenation is now typically achieved by doing a number of smaller procedures that address fine lines, wrinkles, and loss of volume.  For example, I can do a lip lift as an adjunct to other facial work, which will give the mouth a more youthful appearance.  And I do fat grafting to fill in areas of the face where volume has been lost.  For patients who are good candidates for a facelift, fat grafting is often done as an adjunct procedure to replace that lost volume.  It gives a much more natural, attractive result that doesn’t look like an obvious facelift.

Fat grafting and transfer has a dramatic impact, making the face look years younger. We use a number of different fillers now, such as Juvederm and Restylane, but our own body fat can be the best choice in many cases.  It’s our own tissue, so we’re not allergic to it.  I transplant cells from one place to another by harvesting excess fat from the abdomen or hip, and place it where it’s needed to add volume.  It’s longer lasting, and can take years off the face.

Fat can be placed in the area around the eyes that have lost volume and appear gaunt.  It can supplement a facelift, so that the result is a face that’s smooth and taut, with the right amount of fat underneath to support the skin.  Fat grafting is also an excellent standalone procedure for those who don’t need facelifts.  It’s excellent for smoothing out and softening nasolabial folds, and it can last for years.  I enjoy doing fat transfers, and the results are highly gratifying.

What would you like to share about rhinoplasty, in terms of achieving the best result?

The key here is the surgeon’s understanding of what will make the nose fit with the rest of the face – to be the face congruent.   I want the corrected nose to look like it’s always been that way, that it’s harmonious with the rest of the face.  This means the size and shape must fit the individual patient or the outcome will not be good.   Many years ago, the trend was to make the nose small and slightly upturned – a nose that didn’t fit many of the patients who had it done.  Part of the problem is that there is no size and shape that works for everyone: rhinoplasty is a highly individualized surgery.  I have to consider not only what will look good after the healing process is completed, but also what will look good in 20 or 30 years.  What’s ‘cute’ when you’re 16 isn’t cute when you’re 50.


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