The subtle art of giving a tuck
Art done well evokes an emotion. Plastic Surgery in Africa evokes confusion. In my short career practicing the craft I’ve found that there’s always a story that never gets told, a never-ending story that starts in confusion, and is heavily punctuated by emotion, because the scars, past and present though sometimes subtle, linger.
Consultations have never been a transactional experience for me. Yes, you paid and i’m at your service, but what we get from each other is far more than either of us expected. The conversation is always a meeting of two different cultures, traditions and belief systems, and you never quite know what to expect with every exchange. On a professional level, you expect me to leave my ‘-isms’ at the door, I do, but I replace that with curiosity, and that’s where the fun starts. Most patients treat a consult much like they do groceries, you select what you want off the shelf, put it in a cart and proceed to pay. It’s never that simple when the stakes are as high as they are in surgery. Fundamentally, surgery is an exercise in precision and the meticulous detailing starts in the consultation room, for me, it starts a little deeper. Indulge me.
Her legs walked in a cool five minutes before she did, she got from the door to my desk in half a stride. She was tall, very tall, but probably of average height in Sudan, where she was from. She flew all the way down to Nairobi for this, “Sorry for the mess.” I joked, “…Nairobi, is a concrete hangover!”. Her skin tone was richly dark, and draped over her flawlessly. She seemed to almost drip velvety melanin in her wake and I’m pretty sure I caught a glimpse of someone scooping some up in the corridor for keeps as the door slowly shut behind her. She didn’t laugh at my joke, they never do. I did, I always do.
It was honestly one of the most intriguing consults I’ve ever done. They don’t teach you cultural variety in Plastic Surgery school, but they do teach you to respect it. In 2008, Jamie McCartney began casting female genitalia in Plaster of Paris in celebration of one of the most ‘intimate places’, he writes, “It’s not vulgar, it’s vulva”. He called it “The Great Wall of Vagina”. The artwork spans a nine metre wall and was by and large positively received by women all over the world, who even volunteered to model for McCartney for free. Sudan, however, doesn’t enjoy the same kind of liberties when it comes to the phenotypic expression of female genitalia, in fact, it’s taboo for it to look a certain kind of way and that’s why she was here. It took her a while to explain this to me, and the more she spoke the more I wanted her to stop. It was heart wrenching. Women experience the world in a way so wildly different from what men experience and coming terms with this has been humbling to realize and embarrassing not to have recognized earlier.
Where she was from, it was commonplace to bathe outdoors, with other women of similar age along the banks of a small river, at least when she was younger. She had been constantly ridiculed for what culturally was considered ‘too much’. Now married, it not only brought her shame, it strained her marriage, and this she couldn’t bare to live with now that she had the means to have something done about it. Tears dropped down her incandescent dark cheeks as I showed her the 400 submissions to Jamie McCartney’s socially conscious art installation in an attempt at speaking to her insecurities. In life and in Plastic Surgery, it’s important to NOT tell people what to feel. If you listen hard enough, it’s palpable, you can feel it for yourself. The real connection happens when you immerse yourself in their story and walk with them to the beat of their bleeding heart. It’s only once you’re both in similar stride that you understand why they came to you and why they need what they want.
Technically, the procedure would be fairly straight forward to perform, however, science does have its’ limits and it is always incumbent upon me to align her own expectations with the science, never the other way round. This is the difficult bit. Anxiety around perceived physical imperfection can do one of two things to you, wear you down or push you to obsession. It’s a spectrum, and she was at the point of wanting the problem fixed at all costs. ‘At all costs’ is a vulnerable place to be, a tipping point if you like. They’ll get anything done by anyone, at any price and you really have to hope they land in the right hands, and when they do, expectations need to be managed cautiously.
She had traveled alone and didn’t have anyone to stay with. She traveled solo because she didn’t want anyone to know why she was in Nairobi, this always concerns me, I’ll tell you why some other day. That evening, she booked herself into a nearby hotel and came in prompt and early for surgery the next day. She spoke less this time, her guard was back up, kept looking at her watch, easily the longest day of her life. At the other end of this day is something her heart had wanted for close to 20 years. It would end her torment and finally starve the demons of her dysmorphia to death.
It still amazes me how the delicate swing of a surgical blade or the long steady stroke of a liposuction cannula could get rid of an insecurity so deeply lodged in the mind of a person who outwardly looked fine, but on the inside carried the unreasonable expectations of an entire community. What’s crazier is here I am, entrusted to deliver peace of mind.
As with everything else in life, it’s important to understand the level of risk involved in whatever it is you’re getting yourself into. I always take my time with this, but she tries to rush me through, she wants it over and done with, and I, want to avoid a lawsuit. But this is my turf now, so I set the pace, delicate authority is important in this business. She hurriedly signs the informed consent form, with her left hand…i’m not sure that counts in Africa, I make a mental note to confirm with legal guy, he’s leftie too…he hates my jokes, never laughs, I always do. Anyway, the porter comes down to wheel her to the operating room. The procedure was done in about an hour and a half, pretty good result if you ask me, deft; but in Plastic Surgery, the patient is Queen, doesn’t matter what your peer-reviewed literature says.
She’s awake and lucid after about an hour, I had waited around because I knew just how anxious she was about this, I’d done my best to curate a pleasant, attentive patient-doctor experience for her. It isn’t always easy in this line of work. She takes a look and is immediately a little surprised by all the swelling, “It’ll go down over the next couple of days, it’s totally normal.” I quickly chime in, she shrugs her shoulders and curls herself back into bed. “We’ll pick this up tomorrow. I’m only a call away if there’s any problem. Goodnight.” I reassure her, sometimes all they need to know is that you have their back. As a surgeon, you operate daily, a huge mistake is to think your patients get operated on daily. This is experience is all very foreign to them and if i’m being honest, scary.
Early, the next day, I see her again. She’s in much better spirits, it’s amazing what a good nights’ sleep, morphine and IV fluids can do. We take another look at the job together, she sighs in relief. In that moment, her pain was gone, and it wasn’t because of the morphine. Erased overnight. Their usual response is to say something along the lines of “I wish I’d done this sooner”, but what I got was “Will this last forever?”. “Unfortunately not.” I replied, “We may need a touch-up in about 3 years”. I had told her this before, but she was fishing for the answer she wanted to hear, not the one I needed her to. She cried. Not because she’d be back in 3 years, but because the next 3 years would be the most she’s ever lived.
