on the table in my operating room. Maybe she’s dreaming about the face-lift she’s undergoing, and for which she’s saved up over many years. She couldn’t have been more certain that the operation would recharge her. She’d said so months before, when she’d visited my office at the urging of a friend on whom I’d done an eyelid lift. “Feeling ugly and rejected is no way to go through life,” said Lee. I wouldn’t have been shocked had she dumped a lifetime of accumulated coins and bills on my desk right there.
Lee had an unusually heavy neck, baggy eyelids, and lots of jowl, and very much looked her age. Observing her both in person and in photographs at age forty and forty-five, I determined we’d get the best outcome – a defined neck, with chin and jawline clearly separate from the neck – by removing fat from the platysma muscle between her clavicle and jaw, pulling the largely functionless muscle backward, and removing extra fat along the jawline. It’s an operation I’ve performed maybe three thousand times. Barring complications, she would be off the table and in the recovery room within three and a half hours from the moment she was wheeled into my OR. Bruising and swelling would be gone within two weeks, and she would look as if she’d bought seven to ten years.
Before I could operate, though, we had to confirm she was up to it. Her health, generally, was excellent. She had never smoked. Never had a heart problem. The preoperative tests – EKG, blood studies, stress test – all turned up normal. The morning of the operation, she was so excited she practically wheeled herself into the OR.
Now, a couple hours later, I am also experiencing a rush, but it’s because Lee is lying on my table just beneath me, her face opened from ear to mouth, and something is going very wrong.
The operation is still an hour from completion. I have finished removing fat and elevating the skin on her right side, and I am doing the same on the left when Lisa, my trusted anesthesiologist of fourteen years, says, “I have a problem.”
“What is it?” I ask.
“Her blood pressure’s dropping, her oxygen’s dropping, and I can’t reverse it.”
“What do you mean you can’t reverse it?”
“I’ve reduced the anesthetic, I’ve increased her fluid, I’ve given her medicine to bring the BP up, and it won’t go above ninety over fifty.”
“Let’s put her on one hundred percent oxygen,” I say.
Lisa does – to no avail. Two minutes later, Lee’s O2 level is still low and her blood pressure is down to 80/50.
My hands are moving as fast as possible. It’s not abnormal for patients to have brief episodes of low oxygen or blood pressure, but this one is persisting. I can’t simply stop operating. I have to close her up. And before I can do that, I have to stop the bleeding.
“I’m getting worried,” Lisa says. “Hurry up.” Like most anesthesiologists, Lisa is paid to be, among other things, cool. We’ve been through a lot and we trust each other; I’ve done face-lifts and other procedures on friends she’s referred to me. But the mix of symptoms manifesting in Lee is new to both of us. My mind runs through the possible explanations.
Heart attack? Maybe, but her EKG hasn’t changed.
Aspiration? Doesn’t jibe with the drop in BP.
Vasovagal syncope? Her O2 would be normal.
Could this be Lee’s normal blood pressure? Still doesn’t explain the oxygen drop.
Something going on in her head or nervous system? She has no history of neurological problems.
Pulmonary embolism? She’s too physically active for a blood clot.
Even though Lee’s EKG hasn’t changed, I go with the most reasonable possibility: heart attack. After twenty-plus years in training and private practice, this is, remarkably, the first time a patient of mine is suffering a heart attack midsurgery.
“Reverse all the anesthetic,” I tell Lisa. She shuts down the standard cocktail of fentanyl, propofol, and Versed that had ushered Lee into a “twilight” sleep, while I speedily continue closing incisions, tying fine nylon sutures, and inserting nickel clips in the scalp. Finally, Lee’s blood pressure begins to rise. Same with her O2. Good. The sedation has worn off and it’s only local now. As Lee awakens – the still-opened side of her face resembling a cut watermelon – she asks groggily, “Are we done?”
“We have a little problem,” I say.
“What problem ?”
“Do you have chest pains?”
“No.”
Huh. Another indicator she did not have a heart attack.
“Shortness of breath?” I ask.
“No. What problem?”
“We didn’t like some of the readings,” I say.
Lee looks at me as if I were dense, as if I were from Neptune – as if I’ve forgotten why we are all gathered there and why I have gone into this profession to begin with. As if I’ve forgotten why she has spent every last discretionary penny to be lying here.
“I don’t care if I die,” she says. “I waited my whole life to look good. I’m not going one more day looking the way I do.”
Her eyes are piercing; there are no remnants of the effects of anesthesia. “Just do a good job,” she coaches me.
Despite her aberrant readings, I accede to Lee’s wish and complete the face-lift. This time, her signs remain stable. After I finish and suture her, we call for an ambulance to transfer her to the hospital, to make sure she’s monitored.
The moment the EMS technicians place Lee on a stretcher – the face-lift dressing cradling her head – her eyes roll back and she turns blue.
Oh, God, I think. She’s gonna go.
She is having a heart attack.
Fortunately, Lee responded to another drug-reversing agent. She came to; she did not code. That night, in a crowded emergency room, with an IV in her arm, she asked me, “Did you do a good job?” It’s a question she would ask me every day for the week it took her to recover in the hospital’s cardiac care unit.
I nodded.
“Then I’m happy,” she said. “And if I’m not happy, nothing else matters.”
We plastic surgeons are perhaps second only to psychiatrists when it comes to being privy to patients’ intimate secrets. As a doctor, though, I’m committed to strict confidentiality. Divulging anything is not just unethical, it’s illegal: I could lose my license. Indeed, a proper plastic surgeon doesn’t even acknowledge his patients when he sees them at events, unless they’ve been explicitly open about their operation. At a Los Angeles charity function crammed with A-list actors and industry players, several patients of mine roamed the mansion’s grounds while I strolled with one of the town’s most powerful female executives.
“You’re lethal to walk around this party with,” she said, taking me by the arm. “I’d love you to comment on who here has done what.”
“I can’t do that,” I said.
She looked at me sternly, as if that might do the trick.
“I can’t,” I said.
Now she practically batted her eyelashes.
“I can’t,” I said.*
So why would a doctor like me write an exposé about what goes on behind the scenes in my