Four Hawaii-based plastic surgeons discuss the ins and outs of setting up shop on the island oasis
Gentle trade winds caress towering high-rises along the pristine azure-blue ocean along the shores of Waikiki. Multitudes of tourists from all corners of the world frolic in the sun to have their dreams of the perfect vacation in paradise come true.
Can this be the ideal setting for plastic surgeons to set up shop and cater to the eternal need for beauty and youth? Or is it just another outpost, an illusion of the perfect environment?
I set out to shed light on the reality of practicing in paradise by interviewing a few Hawaii-based plastic surgeons. Three allowed me to use their names; one requested anonymity.
“I always had a low profile,” explains the Hawaii-born surgeon of Asian ancestry who requested anonymity. “I think some people would like to be well-known and publicized. It’s just me; it has nothing to do with the profession.” Perhaps there is a different attitude among local people that shuns a high profile, in keeping with the Japanese proverb, “The nail that sticks out gets hammered in.”
On the other hand, there also may be a more relaxed attitude toward outward appearance and status. “Things in Hawaii tend to be more relaxed, informal,” the anonymous surgeon continues. “We don’t wear ties here, and on the weekends we frequently wear shorts when we make our rounds. Patients don’t seem to mind at all.”
Establishing Their Roots
Not too long ago, a different type of hospital occupied the space where a modern multistory tower now provides all types of medical services.
“It was like a plantation,” our anonymous surgeon chuckles. “The hallway was outdoors, the rooms had windows that opened to the outside air, and electrified coils kept the mosquitoes down—but the infection rate was low. The operating room, a wooden building, reminded me of [the television series] M*A*S*H. It was adequate, but it was not what you would call a hospital.”
All this has changed, and so have the patients. Maxwell Cooper, MD, FACS, who was initially exposed to Hawaii through military service 35 years ago and has practiced here ever since, thinks the patients have become smarter “primarily because of the Internet and the television shows that portray live plastic surgery.” He often hears remarks such as, “Doc, you don’t need to tell me that, because I have seen the surgery already on The Science Channel.”
Thinking back at how difficult it was for him to start out in private practice, Cooper says, “Somebody told me it would take 3 years for me to start paying myself a salary, and that’s how long it took. The pay scale is lower for everybody, so there’s less money available.
“A lot of people have to have two jobs, with grandparents taking care of kids, so that they can pay the mortgage,” he continues. “There’s less money left for plastic surgery, or they are going to defer any elective surgery.”
Allen Strasberger, MD, who describes his practice as 50% reconstructive and 50% aesthetic, remembers his initial problems to get established. “Getting on the staff in various hospitals was somewhat difficult, because there was a sort of catch-22.
“You have to have a certain number of cases reviewed before they let you take calls in the emergency room,” he says. “If you were new in town, you didn’t have much in the way of patients unless you did some emergency-room visits.”
James Penoff, MD, the chief of plastic surgery in a large multispecialty group, didn’t have to struggle quite as hard. “I walked straight in and had a practice set up for me. Now, we have a pretty good net of people we hook together through our clinic. And just because I have been around for a while, I have a pretty good net of people that send me cases.”
These surgeons may practice in a unique setting, but they face the same issues as those in other geographical areas.
Strasberger, who does a fair amount of hand surgery, observes, “In the case of rheumatoid arthritis, physicians don’t want to refer patients outside their practices because that would be almost like an admission of failure on their part.” He wishes other physicians would refer these patients to him earlier so that he could improve their quality of life.
On the other hand, the local plastic surgeon who prefers to remain anonymous thinks that, “If you provide good care and the referring physician likes you, you get more referrals.” He describes his practice as exclusively reconstructive in nature.
“I think the average physician in the state is still reluctant to refer cosmetic-surgery cases,” Cooper says. “I think I get essentially zero cosmetic-surgery referrals from my colleagues, unless they refer their wives. There’s still a lot of prejudice against cosmetic surgery.”
He doesn’t think he could survive on a reconstructive-referral basis in Hawaii. “I would move elsewhere, where there are few plastic surgeons and farther in between.”
Another common theme is concern with inadequate reimbursements. “My impression is that the insurance companies pay slower here, and less,” Strasberger observes. “Historically, the reimbursements have been less than on the US mainland, and they are still getting lower. The costs of doing practice have been escalating steadily, at least 20% over my reimbursements.”
“Our reimbursement is low, and our cost of living is higher than elsewhere,” Penoff agrees. “It’s a real catch-22. Most of our insurance is done by a single provider, so there’s little competition involved, and the reimbursement is choked way down.”
He thinks that Hawaii’s cosmetic surgery fees “are probably middle of the road. Certainly, surgeons in New York, San Francisco, and Los Angeles demand huge fees for their cosmetic procedures. I think our prices are pretty good and probably should be higher, since we have the issue with reimbursements and cost of living.”
“I think our prices are equivalent to the West Coast,” Cooper says. “I think you could get better deals in the Midwest and certainly overseas in Asia.”
Another common concern seems to be the encroachment by other specialists on the traditional field of plastic and reconstructive surgery. “It’s rare to see a very distinct line of separation,” according to the anonymous plastic surgeon. “We do see a lot of crossover. Some of them do a pretty decent job, in my mind. What bothers us is whether they are adequately trained to take care of medical problems.”
“We always have a group of people who come from Asia to do surgery,” Penoff says. “They come to town unannounced, they do the surgery either in the patient’s home or in a hotel room, and then they slip out of the country again.
“We used to see terrible complications from facelifts, rhinoplasties, and breast augmentations,” he continues. “They were absolutely horrendous.”
According to Cooper, encroachment by other surgeons is only “a moderate problem here. Some of the so-called cosmetic surgeons are into big-time advertising and draw a large amount of patients. We see some dissatisfied patients with complications, some patients with the wrong operation to start with.”
So what’s unique about plastic surgeons who practice in Hawaii? How do their cases differ from those on the US mainland?
Strasberger sees many more Asians in Hawaii compared to the rest of the United States. “In Ohio, where I did my training, we saw perhaps two or three Japanese patients in a year. But if I don’t see two or three Japanese patients per day here, it’s a slow day.”
He has to be much more aware of keloids and pigmentation problems among his patients in Hawaii. “There are certain operations you don’t want to do on them. Facelifts would be almost contraindicated if patients are known to form hypertrophic scars. You don’t want to do elective procedures on those patients.”
“Being aware that they can scar, I tend to use silicone early on as a prevention,” says the anonymous plastic surgeon. “I use steroids generally as a second line of defense. I am more prone to use it in darker-skinned people and Southeast Asians, particularly young immigrant women from that part of the world. They seem to be bothered a lot by vaccination scars that wouldn’t concern me.”
“There’s the issue of dealing with non-Caucasians, and their healing, whether it’s a scar from accidents, or whether it’s cosmetic procedures,” Penoff adds. “Obviously, the big issue with pigmented skin is controlling hyperpigmentation and hypertrophic scarring. Sometimes you may have to do a test area before you do the whole operation you planned.”
“Treating Asians and Polynesians is much more difficult than treating Caucasians,” Cooper observes. “You can’t do—and I don’t do—laser surgery or deeper chemical peels on those individuals.
“For instance, not long ago, I saw a beautiful Polynesian dancer who had gone to the [midwestern United States] for an augmentation mammoplasty.” Cooper continues, “The surgeon had no experience with Asian or Polynesian skin, so he made an inframammary incision that turned out hypertrophic. It looked like an extra nipple under her blouse.
“There was nothing that could be done about it. You can’t fix those. The best treatment would have been to give her a periareolar or axillary incision.”
Hawaii’s perennial sun seems to take a toll—particularly on pale Caucasian skin, according to Penoff. “We see lots of things that are sun-related, whether they’re cosmetic or skin cancers.
“Since 1997, I have kept a database of more than 700 melanomas, and certainly I would never have seen that number on the US mainland,” Penoff continues. “Basal and squamous cell carcinomas—I don’t even know what the number is, it’s so great.”
When it comes to cosmetic surgery, he finds that, “The Asian facelift is comparable to the Caucasian facelift, but there are marked differences in the nose and eyes that we have to be aware of. Asians need to have a fold that blends well with their appearance, not just a fold that looks Caucasian. With the use of silicone on the Asian nose, it’s just a matter of time before it erodes through at the sharp angle at the tip of the nose.”
Strasberger talks about “pediatric” implants for breast surgery: “A mainland plastic surgeon was surprised that we use pediatric implants here on our patients, but our patients tend to be somewhat smaller”
“The average size of breast implants has absolutely increased over the past 30 years, from 250 to 375 mL,” Cooper chuckles. He tells small Asian girls whose tissues are not stretched out from childbirth, “I can’t do that, at least not all at once.”
As to the idea of opening a spa and attracting a clientele from the US mainland, Strasberger remarks, “I don’t think actually anybody has done that. I think the problem is where you advertise. I don’t think patients want to cut down on vacation time they have here.”
Penoff sees a few patients from overseas, mostly people who are stationed at military bases across the Pacific. He says that spas are just beginning to surface in Hawaii, but as for rejuvenation and aesthetic-surgery spas, “it would take a good entrepreneurial person to get into it.”
Cooper tried to attract patients from Japan, but he sees a fair amount of US patients from Asia instead—military and civilian. “I get some referrals from my Web site. They shop online.”
He once also tried advertising in a high-circulation magazine. “I could have paid patients to come to see me rather than paying the media to run the ad. I got three or four consultations from that, and none scheduled surgery.”
Cooper says some of his most memorable cases center on the Kodak Hula Show and the Polynesian dancers. “They frequently want liposuction or breast implants. Yeah, that typifies Hawaii.”
To the unidentified plastic surgeon, eel bites are quite memorable. “They cut in many places like a shredder. The resulting tendon injuries are very difficult to repair. It’s not unusual to see tendons cut in two places.”
Penoff remembers a spectacular case of a stick fish, which flies through the air. “It struck a young boy right through the eye and gave him a carotid sinus fistula. The boy eventually died.”
Here to Stay
Asked if they would set up a practice in Hawaii all over again, they all agreed wholeheartedly in the affirmative. “I would probably still choose Hawaii,” Strasberger says. “For me, it has been pretty rewarding.”
“It’s been a great ride; the answer is yes,” agrees our anonymous Hawaii-born plastic surgeon. So does Penoff: “I have an increasing desire to stay here.”
For young plastic surgeons who would like to start out in Hawaii, Cooper has the following advice: “Hawaii is like a crowded elevator. There’s always room for one more.” And he adds with a laugh, “Buy my practice so I can retire.” PSP
Gunther Hintz, MD, a retired Honolulu plastic surgeon, is a contributing writer for Plastic Surgery Products.