Recently I had the pleasure of sitting down with one of Montreal’s finest plastic surgeons, Dr. Arie Benchetrit. In our conversation it became evident why Dr. Benchetrit is truly one of the best in this field – after twenty years of practice he is still intrigued by cosmetic surgery. I have to admit, aside from what I have seen on the medical drama shows I watch every week, I am not too well versed in the world of Plastics. And yet, after about an hour of sitting down and getting to know Dr. Benchetrit I felt I had more of an idea of what it takes to not only be a plastic surgeon, but what it takes to succeed as one. So move over Grey’s Anatomy’s “McSteamy”, because you have nothing on Dr. Benchetrit.
Here, Dr. Benchetrit helps us demystify some of the glamour that accompanies cosmetic surgery, as well as discussing the art of plastic surgery, the Hollywood craze, where he believes the specialty is heading in the future, and of course, his most favourite procedures.
Where are you from? Tell us a little bit about your background. I was born in Morocco, and moved to Canada when I was four and grew up in Laval. I went to Vanier Cegep, then I went to McGill undergrad for 1 year, then to University of Montreal for Medical School. And then I did my General Surgery at McGill and Plastic Surgery residency at McGill....
It’s a long residency, isn’t it? Yes, seven years. One of the longest!
Did you always know you wanted to be a doctor? No. I was very young. I actually finished high school when I was 14...I was a bit precocious...and of course at 14 you have no idea what you want to do. In those days you basically went into Health Science, Pure and Applied Science or Law. Those were pretty much the three choices. So Health Science seemed the most obvious to me, for no particular reason, and then once you’re in Health Science you keep going and in Cegep I finished Health Sciences and then I applied to a Bachelor’s in Anatomy at McGill, and then during that year I decided if I’m going to do Science I might as well go into Medicine – it seemed like a good way to use my science background and so I applied to Medicine...and the rest is history....
...is History. And you liked it all the way through? I’ve always liked the science of medicine. I’ve always been interested in the functioning of the human body, the interaction of the body with the environment and drugs and things like that. I’ve always been fascinated by that. The actual practice of medicine within Quebec is a lot different than you imagine it to be, especially when you’re a student – there are a lot of restrictions and a lot of rules and a lot of regulations that don’t exist elsewhere. All that being said, I have no regrets. To me it was a very good choice; a very good way to marry an interest in science with a practical way to use that science knowledge. And then veering into Plastic Surgery, it’s also allowed me to add a creative element, which I didn’t even know it was there when I was 14. My family’s a family of artists – my father’s an artist, my sister’s an artist. That’s my sister’s, that’s my dad’s - (Dr. Benchetrit points to two paintings displayed on the wall of his office) – so we have a lot of artists in the family, and so I never get a chance to express my art on paper, on canvas; and so this is in a sense a way...
It is! It is one of the medical specialties that is very artistic. That’s correct. And so you need an artistic eye, you need a good sense of symmetry, of judgment, and so that helps. All of those interests make for a nice confluence and so it was a good career choice for me. Do you ever do – art? Or no, you leave that to them? I’ve dabbled but not really. It’s not a passion for them like it is for my family.
Is there a difference between Plastic Surgery and Cosmetic Surgery? Yes, it gets confusing semantics especially for the public and a lot of doctors, unfortunately, play on that confusion to mesmerize the public, but uh, plastic surgery is a surgical specialty recognized by the Royal College of Surgeons of Canada and recognized by the American Board of Medical Specialties so it is a specialty onto itself. Within Plastic Surgery there’s basically two branches – there’s reconstructive surgery and there’s cosmetic or aesthetic surgery. So aesthetic surgery per se is not a specialty, aesthetic surgery could be practiced by any doctor, it doesn’t have to be a plastic surgeon – it just means, doing surgery for the purposes of aesthetics. However, while many doctors, including GPs, offer aesthetic surgery to the public, only plastic surgeons have the training to perform all of the various aesthetic procedures. Therefore, there is an ongoing debate about whether non plastic surgeons should be allowed to perform aesthetic surgery which, in Quebec, they presently are legally able to do. To be a certified plastic surgeon you have to be trained, have done a residency, and have been certified either in Canada or in the US or elsewhere as a Plastic Surgeon. Once you become a Plastic Surgeon you can have a mixed practice, which is the case for most, where you can have some reconstructive and some cosmetic, and some plastic surgeons choose to do mostly cosmetic or mostly reconstructive – you really have the chance to skew your practice according to your own interest.
And what type of practice do you have – are you a mélange of both? Well when I started my practice 20 years ago it was all reconstructive because my main interests was surgery of the hand, that’s what led me to Plastic Surgery. So you would do accident victims? Accident victims, patients with congenital deformities in the hand, arthritic patients, peripheral neuropathies like Carpal Tunnel Syndrome, there’s a lot of surgeries for the hand and I really enjoyed it. It’s a very meticulous, very precise surgery and that was really in my nature, I’m a very meticulous and detailed person, so for the first five years of my practice I did almost all reconstructive surgery but the realities of community plastic surgery in Quebec hit after a few years, where a community practice is very different than an academic practice – I was trained in a university and to me, Plastic Surgery meant all kinds of big complex cases – replants, microsurgery – but you just don’t see those cases in the community, so after seeing the same small variety of cases basically over and over and over again it became clear that as long as I stayed in the community that would be the nature of my practice forever. And so I started to gradually incorporate some cosmetic surgery into my practice and then as it turned out I was good at it and developed a large patient through word of mouth referrals, and it grew and grew until now – it’s about 90% of my practice.
Ok, so there’s a lot of demand for cosmetic surgery within the community practice. Um no. I would say that most community plastic surgeons do mostly reconstructive. In fact, if you look at most plastic surgeons here in Qc the majority of it is reconstructive, cosmetic is actually a small portion, but I would say 90% of the cosmetic surgery is done by 20% of the plastic surgeons, so it’s a fairly small pool and we do the bulk of it, I guess. Because we tend to specialize in it; and, of course, Plastic Surgery is based on word-of-mouth referrals and so as you tend to specialize in it you get better at it, you do more, and that’s how you build a practice.
But you said 90% of your practice now is Cosmetic. Well that’s transformed – It’s changed completely.
...over the past twenty years. Exactly, it went from fully reconstructive to nearly fully cosmetic.
Do you miss the reconstructive? I still do some, I still do skin cancer, I still do some hand surgery, I still do some facial fractures, you know I’m affiliated with Lakeshore Hospital, I take call there. So obviously anything that comes into the Emergency Room that is plastic surgery related I will see. So I still enjoy it, but again, it’s the same limitations. In terms of elective reconstructive surgery in the community, it’s not a very varied pool of cases and so I’m glad I made the choices I made.
So plastics is pretty much, I think, the “sexy specialty” to have – although I’m sure Grey’s Anatomy is completely unrealistic...do you watch it? No, I never really watch Nip/Tuck, I never watch Grey’s Anatomy, I never usually watch TV, but I try to stay away from medical shows because I have enough medicine during the day.
Right. Do you find it to be like the public views it? Because it does have that “sexy specialty” connotation or it’s built around that this McSteamy type of thing. Has it changed – I mean your practice has changed over the past 20 years – do you find that it’s changed? The public is very focused on looks... Well I think the public has always been focused on their appearance. I mean cave men and women used animal blood to paint their faces and apply primitive make-up and so I think it’s just part of the make-up of the human being, is to try to appear our best – to look our best – obviously what looks good changes with each generation and the standards for beauty, for fashion change dramatically. But the desire for humans to look their best has not really changed. The difference is now we have procedures, technology, chemical procedures Dr. Joe, that make the achievement of a better more youthful appearance easier and safer than its used to be – and that’s been the main change in cosmetic ‘medicine’, I would call it, (rather than plastic surgery), cosmetic ‘medicine’ most of the procedures we do now to enhance somebody’s appearance are non-surgical, whereas 25 years ago really surgery was the only way to go.
Right. You now don’t need to go ‘under the knife.’ Absolutely not, in fact according to the American Society of Aesthetic Plastic Surgery statistics cosmetic surgical procedures in the last 14 years have pretty much doubled where as the non-surgical procedures have gone up almost 800%. So there’s been a huge shift towards the non-surgical/non-invasive procedures.
So that’s what I was going to ask you, because I was looking at your website – so explain the difference between the surgical and the non-surgical. I mean one obviously means you’re under anesthesia and ‘under the knife’ but what type is rhinoplasty – and what is that? Well surgery means that somebody is using a scalpel on you basically, surgery involves a scalpel. It could be a small incision, it could be a large incision but it involves a scalpel, it involves a cut of some sort. And more and more surgical procedures and plastic surgery involves shorter and shorter scars, I mean, liposuction now has scars that are 3mm long. Some of the eyelid procedures we do are called ‘scarless’ because the scars themselves are hidden so the scars have gotten shorter but it’s still surgery, it’s still an invasive procedure; you’re going through the skin, you’re going through the body’s barriers. And that’s what defines it as ‘surgery.’ Non-surgical involves no scalpel. The most common non-surgical procedure that everybody knows are Botox injections, filler injections for lip augmentations or for wrinkles, the lasers are very popular – whether it’s laser hair removal –
That’s considered also cosmetic? Oh sure. Wanting to be ‘hairless’ is again to enhance your appearance, especially if you’re very hairy...Lasers for wrinkles, what we call resurfacing lasers, we now have machines like the Ultra Shape that can dissolve fat non-invasively with using ultrasound
That’s using only ultrasound? Yes, only ultrasound. And again, non-invasively, as in it doesn’t break the skin. Right. There are machines that can tighten the skin non-invasively like Thermage, which is a radio frequency device, we also use ultrasound on the face for skin tightening. So there’s a whole slew of technological advancements that have made it easier to, again, non-invasively improve somebody’s appearance. And as well the pharma companies have been busy putting out products - injectable products – that we can use for the same purpose.
So would you say that, because of the pharma companies, and the use of all these non-invasive procedures the public is more aware? I would say that yes, with all these procedures the public is more aware, certainly it’s much less of a taboo, much less of a restricted topic than it was 30 years ago, where if you had a facelift or a nose job you sort of kept it to yourself and your family and nobody really talked about it, well now it’s in every magazine it’s in every talk show like you said, some of the most popular drama shows are about cosmetic surgery it’s definitely all over the internet, it’s very easy to find information – in fact, you’re pretty much bombarded with it so I think it’s a much more open issue or open subject, and so I think more people talk about it more. Not always positively but at least people talk about it more.
I was reading about the Ultra Shape procedure. How does that work? I’m curious to know how that works! How much does something like that cost? Basically the machine is an Israeli machine, developed by an Israeli plastic surgeon and engineer. By the way, Israel is the source of almost all cosmetic lasers and most of it comes from military technology. With all the military experience they have there, they’ve used a lot of it to develop a lot of the machines we now use to look better – it’s sort of a paradox. In any case, this machine was developed in Israel about 8 or 9 years ago and it’s been used in Europe for about 7 or 8 years, and it’s been available in Canada since 2007, and it basically generates focused ultrasound – waves that are focused like if you would focus the sun’s beams with a magnifying glass when you’re trying burn a hole through a paper, so the machine basically focuses the ultrasound down to a fine beam and sends these waves into the fat at the surface of the body and the ultrasound basically blows up the fat cells, the adipocytes, at a fixed level – 1.5 cm below the surface of the skin, that’s where they’re focused. So there’s no heat involved with this machine so it doesn’t hurt, it’s just cavitation makes the fat cells vibrate so fast that they “pop” and you do a whole area it pops a lot of cells. The fat then gets transported by your bloodstream and your lymphatics to the liver and it’s metabolized like any other fat you would eat.
That is amazing! Yes, what’s really great about it is fat cells don’t reproduce, they don’t come back , they’re destroyed for good. And so for most patients, results are long-term or permanent. It’s a great invention for patients who are surgery averse. Because there is a large segment of the population that - no matter how much they want to look better – will never ever agree to have any kind of surgery even liposuction, which is a fairly minimal surgery. So for patients waiting on the sideline for something non-surgical to come out, we’ve had a lot of patients asking for that.
But what about if you have an unhealthy lifestyle? You can still generate Adipose tissue, right? No you won’t generate new cells but the current cells that you do have can get larger. It’s not a weight-loss procedure, we’re not doing it to take 10-20 pounds off of someone, what we’re doing is re-contouring an area, most people have areas of “stubborn fat” – areas of fat that just won’t go away – whether it’s the love handles, the thighs, or the tummy – and that fat often resists diet and exercise, it’s also gender specific and race specific, so for those kind of areas that’s usually what we go to with liposuctions – we can do this now with Ultra Shape. It’s not as aggressive as liposuction, predictable or thorough. But it’s what we call the “muffin top” procedure, it will basically flatten that muffin top. We’ve treated over 300 patients with it, I’ve published our data and presented it at conferences all over the world – Europe, Asia – so far the data shows that an average person will lose 4. 5 centimetres in circumference, about 2 inches, after 3 treatments in the area that was treated. Significant enough for most patients to go down at least one pant size.
How much does the 3 treatments cost? It varies depending on the size of the areas we treat. But, on average, about $1,000 per treatment. What are some procedures you like doing most? Do you have a favourite? I love doing rhinoplastys [nose reconstruction]. To me that is true art, because you are literally sculpting right on somebody’s face. And if you’re someone like me who wants to see the results right away there’s nothing better – because you see what you’re doing as you’re doing it. There’s no waiting to see the result. It is very delicate, very precise surgery. You have to be very meticulous, and that’s my personality. I also really enjoy other facial surgeries as well – eyelid lifts, brow lifts, neck lifts – all of those are similar. They’re all meticulous and deliberate type of surgeries.
Has anyone asked for a surgery that was really novel to you – a ‘can you do this’ type of procedure? There are very few things that aren’t available. I don’t do every kind of surgery. I don’t do pec implants or calf implants, for example, which some surgeons do – especially in California – I don’t do penis elongation. So there’s things I don’t do that I do get requests for. But I don’t think I’ve ever been asked about a surgery that simply doesn’t exist.
What are some of the criteria to have certain surgeries done? People talk about cosmetic surgery as if it’s a certain ‘fashion’ or ‘fad’ but it is medicine. The same criteria apply to this type of surgery like other surgeries. You are still dealing with the health of a human being. The first thing you look at is their health status. Obviously we’re not going to do elective surgery on somebody who’s very ill. So the first thing I do is look at their health survey that we have them fill out. Are they on any medication, their history – diabetes – any conditions that could affect the outcome. There is also a bit of a psychological screening that goes on during the consultation. We want to make sure the patient is doing the surgery for the right reasons, that they don’t just look at the benefits but understand the risks and possible complications, the consequences of the surgery. Part of the consultation is to understand that we don’t perform ‘magic’ here we are performing surgery, and there are consequences. So I haven’t left my medical training behind, it’s part and parcel of what I do.
People talk about cosmetic surgery as if it’s not a big deal these days, it’s easy to forget that it is ‘medical’ surgery. That’s right, there is anaesthesia involved. You can have complications from this surgery, even death. The advantage that we do have in cosmetic surgery is that we are mainly dealing with healthy patients. We’re lucky that we’re dealing with the healthiest segment of our population. But just the same, we have to be careful with how we’re operating.
Have you refused doing a surgery because someone is motivated for the wrong reasons? Absolutely. I’ve refused people for wrong motivations, unrealistic expectations, people who I feel are unfit for surgery or I think the risk level is too high – they may be fit for some type of surgeries but not cosmetic surgery.
What are your most popular surgeries? In my practice I would say tummy tucks, breast augmentation.
Is breast augmentation and breast enlargement different? No, breast augmentation is just another way of saying breast implants. Augmentation is you’re making them bigger. Breast augmentation, enhancements, enlargements is just the same thing. To confuse you further you can do a breast augmentation and a breast lift at the same time, where you lift and make them bigger. Younger patients usually come in for augmentation, and older patients usually for the breast lift with or without augmentation.
And on women, obviously. Well I haven’t done many breast augmentations on men, but I have done a couple on men wanting trans-gender surgery in the process of becoming women. I don’t see many trans- gender patients – that’s another niche of cosmetic surgery – there are some surgeons who specialize in that and they see the bulk of the cross-gender population. I see a few, but I don’t do the genital surgery – that’s a very complex specialized surgery.
And that is done here in Montreal? Oh yes, in fact Montreal is one of the world centers for trans-gender surgery. There’s a surgeon here who’s known throughout the world for that.
So some of the Hollywood stories – Heidi Montag, from The Hills – in 2007 she had a breast augmentation, rinoplasty, Botox injections. She had 10 plastic surgeries in one day – browlifts, ear pinnings, chin reduction, a second rinoplasty, a second breast augmentation. And she says she almost died from too much Demerol, but she says it was worth it. A year later, in In Style magazine, she said, ‘it’s not what I signed up for; I should have been way more informed. Doctors should have really walk through all aspects of it, not just the glamorous side.’ She then goes on to say how it has ruined all aspects of her career and personal life, and how she wishes she could ‘jump into a time machine and take it all back.’
Do you think Hollywood and Heidi has glamorized plastic surgery, and put so much focus on the aesthetic...idolizing perfection? I think Hollywood has made cosmetic/ plastic surgery look like a drive-through procedure. They’ve done it with cop shows, war movies, and they’ve done it in the last few years with cosmetic surgery. Shows like Extreme Makeover, which basically took patients who were down on their looks and did everything to them – surgery, hair make-up, whatever – and then by the end of the show, within the hour, the patient went from the Ugly duckling to the beautiful swan. It reinforced the notion that plastic surgery is somehow magical. That you can walk in the office and walk out a few hours later as a different person. What they don’t show you is that the surgeries take a long time, that there’s a healing process, there’s risks and there’s scars. So they swept all that aside and just show you the final product.
When that show was on I used to get emails from patients all the time saying ‘will you just take me on as a project, I’ve been unhappy my whole life. ‘Then shows like Nip/Tuck, it just falsely glamorizes the world of plastic surgery. And then there’s Heidi Montag, and people talking about it. It’s taking cosmetic surgery and removing it from the realm of medicine and I think that is wrong. It is still a medical procedure. It’s a double-edged sword, it popularized surgeries but on the other hand, it made our lives (plastic surgeons) a little bit difficult because we had to manage expectations a lot more. You don’t get your surgery one day and then go to a gala the next. There’s recovery time. You have to manage expectations. Although now with the Internet, I have to say people are a little bit more informed and realistic. So the pendulum is swinging back a little bit, but you’ll still get the Heidi Montag’s and the Michael Jacksons’s, what I call the caricature of plastic surgery, not the real thing.
So what are some things that we could be looking for [on the market] to use where we’re not spending $1,000 on cosmetic surgeries? The easiest and probably the least expensive is to buy a good bottle of SPF 60 and slather it on. Even in the Winter, because you’re getting ultra-violet rays. There’s three things that make you age. One is genetics, which you have absolutely no control over; two is smoking, which will age you prematurely, and three, the sun, which you don’t have to completely avoid, just use a good sun screen. A good part of my practice is reversing sun damage to the skin. So the number one easiest thing, sunscreen. Two a good healthy lifestyle. Eating properly, drinking water, exercising, not letting your weight yo-yo because that has an effect on your skin (it will lose elasticity). And then there’s also skin care, good skin cream, Skin hydration is important. It has no long-term effect, no benefit on wrinkles, but it keeps the skin looking better. Even a $6.00 basic skin cream will do the job.. Of course, getting a good night’s sleep and limiting the stress in your life is good too.
Where do you see the future of cosmetic surgery? I see the trend of the non-surgical expanding and growing. There are things that we can do today that weren’t available five years ago. It’s amazing, just the last five years with the amount of technology....But there are three things, in my view, that will be the big movers and shakers. On the surgical side, one is robotic surgery, which has already made its entrance into Urology and other surgical specialties. They’re already using a robot to do microsurgery in the US and it’s a matter of time before robots will perform cosmetic surgery. Of course, these robotic devices are still controlled by human hands but who knows, one day... Two is tissue engineering, which has been going on for many years. They can now grow complex tissues in a petri dish – collagen, bone – but they’re not quite at the stage yet where they can create a multi-tissue organ .
So what would you then do with that? Well if someone loses an ear in an accident, we now have to reconstruct it with skin from another part of the body, cartilage taken from the ribs etc. But if you can grow skin and cartilage in a petri dish then you can literally grow somebody’s ear and graft it on. We have been doing it awhile with skin, for skin grafts. But now we’re getting into more complex tissues. This isn’t only restricted to plastic or cosmetic surgery, Imagine if you can grow a liver or a kidney in a lab. But one of the most exciting developments, and it’s already being used, is stem cells. Because one of the things we didn’t know before is that fat is one of the richest source of stem cells. Adipocytes stem cells are phenomenal. And we’ve been using fat injections for a long time, to make lips bigger, to fill in wrinkles and scars etc. so fat grafts have been around for 25-30 years. But what some people have observed that if you graft below a scar it will improve and nearly disappear in some cases, and no one really figured out why. It’s now hypothesized that it’s the stem cells in the fat that are differentiating into new dermal cells and so minimizing the scar. We can now isolate the stem cells from the fat and inject them into any site . If you do liposuction, for example, instead of throwing all this extra fat away you can put it into a machine and it separates out the stem cells. You then take these concentrated stem cells and you put them back into the fat, inject this super charged fat into an area and not only get a better cosmetic result, through better survival of the fat graft, but the stem cells can perhaps differentiate to improve the quality of the skin in the area. So scars are one thing but the potential for this is amazing. Imagine stem cells that differentiate into cardiac tissue when injected in the muscle of a defective heart, or that differentiate into bone or cartilage or other needed tissues. We ‘re not quite there yet but that’s where we’re going. And this is an element for cosmetic surgery? Well it applies to cosmetic surgery because we use fat grafts anyways. For example in Europe, and in some trials in North America, they’re already doing fat grafts for breast augmentations instead of using implants. You’re taking a patient’s own fat and injecting it into the breast. You’re recycling. Instead of using a silicone implant. Yes, you are recycling. So for some patients who don’t want to use implants this may become an option. So the issue now is getting the stem cells to differentiate into the different tissues that we need like the bone, the heart, the muscle or intestine. So to me that’s a really exciting aspect of plastic surgery and medicine in general. And it’s ongoing right now; it’s not a pipe dream.
Well Dr. Benchetrit I thank you very much! This was all very interesting and I can now say I fully understand the intricacies of cosmetic surgery. Thank you.
Interviewed by Emily Shore