Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 1271e1272

LETTER FROM AMERICA

The best cosmetic surgery that money can buy

Warren Buffett is acknowledged as the greatest investor inmodern times.1 As chairman of Berkshire Hathaway, a pub-licly owned corporation, Buffett writes an annual share-holders letter that is widely quoted in the financialmedia. In this year’s letter, when discussing Berkshire’sFlightSafety division that provides flight training to mostof the world’s airlines, Buffett wrote:

‘Going to any other flight-training provider than the bestis like taking the low bid on a surgical procedure.’2

When I read this sentence I asked myself, ‘Is Buffettcorrect or do otherwise rational people look for the leastcostly cosmetic surgery?’

First, note that it is important to underscore the firstpart of Buffett’s statement: ‘Going to any other. than thebest’. It is easy to ascertain who is the best flight-trainingprovider because there are readily available metrics formaking that determination. Ratios of the number of nearmisses or crashes divided by the number of hours flown offormer FlightSafety students versus its competitor’s stu-dents allow the consumer of flight-safety services to rankproviders and determine ‘the best’. But, how does a ratio-nal patient measure ‘the best’ when it comes to cosmeticsurgery? Even if a prospective patient had access to data on

1 Known as the Oracle of Omaha, Buffett leads the 2008 Forbeslist of world billionaires with a fortune in excess of $60 billion thathe plans to donate to several charitable foundations. Buffett’sprinciple source of wealth is his ownership of over 1/3 of BerkshireHathaway. Single shares of Berkshire’s class A stock have traded forover $150,000 each. Berkshire is a conglomerate with over 75 oper-ating companies and ownership of substantial portions of othermultinational corporations including American Express, CocaCola, Proctor & Gamble, Sanofi-Aventis, Johnson & Johnson andTESCO. Berkshire’s principle source of income is its insurance divi-sion. In 2007 one of its insurance companies relieved many of thenames at Lloyd’s of financial worry by reinsuring Equitas, therebyremoving their liability for claims for disasters prior to 1992.

2 http://www.berkshirehathaway.com/2007ar/2007ar.pdf.Accessibility verified on April 21, 2008.

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cosmetic near misses and crashes (i.e., morbidity andmortality) that is insufficient. Providers can have ‘unsatis-factory results’ after any cosmetic procedure without therebeing any complications or deaths, e.g., the facelift patientwho has neither nerve damage nor flap necrosis and did notdie, but who feels that her result is unsatisfactory becauseit is not sufficiently dramatic.

One might assume that prospective patients make theirdecisions on who is ‘the best’ based upon reputation. Whiledoing my hand fellowship in Louisville, I was amused todiscover via the rumor-mill that Ralph Millard charged highfees for cosmetic surgery because he was ‘the world famousMillard’. In fact, Millard charged very low fees for cosmeticsurgery. When Millard and I discussed my possibly joining hisgroup he proudly declared that he was the least expensiveplastic surgeon in Miami. I told Millard that he was wrong.‘Who charges less?’ he gruffly challenged. I said, ‘Buster’,the nickname of his then most junior associate and mycurrent office roommate Walter Mullin. Millard groanedbecause he hated to be proved wrong. Millard and hisassociates were the low cost providers in private practice.Their popularity was proved by the fact that prospectivepatients who called Millard’s office would discover that ittook over nine months to schedule cosmetic consultationsand if he consented to operate they would have to wait atleast another year for their surgery.3 When Millard wasdeeply involved in writing his monumental opus Cleft Craft,his then associate Walter Garst operated up to six daysa week and worked his way down the list of ladies whowanted lifts but did not want to wait years for Millard todo their surgery.

There was only one Ralph Millard, but when I wastraining in Miami there were at least fifty board-certifiedplastic surgeons in the area. However, the public did notuse board certification as a measure of ‘the best’. Why?There was a resident clinic that was the lowest costprovider for cosmetic surgery in Miami. None of the

3 Reconstructive consultations were scheduled and treated ina more timely fashion.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

1272 Letter from America

residents were board-certified!4 We would discuss the caseswith our chief, Millard, and show him pre-operative photos,but we had minimal to no operative supervision. As I recall,rhinoplasties cost about $250, bilateral breast augmenta-tions, including McGhan implants, cost about $500, andface and neck lifts with bilateral upper and lower blepharo-plasties cost about $750. Residents could do as many ofthese cosmetic procedures as they desired. I personallyperformed over 60 facelifts in 18 months. The averagewait for breast augmentations and facial rejuvenation wasover two years with a list of several hundred patients desir-ing this low cost service.

The resident clinic no longer exists and Millard has beenretired since 2001. What is different in 2008? How does theaverage patient find ‘the best’?

Advertising5

Notwithstanding the fact that knowledge of the residentclinic and Millard’s reputation spread by word of mouth, itis advertising that now drives the desire for cosmeticsurgery. When I joined the local plastic surgery society in1980 the members spent considerable time and emotionalcapital ventilating about the ‘Yellow Pages’ allowingotolaryngologists to advertise in the plastic surgery sectionof the telephone directory.6 From simple listings of names,addresses and phone numbers Yellow Pages advertising hasevolved to pictures of models in bikinis displaying the finestmammaries money can buy. Unscrupulous advertisers hadno compunctions about using models who were not

4 There was an exception, J. William Little, who completeda full plastic surgery residency at Case-Western Reserve did a sec-ond residency with Millard and became board-certified less thantwo months before completing his training in Miami.

5 In 1987 The American Board of Plastic Surgery� ‘Recognize[d]the roll of legitimate advertising in the changing medical scene’[emphasis mine].

6 Naı̈ve colleagues failed to realize that the Yellow Pages wasnot a scholarly journal interested in the search for the truth. Itwas a for-profit venture solely motivated to sell advertising.

patients. The Florida Board of Medicine cracked down onthis type of advertising and the ads must now state thatthe pictures are of a ‘real patient’. One colleague com-plained to me that another colleague ‘s display ad had pic-tures of a ‘real patient’, but they were his patients and notthe advertiser’s!7

There is a saying, ‘Insurance is solddnot bought’. Thesame can be said for cosmetic surgery. Now the public istold and sold through advertising in print and electronicmedia who is allegedly ‘the best’. Whether conned orconvinced, the prospective patient chooses the advertiserwhom she believes is ‘the best’ and, as Buffett states, doesnot seek the lowest cost provider. However, if she feelsbelieves there is no measurable difference in the quality ofthe ‘plastic product’ then she will base her decision, as onedoes for any commodity, solely on price.

Despite millions spent on marketing ‘the best’ cosmeticsurgery in twenty-first century America, it is best toremember what Shakespeare wrote in sixteenth centuryEngland: ‘Beauty is bought by judgement of the eye, Notutter’d by base sale of chapmen’s tongues’.8

M. Felix FreshwaterUniversity of Miami Miller School of Medicine,

Division of Plastic Surgery,9100 S Dadeland Boulevard Ste 502,

Miami, FL 33156-7815, United States

7 The loss of collegiality is further seen when recently an officerof the local society told me that he had received a ‘cease and de-sist’ letter from an attorney representing two other society mem-bers. The officer’s website contained the phrase ‘Miami PlasticSurgeon’ and the other members previously had trademarked thephrase ‘Miami Plastic Surgery’ and claimed it as their intellectualproperty.

8 Shakespeare W.: Love’s Labours Lost. Act 2, Scene 1.