Trinidad Institute of Plastic Surgery’s chief of surgery Dr. Arno R. Schleich MD was recently interviewed by his former teacher and renonwed craniofacial surgeon Dr. Barry L. Eppley MD DMD, who runs an internationally renowned website on plastic surgery for its World of Plastic Surgery Op-Ed.
Dr. Eppley and Dr. Schleich talk about plastic surgery and cosmetic surgery in Trinidad and the Caribbean, cultural specifics and challenges facing a plastic surgeon practicing in these geographic areas.
Read the feature in World of Plastic Surgery!
Dr. Eppley: Where is your main practice location in the Caribbean ?
Dr. Schleich: Port-of-Spain, Trinidad and Tobago, Caribbean; that’s where my main office is located;
Dr. Eppley: How long have you been now in practice ?
Dr. Schleich: It’s five years since my board certification in plastic surgery; I then went into private practice after leaving academics; for three years I have been practicing in Trinidad in the Caribbean.
Dr. Eppley: What are the most popular cosmetic procedures in Trinidad in your experience ?
Dr. Schleich: In my case mix it’s body contouring – liposculpture, tummy tuck – followed by breast augmentation and breast reduction;
Dr. Eppley: Are there any new and emerging trends in cosmetic surgery in Trinidad ?
Dr. Schleich: The big thing in the Caribbean in general and Trinidad in particular is body contouring. This makes sense, as the Caribbean islands are very body oriented, beach plays a big role, and clothing is adapted to the tropical climate. The big trend now is gluteal reshaping with fat transfer aka Brazilian butt lift. This is a fantastic procedure to do in Trinidad and the Caribbean – all ethnicities are represented, women there are already curvy, still have some fat to give though, and the results are very satisfactory, which makes the procedure a real pleasure to do. Or as one lady recently put it after her gluteal reshaping: “Doc, you know, now it is how it’s supposed to be – when I walk down the street with your handiwork the guys start bumping into the lamp posts!”
Dr. Eppley: Are there any unique ethnic, racial and cultural consideration for cosmetic plastic surgery in Trinidad ?
Dr. Schleich: Definitely; I was trained in Germany in plastic surgery and double fellowship trained in the US in hand, wrist and microsurgery and craniofacial surgery in regions with predominant caucasian or light hispanic populations. I now practice in Trinidad and over 70% of my clients come from the islands, the rest is from the US, Canada and UK. Amongst these, 99% is dark skin – Afro-Caribbean, dark East Indians, Creole etc., rarely anybody less than Fitzpatrick V. Every incision is a big issue. Mind you, most heal well eventually, but it takes quite a bit more time and effort and I do quite a bit more active scar treatment after procedures despite the scant evidence of its effectiveness than I used to when I was still in practicing in the US. Healing well eventually is also not self evident in my opinion – it took me a couple of years of experience to reach the conclusion that it really heals well eventually and be able to provide this reassurance to a client with a reasonable amount of confidence.
Facial aging is another big difference. Dark skinned people do age differently and much slower, at least in the face. The bone structure is different, too. My facelift and periorbital rejuvenation population are predominantly medical tourists from the US or Canada. The local population gets to this stage probably fifteen or more years later than say a light skinned redhead and then often have a reduced interest in this kind of surgery in favor of body contouring, where everything has to be full, firm, curvy and voluptuous. So say Kate Moss doesn’t stand a chance to raise anybody’s eyebrow on any Caribbean catwalk – just the contrary to the ideal of Caribbean beauty.
Gynecomastia appears to be much more frequent, particularly in East Indians. I am still not sure if the case numbers are due to a factually increased prevalence, a supply and demand issue, as not many other surgeons able to do the procedure well, or a matter of patient perception – Caribbean men do spend a considerable amount of time bare chested … But as a matter of fact I operated more gynecomastias in my first year in Trinidad than my entire previous career.
Enlarged breasts are generally a problem in Trinidad and the Caribbean, not to the absurd degree as I experienced it in academic and private practice in Mississippi, but for affected women a real health problem, while virtually all island governments and health systems consider breast reduction “cosmetic”. The augmentation/reduction ratio – Schleich’s number S, a fairly accurate measure of the local expansion of the breast universe – in my own practice in Trinidad is about 1.5.
The true culture shock for me, however, were rhinoplasties. I am probably at the moment one of the few “Western” surgeons with an almost exclusively ethnic rhinoplasty population. Everything you and me wrote in our recent book is true – it is a very, very difficult and unforgiving procedure, a little easier in East Indians and Hispanics than Asians, Afro-Carribeans or Creoles. I am a fellowship trained craniofacial surgeon and thus maybe a little bit more facile with all sort of autologous grafts than others, yet a “very” ethnic Afro-Caribbean rhinoplasty is still something which causes me sleepless nights and increased antacid consumption.
Now Trinidad is very special. In my humble opinion some of the most beautiful women on the planet live on this small island – and yes, I am biased as I am married to the most beautiful of all of them. Statistically, there have probably been more Miss Universes, Miss Worlds, centerfolds models etc. per population of only 1.3 million than anywhere else. So the baseline for a Trini woman is to be beautiful. The sad thing is the high rate of permanent facial disfigurement resulting from really bad acne scarring, which interferes with their natural beauty. I don’t see a silver bullet for this problem, except treating active acne appropriately, which is a whole other can of worms, but I really wish I could come up with one. Everything I have tried is a crutch with much, much more incomplete resolution of the problem than in Caucasians. Lasers are generally of limited usefulness in my client population, TCA peels work well for rejuvenation – yes, Obagi is right, one can do a Blue Peel with excellent results in Afro-Caribbeans and East Indians are a picnic – but are unpredictable for a lot of acne scars; fillers, fat grafting, platelet rich plasma, persutaneous collagen induction +/- meso substances are inconsistent, just too many of these scars for subcision etc. Currently I reverted to therapeutic minimalism in the form of sandabrasion, which at least has very few pigmentary side effects, fewer than diamond wheel mechanical dermabrasion, makes it better, but not perfect;
On the bright side – cellulite is really rare !
Dr. Eppley: Makes me want to move to Trinidad …
Dr. Schleich: Yes, it is a great place for a plastic surgeon, clients are a pleasure to work with and remember, in the majority of cases they are already swimsuit models !
Dr. Eppley: What is the average cost of popular plastic surgery procedures in your practice in Trinidad and the Caribbean ?
Dr. Schleich: Private hospital services in Trinidad are relatively expensive compared to the average per capita income of the population, but mostly quite a bit less than in the US; hospitals charge by time and supplies used, so it is sometime difficult to give a number, because the cost depends on the extent of the problem for example two liter lipo are less expensive than four liters lipo, which makes sense; I use only the latest and greatest high end Brazilian implants, which are about twice as expensive as the cheapest available Mentor product, and so on; so a gross estimate of the total, all inclusive procedure cost for some all time favorites:
breast augmentation 5000.00 USD, rhinoplasty 6500.00 USD, liposculpture less than 4L aspirate 5500.00 USD.
Dr. Eppley: Are most of your procedures performed in office, private clinic or hospital and why ?
Dr. Schleich: In office about 10%, in private hospital about 90%. In office I virtually only do aesthetic medicine procedures – fillers, botox, I in fact use Xeomin, peels, microsclerotherapy, sandabrasion, percutaneous collagen induction etc.; all “real” procedures are done in private hospitals, which in Trinidad are interestingly colloquially referred to as nursing homes;
the “why” is an interesting question – largely because I have never seen myself having a huge interest in running a surgery center; the cost factor of the nursing homes is of course something I am getting increasingly focused on as this is a factor we cannot well control ourselves and it more than occasionally forms an obstacle to medically indicated care e. g breast reconstructions; exceptions prove the rule, but a sizable number of private hospitals in Trinidad have shifted their focus too far to the business side and away from the patient, while their equipment, personnel and facility decayed and eventually became substandard; those which are still patient centered are the ones where I continue to operate;
Dr. Eppley: Arno, thanks so much for the time to make this contribution to World of Plastic Surgery.
Dr. Schleich: It is entirely my pleasure, Barry; hope to see you soon !