by Safi Ali-Khan
This is the second piece of a series dedicated to exploring the nuances of plastic surgery through interviews with resident and attending surgeons. The first entry can be found here.
This interview is particularly special, in part due to Dr. Hidalgo’s exceptional career, and also because he was the first plastic surgeon that I had the privilege of being introduced to. Our chance encounter occurred as I was preparing my applications for medical school, and during a brief conversation, he described to me a vision of the ideal plastic surgeon as a perfect cross between artist and entrepreneur, a creative visionary who constantly seeks to expand the boundaries and limits of the field. His words were hugely influential in guiding me towards the specialty, and they inspired many of my future endeavors with the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health.
Upon devising this current project, I knew that Dr. Hidalgo’s perspectives would be an enlightening addition, both for me and for readers (especially like-minded medical students). It is with great pleasure that I present our conversation here, edited for brevity and clarity.
SAK: When we had first met [in 2014], I was interested in plastic surgery, but I hadn’t had any exposure to it. I looked you up at that time, but I didn’t know anything about your career and accomplishments. What was interesting to me was that you are an artist and you have your art displayed on your website, so I wanted to start there and ask how you got into art.
DAH: Well actually I was interested in art first, before medicine. I was basically self-taught. I had two older brothers and I was by myself most of the time so I just started drawing things, for as long as I can remember…In college I was contemplating being an artist and not a doctor. So it was back in college where I was at that crossroads and I had to decide which way to go. Plastic surgery has been a way for me to circle back and get into art again. I certainly use a lot of those visual skills on a day to day basis. But it’s not the same as art.
SAK: How did you become interested in medicine?
DAH: I had a mentor at Georgetown who was a general surgeon and also an artist of sorts. So we had similarities from the art side and he said “David I want to introduce you to surgery and see if you like that,” and he took me to the operating room and actually had me assist on a little tiny procedure and I was really taken by it. That started my interest in surgery. At the time, Georgetown one the of the cardiac surgery pioneers, actually [Dr. Charles A. Hufnagel] who made the first heart valve that was implanted in a human was there, so I was enamored with cardiovascular surgery. It was very impressive, so I wanted to be a cardiac surgeon originally. As I went through premed I was influenced by this surgeon at Georgetown, but I was still taking fine arts courses at the same time. Then it became time, like yourself, to decide what to do, and I signed up for a general surgery residency at NYU.
SAK: From general surgery, how did you find your way to plastic surgery?
DAH: While I was a general surgery resident, I did a lot of medical illustrations for the general surgeons, for their articles. I always had my hand in it. Then one day, I was in the recovery room and they had a plastic surgery patient who was one of the first microsurgery limb replantations. I was in the recovery room taking care of one of my general surgery patients and I just started looking at that patient and asking what happened and it sort of got me going in terms of the microsurgery part, so my first link to plastic surgery was through microsurgery. I did a subinternship on plastics and I really liked it, and I started illustrating a book that they were writing on microsurgery, I actually have it here somewhere…So they asked me if I wanted to get involved doing these illustrations for this microsurgery book and I started doing these drawings…nerve drawings, there are flap drawings…I started doing all these donor sites trying to figure out where we were taking flaps from – they were working out the anatomy back then and I was doing these drawings for them trying to figure out what’s there.
SAK: This was still as a general surgery resident?
DAH: Yeah, this was at NYU. So they’re working out donor sites and I started doing the drawings for them and it turned out no one was writing the book. So I had like 120 drawings and no one was writing it, so I started writing the book. I ended up co-authoring this book – did the drawings and co-authored the book – and that sort of got me started in plastic surgery. What I liked about plastic surgery was that it wasn’t restricted to one part of the body and it was more creative than things like cardiac surgery. I found that cardiac surgery was actually boring, and when I was at NYU as a second year resident they would let me scrub on these cases, they put patients on the heart-lung machines, and let me do some of the proximal grafts and I did a bunch of those and I said ‘You know what this isn’t terribly interesting,’ as exciting as it is. On a day to day basis it wasn’t that interesting, so I gravitated more towards plastic surgery and that’s when I did the plastic surgery residency there.
SAK: So it was primarily the creativity and the freedom to operate all over the body.
DAH: Exactly. The biggest thing is that whatever you do as a plastic surgeon you see it, it’s different than taking out a gallbladder, you actually see what you did, for better or for worse when it doesn’t actually come out as you envisioned.
SAK: One of the things you had said to me when we last spoke was a description of your ideal plastic surgeon as a perfect mix between artist and entrepreneur. I wanted to revisit that statement and see if it still resonates with you, or if your opinion is different now.
DAH: Did I say entrepreneur?
SAK: You did.
DAH: That’s an interesting thought. I certainly think, as a plastic surgeon, if you have an innate artistic ability it puts you head and shoulders above the average plastic surgeon because you can see things that most people can’t see, or things that they think look fine you see a million things wrong with them, and I see that even today in the operating room when the nurses look at me like “why aren’t you finished, what are we looking at,” they don’t get it. So how you see is key. As far as the entrepreneur part I think what I was thinking there is not like Elon Musk, but it’s more ignoring, or seeing beyond the boundaries, and venturing out and doing something innovative. I think the proper word is innovator…I think the best plastic surgeons are artistic and innovators.
SAK: Who were some of the mentors you had as a resident?
DAH: My main mentor was the guy I wrote this book with, Bill Shaw. Bill Shaw was a pioneer of microsurgery and he was an amazing guy. He didn’t think in conventional terms and he’s one of the reasons why NYU at the time was so innovative. Microsurgery had just come about, and nobody knew where the boundaries were, and we were just stretching the boundaries doing all these things, and he was on the forefront of that. I learned a lot from him about that, and it also sparked some creative thoughts as well in terms of things that I subsequently did.
SAK: Actually, one of the first cases I saw that really hooked me into plastic surgery was a fibula flap [for mandibular reconstruction], so I wanted to ask a little bit about that and where that idea came from.
DAH: For me that was probably the most significant work I’ve done. It was a confluence of an opportunity, which was Memorial Sloan-Kettering, where they had lots of cancer patients missing jaws, that was the opportunity, combined with the preparation I got at NYU, in addition to having that creative thought that made it all happen. From NYU, going through that program, you understood all the tools at your disposal, and you were confident in how to use them. So you have that toolbox you’re walking around with and what happened at Memorial is the opportunity of that particular problem posed the question of how can we fix this the best way. We had the ileum as a free flap, but it was the wrong shape, it was cumbersome, we were trying to put a square peg in a round hole with that free flap donor site. It struck me that the fibula would be better because the bone is perfect, it comes as a straight stick, you can cut it, you can do whatever you want with it, you can shape it exactly like what you want, but that whole thought came naturally by having a problem that did not have a good solution, and doing the same old remedy and being frustrated by its limitations. And having the background. Fibulas were only used at NYU for trauma, for replacing humerus, femur, for long bone replacement.
SAK: Without dividing it.
DAH: Right. So it was a no-brainer that worked great. It was at that moment that we had a problem, we had a lot of patients with that problem, we had a solution that wasn’t great, and the idea came from having the previous experience using the answer in a different way. We were using it for long bones and the lightbulb moment was when I said to myself why not use the fibula for a mandible, and we can cut it, we can put plates and screws on it, and that was the first one. We did that, it worked, it evolved, the first ones were a little more primitive, but it evolved very quickly, and it’s become standard of care around the world today.
SAK: What attracted you to microsurgery?
DAH: I think I was attracted to two things, the precision, you know it’s all or none, the thing works or it doesn’t work. So I was attracted to the precision and I was attracted to the possibilities that it opened up by transplanting tissue from one part of our person to another without the whole transplant issue. It was those two things.
SAK: And from there what made you pursue an academic career?
DAH: Well, the interesting thing about training is you’re in a lock-step process where you go to medical school, you go to surgical residency, you do your fellowship, but at that point it’s like stepping off a cliff because there’s no more structure and you have to design a life for yourself, and it’s one of the hardest transitions. So for me I wanted to use the microsurgery skills that I had, I knew that was going to be in an academic environment, so it was a matter of finding a place where there was an opportunity, and that was just plain luck.
SAK: Your practice has obviously changed significantly over the years. Why did you decide to go into private practice after so many years in an academic setting?
DAH: I think it was the exposure at NYU to the group of attendings that were there at the time. It was quite different to the way it is today.
SAK: How so?
DAH: Back then we had what I would call a giant in every subspecialty of plastic surgery. Aesthetic surgery we had Tom Rees, microsurgery we had Bill Shaw, craniofacial we had Joe McCarthy and John Converse before him, hand surgery we had Bob Beasley, I mean these were all giants. And the cosmetic guys, the younger ones are the old guys now, [Daniel] Baker and [Sherrell] Aston. So going through that training what I learned is that a plastic surgeon doesn’t have to do one thing, they can do everything, and part of the appeal is the variety of it all. I didn’t want to get pigeon holed into one thing. I wanted to do that for a while, but I wanted to evolve into something that was broader in scope. I saw the guys who were doing aesthetic surgery and doing it seriously, and they were doing reconstruction too, so I said you know what, you don’t have to be one thing. Other people will define who you are but you don’t have to define yourself, or if you do you want to make sure it’s what you want it to be. So when I was at Memorial, I missed doing some of the things that I do, the aesthetic surgery basically, and there wasn’t really an avenue for that. But I had sort of a hybrid situation where I was there most of the time doing reconstruction but then I got this office and I was here a day a week, so I was sort of transitioning. And for me it was the right thing because one of the nice things about plastic surgery is that you can evolve, start out in one thing and end up somewhere else, and it makes it more interesting than doing the same thing throughout your whole career. The other part for me that was at a higher level was that I wanted to do things that were innovative, because that really gives you a charge to come up with a new idea, implement it and see it work. It’s beyond just doing cases every day. When I was at Memorial for a while I sort of hit a wall and I said I don’t think I’m going to have another creative thought in this arena, and that notion has sort of withstood the test of time because fibula surgery today is still pretty much the same as it was 30 years ago when I started. So at that point I was doing breast reconstruction and TRAM flaps, we didn’t have DIEP flaps yet, and I said you know what this territory is pretty well worked out, I want to do something different, and that’s how I finally migrated to aesthetic surgery. But it stemmed from my training in which I saw people doing everything. I didn’t just want to get locked in.
SAK: What are some of the advantages or disadvantages to being in private practice versus academic, of having shifted your career around?
DAH: Well there are intellectual differences and there are structural, practical differences. The practical differences are that when you’re at an institution you can sort of keep your head down and focus on your work, you don’t have to worry about administrative things by and large. When you’re in private practice you’re running a business, so you have employees, you have expenses, it’s different. It’s not for everyone. So that’s the structural difference. The advantages are, as my own boss, I can do what I want, and when you’re at an institution you have to answer to the administrators and if you want a new Xerox machine you have to ask them for it, you know. There are pluses and minuses and both have advantages and one is not clearly better than the other. The private practice world is not for everyone either. Intellectually, the pressure to contribute to the field comes from within. When you’re at an institution they put pressure on you to develop your CV and you can end up doing a lot of busy work, cranking out papers that don’t have a lot of value. The advantage to being in private practice is that I don’t have to do that, I can just focus on interesting problems that come up periodically. They don’t come up every day, but every year I’m working on two or three different things, and it’s a luxury to be able to do that. It’s probably [as] equally satisfying [as] operating on somebody.
SAK: With all of that in mind, as you’ve learned more about business and private practice, is there anything new you’ve learned about yourself, your perception of doctoring or plastic surgery in general?
DAH: There’s a lot of ways I could go with that answer. Being a physician has changed greatly since when I started. It’s changed because of the increase in regulations, it’s changed because the whole reimbursement system has really changed in a way that’s not favorable to physicians. Those are two big issues. The internet has probably had the biggest impact on being a physician, I think degrading the way we are supposed to be as physicians. There has been a complete breakdown of the patient-physician relationship in many ways. It comes from patient’s being able to give anonymous reviews of their doctors. I mean, you can do that in restaurants, but when you start doing that about professionals, it’s a degrading trend. In some ways, as I’ve gone on, the normal feeling of fulfillment that you get from doing the work is still there, but it used to be that there was a built in respect that patients had for physicians, and that still exists up to a point, but it’s different, particularly in plastic surgery, I don’t know what it’s like for the hospital based guys. It’s changed in a way that for me is not for the better. And as I look at what I do, to me doing things day in and day out for individual patients, the gratitude that you initially get – like one of the most gratifying things was the first time I took out an appendix, I diagnosed it, took the guy to the operating room, chief resident helped me take out the appendix, that was like wow, it was fantastic – unfortunately, that gets old pretty quick, and we’re not motivated to have patients tell us how grateful they are. I mean, it comes with the territory, if you’re doing your job that comes, but it’s not why we do what we do everyday. We do what we do because we’re interested in the problems, we’re always interested in the patient’s well-being, I want to make that clear, but you know we don’t do it so they tell us how grateful they are. So it has to be something else, it has to be the nature of the work itself. For me, it’s going beyond that, and trying to improve the specialty and change the way we as physicians do what we do. It’s a lot more satisfying to influence a thousand surgeons than it is to operate on a thousand patients, because the multiplication effect of influencing physicians has so much more impact. It’s also very satisfying to change the way the river’s flowing, whether it was with the fibula, or some of the other papers that I’ve written. I look back at those as the landmarks of a career. So in terms of why we do what we do, we do it because we like it, we want to be good at it, and we want the respect of our peers which is the highest form of confirming that you’re doing the right thing. Beyond that, it’s about legacy. What have you done to make things different and better. Legacy is small in medicine, it’s not like being the president of the United States – that’s a legacy, if they do it right. For medicine, legacy is small and transient. We don’t study famous doctors. We don’t really know who the stepping stones were to how we do things today. That’s one of the, not failings, but disappointments in medicine. It’s hard to create a long lasting legacy, if that’s an interest. And it’s not about writing articles. You could have 150 articles on your CV but if they’re not saying much and people aren’t reading them…I sort of look at where I am and who I am by, mostly, by those landmark articles that I’ve written and things that I’ve changed. And not just the articles, it’s teaching at conferences, lecturing and that sort of thing.
SAK: Looking back on your training as a resident, what do you think was missing from it?
DAH: I think people who are coming out today can answer that question better, because back in the day there was nothing missing. It was a different system. And at Bellevue, NYU – particularly Bellevue – there were no attendings around after hours. So you learned from the residents, and you got a huge amount of responsibility. I got a huge amount of operative experience, huge amount of responsibility as a chief resident in general surgery. If they brought in three people who all had gunshot wounds at the same time you’re the guy in charge. You had to triage them, operate on them, do everything. And that plus the star studded faculty we had there, I don’t think I could possibly have had better training.
SAK: Even from a business aspect, once you got into practice and were starting your own practice, did you feel like there were things you wished you had learned earlier on?
DAH: As far as running a business, no one in medicine is going to teach you that. You’re like any other retail person out there. All of those lessons are painfully learned. You get a lot of scars from that whole process. So no, I don’t think that there’s any way that medical training can prepare you for that, and maybe it doesn’t even need to because the whole model is changing. Plastic surgeons and dermatologists are probably the last ones that can be out in private practice, the trend is working for hospital, being on salary and working at a hospital. That’s another part of the change in medicine, so it’s going to be difficult for young people coming out to start a practice.
SAK: Any advice for residents who are about to make that transition?
DAH: Well there’s only one way to do it if we’re talking specifically about plastic surgery. The only way to do that is to join a senior person. You have the basic tools of the trade so to speak, but that’s it. You don’t have people who know who you are, you don’t know how an office works, so it’s a huge learning curve, and that’s really the only way to do it I think, today. It’s unreasonable to try to just go out and hang out a shingle. You can do that, but…I had a young guy who’s been out a year come back and said to me “My God I didn’t know it was going to be anything like this,” meaning that he was doing a lot of things that he didn’t want to do, and he couldn’t see how he was going to get from where he is to where he wants to be, he didn’t see how you get there. So I think it’s very challenging.
SAK: For those people that do feel stuck, is there any thing that helped you when you were thinking about making a shift from one point to the other?
DAH: I think you’ve got to start out in a good place. If you’re a baseball player and you want to be on the Yankees, it doesn’t just happen. You’ve got to be really good to start. So you’ve got to have the innate skills and ability as a prerequisite, and then the other thing is you’ve got to be totally single minded, and you’ve got to do it twelve hours a day every day. I’ve been doing it over 30 years, I’m still doing 12 hours a day. So, you have to have the prerequisite skills and ability, and you have to be single minded, and as they say you have to put in the sweat equity to get there, and that’s no guarantee, but you won’t make it without those things.
SAK: In terms of still having a balance in your life to make art, spend time with your family, whatever, and being that single minded, how have you made that work for yourself?
DAH: You can’t be balanced and a leader, I don’t think. You can’t be balanced and be extraordinary at what you do. I may be wrong. I couldn’t do it. Your work is the driving force in your life, and you fit things in around it. Now, if you have a family, you have to bend and you have to make things work. You don’t want to be a great plastic surgeon and divorced, that doesn’t work. It’s a juggling act. But by and large you have to be single minded, focused, and thinking about it pretty much all the time.
SAK: Looking forward into the future of plastic surgery, what are some of the things you’re most excited about in terms of new innovations and technology?
DAH: I’m not looking for something revolutionary. I’m more interested in evolving the things that we have to make them better. Medicine is like that. You look at electronics, again the car industry…technology you can make leaps, but our vehicle is the human body. The human body hasn’t changed in millions of years probably. I mean that’s an exaggeration but it hasn’t changed in a long time and it’s not going to. We’re limited as surgeons in terms of what we can do by the rules of the human body. We can come up with innovations like microsurgery that allow us to move stuff around but we’re not fundamentally, like with electronics and car evolution, we’re not going to proceed at that pace. It’s not reasonable. And we don’t even know of the things we’re doing whether they really work or not, because in plastic surgery we’re not studying it carefully enough. Like brow lifts, do they really work, there are five or six ways to do it, nobody knows, everybody does it the way they like but nobody knows, 10 years, which way works the best. So the things that interest me about plastic surgery are evolving what we do. Every now and then something revolutionary comes around, like liposuction was huge, microsurgery was huge, open rhinoplasty completely changed rhinoplasty, but you know these things come along once in a while. It’s equally important to figure out what we’re doing, and doing it better. And that’s very much doable…I’m not looking for something magical to transform what we’re doing. I’m looking for answers that are anatomy based that help us solve problems. We have understanding of how to do a face lift and some of what we’re finding out is maybe it’s not correct. It’s a different speed of development than other endeavors.
SAK: Anything you can share about particular projects or problems that you’re working on right now, or even just your method in terms of approaching problems?
DAH: There are a couple of things. As humans, involved in a single area, people have good ideas and people have bad ideas. And sometimes bad ideas take hold, and part of it is to expose those bad ideas and say we shouldn’t be doing this, this doesn’t make sense. For me one of those areas is anatomical breast implants. I did a randomized controlled trial to prove that anatomical implants are not aesthetically superior to round implants. So we’ve sort of been fighting that battle because industry is behind those, and industry is pushing those. And now we find that those implants, because they require a heavy textured surface, can cause [anaplastic large cell lymphoma], so they can actually do bad things. And the motivation for using them is not correct, it’s not for getting the best result. So there are things like that that I’m interested in, sort of righting the ship…They should have done the study that I did 20 years ago before they put these things on the market, but it was all hype and marketing and it got started, and now we’re sort of trying to correct that. Things like that are interesting to me. Also, the problem of capsular contraction with breast implants has been a nemesis of plastic surgeons for 30 years, 50 years. Now, this speaks more to the innovation that you were mentioning, we have a biomaterial called acellular dermal matrix, so I have found that patients who have recurrent capsular contracture, done the same operation, it comes back – and you’ve heard the saying of doing the same thing over and over again and expecting a different result – so that’s what we’ve been doing because we had nothing else to offer them, so now we’re using that biomaterial to cover the surface of the implant as an interface between the implant and the breast tissue, from the bottom of the pectorals muscle down to the inframammary crease. I’ve done that on 20 of the most difficult cases and they’re all fixed, solved, normal. That bit of technology is extremely interesting, so we did a video of the surgery, it’s going to be on YouTube, we’re making a website about it. So those are two examples.
SAK: Great, thank you. You mentioned the role industry has on the kinds of breast implants that are offered, and the role of industry in guiding medical practice for better or for worse at times. Speaking more broadly about the role of outside industries and the mass commercialization of plastic surgery that’s happened recently, what do you think the impact of those are on the field, its practitioners and patients?
DAH: First of all, industry is good for plastic surgery. If they didn’t make breast implants we wouldn’t be putting them in. However, a lot of industry today, as it applies to the medical field and specifically aesthetic surgery and aesthetic medicine, is that it’s all hype and marketing without any solid science behind it. It’s distracting, most of it is not harmful to patients, but [at the] end of day a lot of it is a waste. It’s a way for physicians to earn a living by using these things, it’s not really good for patients, patients get false hopes, so it’s kind of a quagmire, because if you’re an ethical person, you’re not going to engage in those things, and you may be at a disadvantage if you don’t. I think industry is like the internet, it’s both good and bad. They develop things, they make things better, but a lot of it comes with hype, without any real science, without any data, and therefore it’s not a good thing.
SAK: Looking back at everything we’ve talked about and everything in your own experience, what do you think is the most special thing about plastic surgery?
DAH: I would say, for the surgeon, it’s immediate gratification. You are faced with a problem, whether it’s breast reconstruction, or aesthetic surgery, if somebody is a normal person, a happy person, but they’ve lost something, they’ve aged or they don’t feel competitive in their job, or whatever, it’s fixing that problem with your own two hands. That’s the most gratifying thing about plastic surgery. Probably the singular most gratifying thing.