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In the real world of surgery, however, a new look is not achieved just by snapping a photo and electronically altering an image. The gory manual labor begins as DiGeronimo and his two surgical assistants prepare a 21-year-old student, John, for the procedures that may change his life: a nose job (or rhinoplasty) and the setting of oversize ears closer to his head. John's goal is to be an actor, and he has been disturbed for years about his appearance. He already has had two nose jobs by other doctors, the last one causing the cartilage in the front of his nose to collapse. Now he's seeking to undo the damage of previous work, and, finally, to get the look he craves.
Nurse Rodney Davis, a free-lance anesthetist who works for DiGeronimo and other doctors, helps John onto the black operating table and covers him with a thick yellow and brown blanket A the temperature is kept cool to ward off germs A before injecting an intravenous needle into his right arm. Within minutes John becomes groggy after Davis adds sedating drugs to the IV tube, which funnels into the patient a dextrose and saline solution that provides liquid nutrients during surgery. In today's cosmetic surgery, doctors usually avoid using general anesthesia so the patient faces reduced drug risks and is more cooperative during surgery, while still being numbed and sleepy. DiGeronimo begins the painkilling process by injecting needles into the side of John's skull, along the ears, and in the nose.
The doctor starts with the ears. He coolly slices a curved line behind John's right ear, removing skin and exposing a bloody area of cartilage and muscle. Then he takes a long needle and begins scratching the exposed cartilage so he can bend it more easily. After doing that, he proceeds to quickly stitch together the back of the ear so it folds up, making it look smaller and bringing it closer to the head. "See that ear there?" he asks playfully. "Watch what happens when I tighten it," he adds, tugging on the thread and making the ear wiggle. He presses the ear closer to the skull, runs another thread hooking the back of the lower part of the ear to the skull, and pulls on the thread. At various points during every procedure, DiGeronimo is absolutely silent as he focuses on a challenging task, while at other times he chats amiably as he performs a job such as stitching up an incision, exuding the confidence of someone who has been in practice for nearly sixteen years.
On the table, John stirs awake for a moment, moaning in a foggy voice, "It hurts so much."
"We'll give more local [anesthetic]," DiGeronimo announces. Both the doctor and Nurse Davis are calm about the patient's temporary pain because they know the drug's dosage can be increased with the press of a switch attached to the IV tube, adding more fluid to the bloodstream. After less than an hour, DiGeronimo starts on the more daunting task: reshaping the nose.
"This is what I really love, doing a nose that's been done before," DiGeronimo says. "It makes it an even bigger challenge." He affixes what looks like an odd miner's-cap-style headlight over his forehead; it is actually a magnifying glass attached to a fiber-optic tube running from a light-source box on the floor. Then he chooses a scalpel and begins cutting the tips of John's nostrils. Blood starts flowing, so much so that a tube is placed up his nose to draw off the blood. The doctor reaches into the nose with scissors and extracts a bloody piece of cartilage. "This side of his nose was totally blocked," he says, continuing to cut flesh. Now he lifts up the skin that's covering the entire nasal bone underneath and moves it to the side as if it were a rubber mask. He plunges long scissors deep into the nostrils and cuts some more. "Are you going to file it or break it?" Davis asks.
"Break it," DiGeronimo says. Like any sculptor, he uses his chisel, positioning it carefully underneath the skin on the middle of John's nose and instructing the assistant to start tapping with a hammer. It is a far harder task than moving a computerized pointer on a TV monitor. John stirs uneasily under the blanket, and DiGeronimo snaps, "Keep him down, Rodney." Davis injects additional medication into an opening in the IV tube, then reaches up and flicks the switch that permits more fluid to flow into the patient.
DiGeronimo removes more cartilage, then exults like a cowboy lassoing a steer: "Whee-hah!" He boasts, "When I finish him, he'll be able to run a marathon with his mouth closed!" The doctor chisels some more to narrow the bridge of the nose, scoops out more cartilage to reduce a bulbous protrusion near its tip, and announces, about an hour after he started, "Okay, let's sew it up."
"There's a lot of difference," Davis says admiringly. "He'll look a lot better."
After putting an aluminum splint on John's nose and wrapping the patient's ears with bandages, DiGeronimo helps John walk into a reclining chair in the recovery room. He is woozily becoming alert, and virtually the first words he says are "How do I look?" Waiting for him are his parents. His mother tells him, "John, it looks like a little nose."