Don't Think You're Writing Historical Novels? Think Again.

There was a time when people (women) did the laundry down by the stream, pounding the clothes with rocks. Then came the washtub and washboard. Then the wringer washer. Then the automatic washer. The automatic dryer replaced the clothes line. Trust me. I don’t want to go backwards (even if the clothes did get cleaner in a wringer washer) but sometimes I wish I could yell "stop!" and take a breather from how fast the world is changing.

Especially when it comes to my stories. Because most contemporary stories are written in the ever-present "now," we writers have to stay abreast of what's going on in the world.

Trust me. It ain't easy.

The world is becoming more gadget crazy every day, and technology just keeps bringing us more and better gadgets than we know what to do with. Some of those gadgets change the face of society so rapidly that your stories are dated within just a few years. Think about it. How long ago were cell phones the new thing? No one had them twenty years ago. Now everyone does. Well, everyone but me, but only because I don’t want to be in-touch 24/7. That and I know how reliably I lose or break things. And I’m sure that when I needed it, it would either be dead or home in the recharger. (Or if they follow the current trends, it will be so damned small I won't be able to find it.) So though I do think it’s très cool when I see someone in a big box store call their mate or their kids who are on the other side of the store to coordinate with them, it just seems like more hassle than it’s worth to me.

Land-lines are going the way of party lines. And dial-up internet? Fuggedaboutit. Boombox? Nah. (See my IPod?) VCR? You can’t give those tapes away. Yet each of these were once state-of-the-art innovations.

If your character uses a VCR, your story is now dated.

Soon, any character who complains that he has 100+ cable channels but there's nothing on TV will be old school, because TV on demand is already here.

How long will it be before having a character pick up a book instead of a Kindle or Nook dates the story?

 I remember seeing a Columbo episode (way back in prehistoric days) where he proved the suspect was the murdered because a traffic cam ticket (complete with picture) proved the suspect was where he claimed he wasn't the the critical moment. It was brilliant stroke of plotting at the time. Now it's common to see fictional cops track someone by the tolling sticker on their car. If your car is equipped with On-Star or Lo-Jack, they can pinpoint its location. How long before every car sold has built-in GPS? How long after that will they be able to tell not just where it is, but everywhere it's been?

 If you have a cell phone, you're even easier to find because they can triangulate your position from the cell towers.

High-definition TV isn't going to be dominant for long. 3D TVs are already here and as low as $1k on Amazon already. How long will it be before we have hologram movies? And after that, will the audience be able to wander through the hologram, watching whatever they want, almost like a participant? From there, it's not hard to envision the leap to Star Trek's holodecks.

I probably won't live to see it. Then again, I know people who never imagined they'd have a box-like appliance that would cook their meals in minutes.

I don't want to even go into how fast DNA-science is improving.

Woe to writer who ignores these tecnological advances because they're already common enough that readers will question why the authorities aren't using these methods to solve their problems.

Can you imagine what next year will bring? Or the year after that?

Wouldn't a crystal ball be nice right about now?

And it's not just technology that changes. A critique buddy of mine informed me that it's a rare under-30 woman who wears panty hose. Not sure how universal that is, but it reminds me to check whether societal attitudes are different if I'm writing a character out of my age group.

Those attitudes are a major component in this widespread embrace of new technology.

For instance, let me tell you about the refrigerator the daughter of a friend of mine just bought. It's Wi-Fi capable. Seriously. It can tell her the weather outside and look up recipes. It has speakers for the built-in radio. It can twitter, for crying out loud.

It has both her mother and me scratching our heads and wondering "why?" But her daughter is a different generation and doesn't find it nearly as incomprehensible as we do.

The future is here, folks.

Fortunately for my sanity, some things don't change quite so fast.

One of my favorite stories is the one where, after the fall of the Iron Curtain, NASA scientists finally got to ask Soviet scientists how they solved the problem of pens that wouldn’t work in space where there’s no gravity. (If you didn’t know that the pens that will write upside-down are compliments of NASA, now you do.)

The Soviet Scientists' reply?

“We used a pencil.”

I love that sort of out-of-the-box, low-tech thinking.

So what technology amazes you? And have you thought about how to incorporate it into your stories?

First Plot Point

Most stories are told in a 3-act structure. Each act takes the hero/ine into a different world. Blake Snyder (author of Save the Cat! which I reviewed here) defines these three worlds as
  • the thesis world (where the character is comfortable)
  • the antithesis world (where the hero/ine's world turns upside-down)
  • the synthesized world (the new world the hero/ine proves him/herself and applies what he/she has learned.)
There are some basic things to look for for each of these turning points. The first one (where the character steps out of their comfortable world in act one), which comes about 1/4 of the way into the story, is usually easy to spot, if you know what you're looking for. The common wisdom says that the main things to look for are:
  • The hero must make a choice. (In the Hero's Journey based on Joseph Campbell's analysis of myths, this is where the hero/ine answers the Call To Adventure) The hero may make this choice kicking and screaming and often doesn't really understand what they're getting into, but it must be his choice. (This is what they all tell you, but is it true? We'll look at that, too.)
  • The story must change directions 

Movies tend to be more universally familiar to everyone, so I'm going to use a number of them to illustrate this.

Romancing the Stone [Blu-ray]In Romancing the Stone, Joan Wilder's sister has been kidnapped and needs her to bring a map to Columbia. In spite of the fact that she gets motion sick on escalators, Joan goes, thereby stepping out of her comfort zone in Manhattan and into a third world country she's totally unprepared for.

Sara Conner in The Terminator makes her choice by taking Kyle's hand when he says, "Come with me if you want to live."

In Dirty Dancing, Baby makes the choice to become involved with the dancers' problems when she asks her father for the money because "someone's in trouble." For the first time in her life, she lies to her father, denying that it's for something illegal (as abortion was back then.)

Ethel and Norman agree to keep 13-year-old Billy for the summer in On Golden Pond, so their daughter and the boy's father can take a trip to Europe.

In Sleeping with the Enemy, Laura chooses to fake her own death to escape her abusive husband, leaving the hell she knows for a new life.
Sweet Home Alabama
After forging a successful New York career, Melanie returns to Alabama to get her husband to sign divorce papers so she can marry the mayor's son in Sweet Home Alabama.

In The Sting, Redford and Newman make the choice to run a revenge con on the man who killed Redford's conman mentor.

Luke Skywalker refuses to join Old Ben Kenobi until the Empire's storm troopers kill his aunt and uncle in Star Wars, but in the end he chooses to sign on, spawning five more movies.

Small town cop and neatnik Scott Turner's life is turned upside-down when he reluctantly takes responsibility for Hooch, an unmannerly junkyard dog, who is the only witness to his previous owner's murder in Turner and Hooch.

In Victor/Victoria, Victoria and Toddy hatch a plan to pass her off as a female impersonator. Though she's skeptical at first, she lets him convince her.

In all these cases, the hero/ine made the choice to step into an alternate world. Sometimes that choice is the only reasonable one to make. But is that step into the new world always the hero/ine's choice? The movies below would argue it's not. In these stories, the only choice the character has is to deal with what life has dealt them. Let's look at some of those.

Avatar (Original Theatrical Edition)When the seeds of the sacred tree perch all over Jake's body, Avatar changes directions. Jake is no longer an alien invader but the special someone who has been foretold in Neytiri mythology. Though Jake doesn't understand what this means, at this moment, he can no longer be who he was before.

In Peggy Sue Got Married, Peggy Sue is thrust back in time to high school, not long before she got pregnant by her boyfriend. This isn't her choice, but it most certainly changes the direction of the movie. Once she's in the past, she has little choice but to go with it. (Unless you count telling everyone the truth and being thought crazy.)

In P.S. I Love You, Holly steps into the second act when her husband dies. Does she choose this? Hell, no.

In Ransom, Tom Mullen steps into an unknown world when his son is kidnapped. Again, not his choice.
The Rock
A chemical specialist for the FBI is told he will go with the seal team on their mission to free Alcatraz from the military rouges who have taken over The Rock. Maybe this is a choice, if he you count his ability to quit his job as an option.

After a bathroom accident, ad man Nick Marshall can hear women's thoughts which pushes this misogynistic man into a world he neither chose nor wanted in What Women Want.

Twelve-year-old Josh Baskin makes a wish to be "Big" which is magically answered. Though this might be considered a choice, he never actually expected his wish to be granted nor is the result really what he had in mind. This is, in many ways, the same movie as Peggy Sue Got Married because the real choice comes at the end of the movie when the characters choose their old lives.

In many of the examples where the character didn't make a choice, the protagonist is thrust into the antithesis world by magical means, but not all of them. This seems to argue that having the character make the choice strengthens the story, but that it's not a deal breaker if they don't. The story must, however, change directions at the first plot point.

How do your stories change direction? Does your protagonist make the choice?

Lessons From a Lifetime of Writing - A Review

Lessons From a Lifetime of Writing: a novelist looks at his craft
(Republished in 2008 as The Successful Novelist: A Lifetime of Lessons about Writing and Publishing)
by David Morrell
Writers Digest Books (2002)
Table of Contents of the 2008 version is available on Amazon.



The Author
David Morrell has written more than 20 books. His best known is First Blood. Yes, as in Rambo: First Blood. I always find it reassuring when the author of a writing book has written books that are still in print years later. Even better when it's a book I recognize or have read. Having written a character that/s become a cultural icon, I expect him to know his stuff.


That said, I wasn't sure what to expect from the title of this book. Was it going to be about his personal journey as Stephen King's book  is, or would it be more of a how-to book? Turns out it's a bit of a hybrid.


Morrell writes about his journey, but his insights are universal. Such as when he writes about what you should write about, he relates what he was once told by Science Fiction author Philip Klass (pen name, William Tenn):


Look inside yourself," Klass said. "Find out who you are. In your case, I suspect that means find out what you're most afraid of, and that will be your subject for your life or until your fear changes."


Morrell calls this "fiction writing as self-psychoanalysis." Because of his childhood, Morrell's fascination is the father-son relationship. This isn't exactly a fear, but it's a part of his personal history he seems to have never worked through completely and so he keeps returning to it. I understand this completely because, having come from a dysfunctional family, my fascination is with how family shapes you. These personal issues are where good characters are born.


Like a lot of writers, I enjoy playing "what if." Morrell adds another question to my repertoire. So What? He recommends employing it as you start playing with your story idea. His own method is to write sort of a stream-of-consciousness conversation with himself. In this way he explores the idea, locating the dead ends without having to write the actual scenes that lead nowhere. This is one of my favorite things that he shares. He also keeps this "conversation" so he can refer back to it to remind himself what he was thinking when he made his story decisions. I've adopted this method and I love it.


There's so much good stuff here. He talks about things like respecting your walk-on characters, the value of hands-on research, writer's block, finding your character's motivation, and dialog tags, among others.


He's also a bit of a contrarian. For instance, unlike most other writing advice, he doesn't jump on the bad-adjective bandwagon. Instead, he illustrates how to disguise the use of adjectives with a passage from Farewell to Arms:


In the bed of the river there were pebbles and boulders, dry and white in the sun, and the water was clear and swiftly moving and blue in the channels. 


Morrell then writes: Surprisingly, this sentence has five adjectives and one adverb, if you take the time to notice them, but Hemingway usually doesn't give you the time to do that. The sentence is constructed so that the adjectives don't precede the nouns they modify and thus impede the flow of the sentence. Instead, they come after the nouns and stand alone, occupying so strong a place in the sentence that they feel like concrete nouns. 


He also doesn't like the idea of reading dialog out loud. In fiction, Morrell states, dialog is an act of silent communication. Reading it aloud allows one to add inflection that isn't there on the page and to convince yourself that the dialog is good (when perhaps it isn't.) He has a point. (A good compromise might be to allow Adobe to read it out loud for you. I guarantee, you won't risk mistaking poor dialog for a performance by Lawrence Olivier.)


One story he relates is about the writer's block he encountered while writing Extreme Denial, a story that started out as being about two men, two neighbors who were best friends, one of whom is in the witness protection program. A hundred and fifty pages in, the story stalled and refused to budge. He couldn't quite figure out what the problem was but, following advice he got from his agent, he made some changes to try to expose the problem with the story. It worked. He saw that his motivation for one of the men was illogical; that it was an idiot plot. He changed the story and presto, the story is off and running again. What was the change his agent suggested? Change the sex of the characters. In the end, he only changed the sex of one of the characters, and that simple thing makes the story far more compelling.


Rambo [Blu-ray]Some of the thing he shares are things I wouldn't think about on my own. For instance, he tells how his agent made sure that the movie contract for First Blood contained a clause about how he would be paid for sequels. He didn't see the point since Rambo dies at the end of the book, but the movie industry managed to stretch the character into three movies. How important does he think it is to have a good agent? I bet you can guess.


Another point I found interesting concerns how books that open on bestseller lists get there. Or at least the ones you see posted in stores like Fred Meyer. He learned about this because he emulated Jacqueline Suzanne's promotion methods of courting the folks who worked in the book warehouses. On one occasion, when he brought donuts and coffee to the warehouse staff, the manager took him into his office where he made up his list.


Number one is this title. Number two is that title. Those aren't true best-seller lists. They have nothing to do with sales. They're prepared six months in advance based on arbitrary rules. The top five are for brand-name authors (King, Grisham, Clancy, Steel, Cornwell, whoever has a new paperback that month). The middle five are for non-brand names that have flashy story ideas: The shark that ate Pittsburgh. The bottom five are genre books: a Western, a romance, a detective story, whatever. This system varies from distributor to distributor, but not much.


Now we're not talking the NYTimes bestseller list here, but it does make me question how they do it, given that I've seen books at #1 the day they're released. Particularly since the publishing houses are so unsure of what's sold that they have to keep a reserve against returns, and indeed, booksellers are allowed to return unsold copies months later.


So do I think this is a worthwhile book? Oh, yeah. Morrell doesn't give you "rules" or even a lot of writing advice. He doesn't harp about conflict or story structure. What he does give you are tools. He encourages you to think outside the box. How to find that story that you need to tell. You can bet that you'll find this book on my keeper shelf.


If you'd like to see reviews of other writing sources, go here.


What's the best writing lesson you've learned from a writing craft book?

10 Pet Peeves I see in stories

Like many of you, I've been an avid reader all my life. I've actually thought that one of the worst things about dying someday would be all the wonderful books I would be leaving behind unread. At one time, a good story with good characters was all it took, but once I learned how to write effectively, I became much pickier about what I read. This isn't always a good thing. I love the first six books of the Drangonlance series--I even own the annotated versions--but I can't read them now. It's too distracting because I so badly want to edit the writing. 


Of course, different things annoy different readers, so I thought it might be educational to learn what annoys you, so to that end, I've made a list to share of the things that annoy me. Here's my top ten. What can you add?


1. When character change/growth occurs without any trigger for the change. I'm not just talking about the Main Character (MC). I've seen the MC's problems get resolved because secondary characters suddenly "see the light" and change their ways. Without something motivating the change, it just pisses me off. (Not only should you be able to point at the change and answer the question of "why" the change occurred, but the question "why now?")


2. Mary Sues. I hate when a character is "the most" or "the best" anything. If you're heroine isn't Sophia Loren or Catherine Zita Jones or Angelina Jolie (or whoever does it for you), she is simply NOT the most beautiful woman walking. Nor is your hero the most handsome, most Alpha, sexiest, most drool-worthy, most anything who ever lived. I have zero interest in MCs who can do no wrong and never fail at anything. I want MCs who are flesh and blood. Yes, the heroine's lover should see her as sexy as all get out--where he's concerned, she may even have a Glittery Hooha--but if every man in a hundred miles is lusting after her, I'm going to find her boring and unrealistic. And unless she's put in the time and effort and sacrifice to become "the best" at something, I'm not going to buy "the best" tag either. (How to tell if your character is a Mary Sue)


3. When a story and its characters are torn right from the tabloids (with the exception of non-fiction True Crime obviously). So yes, I'm tired of reading about Jennifer, Brad, and Angelina already. I don't need fiction from an author I regularly read rehashing that triangle--but I got it anyway.


4. When the author has a character ignore something because it's inconvenient for them to notice it. I can buy that MAYBE in the heat of the moment, but once the character has time to reflect, they should be able to piece things together. I can name some fairly popular authors who've done this (but I won't), and they've done it in books I've otherwise liked a lot, which sets up a serious internal conflict about whether I should continue to read that author.


5. When the viewpoint character knows something or has a flash of insight and it's not shared with the reader. I'll forgive it if it they don't keep me in suspense for more than a few pages, but any longer and I get ticked off. It's an artificial way to inflate the tension. In short, it's a cheat.


6. Author intrusion.The flip side to #5 is when an author intrudes and tells me something is going to be important. They might as well have a big neon sign pointing at the line that says "This will come back and bite the MC in the butt." I hate that. I'm at least as smart as the average bear. Don't condescend to me. It's insulting.


7.  Details that have no reason to exist. I love when an author hides clues in plain sight but that require you to be on-the-ball to catch them. When an author describes something in detail, I tend to pay attention because I expect that, sooner or later, a clue will be placed in just such an innocuous place. So when a writer continues to describe things in minute detail, but there's never a clue to be found, I get annoyed. This is something I might not notice unless I go on an author-binge, but if I do (and I've been known to), trust me, I'll notice.


8. Characters who never grow. Stephanie Plum & company. Need I say more? (Of course I bought about 15 books before I'd had enough.)


9. Openings that include a bunch of obvious back story on page one. I tend to put these books down without ever getting to page two. That said, some authors have a knack for doing this in ways I not only don't mind but that suck me in, forcing me to bond with the character. Harlan Coben is an absolute master at this, but even he uses it judiciously--which is probably why it works for him. If your name isn't Harlan Coben and you info dump on page one, don't expect me to read your book.




10. Excessive head hopping. I start to feel like I'm on a whirly-gig and I don't know who I should care about. In romance, I don't want to see much more than the hero and heroine's viewpoints and even in other genres, it's annoying. I have a list of authors I absolutely won't read because of this, even though they write otherwise good stories. I have another list of authors who walk the tightrope. Their books tend to keep getting moved downward in my to-be-read stack.


What do you see in books that annoys you? Any deal breakers?

Careers for your Characters - Plastic Surgery Assistant


 If you've been following my blog for a while, you know I'm always interested in unusual and interesting jobs for my characters. Some people have thought my focus on this here is a little strange, so I was delighted with a recent blog at Larry Brooks' Storyfix about 3 Edgy Little Tips to Make Your Story More Compelling
. The very first tip? Give your character an interesting job. God love Larry. I couldn't agree more.


There are so many ways for character details to individualize your character. I've used the car they drive, the bumper sticker on the car, t-shirts with something printed on them, the music they listen to, the perfume they wear. These are small things that add up, but they're small potatoes next to their chosen profession. Shouldn't what your characters have chosen to do for 40 (or more) hours a week say something non-generic about them?

If you chose well, you can make their job reflect other things in the story. For instance, if your theme is that beauty is only skin deep, or the beauty is in the eye of the beholder, or that physical beauty doesn't last, or something similar, how much would it resonate if you have a character who works for (or as) a plastic surgeon? (If you don't know what your theme is, you might want to read this.)

If this idea excites you, but you're thinking, "I don't know enough about plastic surgeons to write about it," don't despair. 


That's why I'm here. 




And why Kari O'Driscoll is here. 


Tell us about your experience working in the plastic surgery industry. 
I was hired as a medical/surgical assistant. That meant that I was responsible for presurgical consultations, taking vitals and medical histories and assessing what exactly the patient was coming in for. I accompanied the doctor (an enormous Nigerian man) as he did his physical examinations and counseled the patient with respect to options and possible complications. On the day of their surgery, I would greet them as they came in and get them prepared for the surgery itself, whether that meant meeting with an anesthesiologist or drawing lines on their bodies to indicate incisions, etc. I assisted the physician during the operation, passing him instruments, prepping the patient's surgical area, and cleaning up in the OR afterward. We had an OR in our clinic, so there was no need for a hospital. 


Post-surgery, I helped monitor the patient and spoke with the family members waiting for them, gave them post-op instructions and made sure they had all of their medications to take home with them. As they came in for follow up visits, I removed stitches and staples and drains, fielded phone calls regarding any issues they had, and took photos (always, before and after photos). 


Because we were a small office, I also did the medical transcription for the doctor, so I was pretty much involved in every aspect of the patients' journey with us.


How did you end up working in a plastic surgeon's office?
I really didn't get the job through traditional means. I had just completed my bachelor's degrees in biology and chemistry with an eye toward going to medical school, but I decided to take a year off. I had had experience as a counselor in a family planning clinic, assisting with minor surgeries (abortion, vasectomy, STD treatments, etc.) and doing lab work like urine and blood tests, so I think it was my practical experience that got me the job. Also, because I hadn't been traditionally trained as a medical or surgical assistant, the physicians saw the opportunity to train me the way they wanted things done. I shadowed a guy who was very experienced - having been trained in the Army as a surgical nurse - and he taught me the things I didn't know yet. Other than that, I went to the local vocational college to take a phlebotomy (blood-drawing) course.  

What surgeries are common?
We provided a vast range of services from traditional cosmetic surgery (facelifts, tummy tucks, nose jobs) to reconstructive surgeries for people with burn scars or women following mastectomies. 



Recovery times really vary (you can add a few weeks to each of them if the patient is a smoker. Their circulation is always compromised and we usually refused to do any kind of facial surgery on patients over 40 who were active smokers). The most common ones are:

Rhinoplasty (nose job): Requires general anesthesia. Definitely the nastiest, bloodiest surgery there is. Generally, for the first week, the patient has a silicone splint in each nostril to hold the cartilage in place as it heals (stitched in) and they look like they've been hit repeatedly with a baseball bat - bruised and puffy around the eyes and nose. They come back a week later to have the splints removed and external tape put on and within another week (two total), the swelling is mostly gone and they look pretty good.

Eye lift (Blepharoplasty)/Face lift: Faces heal really quickly and generally we tried to do light anesthesia so that we could ask the patient to sit up during the surgery and make sure we were aligning the two sides symmetrically. Stitches out after four or five days - maybe as long as a week - and all swelling/bruising gone by then.

Facial implants (cheek or chin): Pretty similar to the face lifts, but more likely to have general anesthesia.

Breast implants/augmentation: General anesthesia. For the first week, the woman's chest is bound like a mummy only tighter in order to compress the implants against the chest wall and allow them to scar in place. We ask that the patients use their arms as little as possible for at least 10 days (no vacuuming, lifting children or anything heavier than 5-7 lbs., no raising arms above shoulder height...), and frankly, they're generally bruised and swollen so they don't want to anyway. After a week, they come back for us to change the dressings and check the stitches and they get bound again. Because the skin on the chest is so thick and we generally placed our implants half under the pectoralis muscle and half protruding just under skin, it takes a while to heal. At their 2-week post-op visit, we usually took the stitches out, secured the scar line with steri-strips (a kind of paper bandage reinforced with string almost like strapping tape), and checked to make sure they were healing okay. After six weeks, the patient is generally released to do all of their normal activities and they're feeling good, but for those first six weeks, they're pretty sore and bruised.

Breast reduction: Similar to augmentation, but no binding post-surgery. Because of the amount of fat and tissue removed, the biggest risk for these patients is dehydration. Additionally, they go home with surgical drains - a kind of plastic tubing buried in the scar line that runs out of the surgical site and leads to a small plastic bag to drain off excess fluid. We removed the drains a few days post-op and sealed the site with steri-strips and told them not to use their arms. Again, nobody really wants to. Two to three weeks post-op the stitches are removed and after six weeks they are pretty good to go.

Liposuction: General anesthesia. We tried to do one or two areas at most during one procedure: for example, hips and lower abdomen or buttocks and lower abdomen. This really depends, though, on the amount of fat being removed. Like with breast reductions, the amount of fat you remove greatly affects the relative hydration of the patient and it can really wreak havoc if you take out too much. Also, this is the most dangerous of all the cosmetic surgeries because of the risk of a fat embolism - a piece of fat breaking loose and entering the bloodstream and causing a clot that can lead to a stroke or death. The doctor has to really shove that cannula (long straw-like instrument) around in there to break loose the fat and suck it out. The cannula is about 12-15 inches long and is attached to a flexible plastic tube that runs about 3-4 feet to a vacuum container. The incision made is about 3/4 inch and you can slide the cannula in and really move it around to get a wide area with a small incision. For that reason, recovery times are usually pretty quick; 3-4 days with stitches out in a couple weeks. There are a couple of stitches and some tight wrapping to ensure that the skin is pressed against the remaining tissue enough to bond together and not leave loose skin. This dressing is left in place for a few days. Occasionally we would have women who just wanted small amounts of fat tissue removed from their bellies or butts and reinjected into their lips to plump them. I don't know how often this is done anymore, but it's a pretty expensive procedure that is complicated. They might as well just get liposuction and then have something sterile injected into their lips that lasts longer. The body absorbs fat tissue injected in the lips pretty quickly and so it has to be redone fairly soon.

Tummy tucks (abdominoplasty): General anesthesia. This procedure involves both liposuction (or just simple cutting removal of a lot of fat tissue) and skin removal/tightening. Occasionally, we had patients who had lost a lot of weight and just had excess skin to remove as well. Basically, a large incision is made horizontally from hip peak to hip peak low across the belly, another is made around the belly button (to keep it in it's natural place), and the skin is pulled down tightly to make it taut. If a large amount of fat tissue is removed, we watch for dehydration as well. If, when the skin and fat are lifted up, we notice that the abdominal muscles are weak or have spread away from each other, we can essentially stitch the two sides of abdominal muscle closer together to make them tighter before proceeding. Once the amount of skin to be removed is determined by the surgeon, they cut it off and re-stitch the skin together. Finally, they make a new hole for the belly button to poke through and stitch that up. The incision is fairly long and in a really sensitive place, and the patient is bound in tight bandages again for a couple of weeks. There is a lot of bruising and often the nerves take a while to regenerate so there is tingling or nerve shocks for a few weeks post-op. Stitches out in 2 weeks or so, and depending on the amount of fat removed, there are often drains in place for tummy tucks, just like breast reduction.




A lot of plastic surgeons are also certified as hand surgeons as well, in order to get a fuller clientèle, and this was the case for the doctor I worked for. This meant that we also did carpal tunnel surgeries and reconstructive hand surgeries, reattaching fingers after trauma and microsurgery to fix tendons and nerves and small blood vessels. 


The most common reconstructive surgeries involve scars. They are pretty quick, minimally invasive, and don't always work out. For people who have large keloid (think raised and slug-like) scars, there is no guarantee that their body won't scar that big again. People who are prone to keloids don't often have good results with scar recisions.

Burn scars can be treated fairly well with tissue expanders depending on where the scar itself is. A tissue expander is like a saline breast implant that is deflated. The surgeon finds some healthy tissue adjacent to the burn scar and inserts the expander beneath that skin. The expander is fitted with a valve that can be located by a magnet and every week or so, the patient comes in to have 100cc of saline injected into the expander, gradually expanding it and "growing" the healthy skin on top of it. When the expander is large enough that the healthy skin has expanded to completely cover the scarred area, the expander is removed, the burn scar is cut out, and the healthy skin is pulled over the area to cover it. The patient is left with a linear scar in place of the original, large burned area. It works pretty well, but depending on the size of the original scar, it can take months to expand the tissue to cover the area. And it can be painful to stretch the skin week after week. 



The most dramatic surgery I was ever involved in was for a woman who had suffered child abuse and been burned over about 40% of her body on one side. She had scars from her lower neck, extending down her under arm and covering most of her torso on one side. She had about 15 expanders and, when they were fully expanded, she wore only loose sweatshirts to cover the lumpiness of her body. The final surgery took hours to complete, but she was left with only two long scars (hundreds of stitches) and mostly healthy skin. Within a year, she was wearing a swimsuit in public for the first time in her life. She had been "reborn" a 40 year old woman who was not ashamed of her body. It was the coolest thing! We both sobbed when she came in to have her stitches removed and it took me over an hour to get them all out.

There were plenty of women who came in for breast reconstructions following mastectomies for breast cancer, men who wanted testicular implants following surgery for testicular cancer, and more than one person who wanted facial implants following bone cancers. Those surgeries were fairly straightforward and very rewarding.

 There were plenty of reconstructive surgeries we did on hands as well. Because all of the plastic surgeons I worked with specialized in hand surgery/microsurgery, we got our share of ER calls for people who had sliced fingers off, severed tendons in their hands, or crushed fingers underneath machinery. There were several industrial accidents a month and, without fail, at the first sign of summer, we had a rash of men coming in through the ER after sticking a hand under the lawnmower to dislodge some piece of debris that was stuck, thereby slicing off a finger. Similarly, around the holidays, we often treated women who had done the same with the food processor.
Most of the time we were able to re-attach the fingers, painstakingly matching nerves and tendons and cappillaries. The crush injuries were more complex, because often the nerves and blood vessels were too crushed to reattach. 


In one memorable case, a manual laborer had crushed his thumb to a pulp underneath some massively heavy equipment and, rather than leave him without an opposable thumb on his dominant hand, we removed one of his big toes and attached it to his hand. Beyond looking a little odd, it healed beautifully.

We treated some junkies who had shot up with dirty needles and waited so long to get the infection treated that it had eaten away at tendons in their arms - one famous bass guitarist from Seattle lost his livelihood that way. Another guy threw himself through a plate-glass window while he was high and trying to elude the police and we had to repair his ulnar nerve and major tendons in his arm while he lay handcuffed to the OR table and a deputy stood in the corner.

Any skin defect you can imagine fell under our purview as well. We treated people with diabetes whose skin ulcers wouldn't heal. Often we would cut away (debride) dead tissue until we got to good, healthy tissue and patch it with a skin graft. In one woman's case, we started with ulcers on her toes and within a year, we had grafted a few times, but the damage was so severe to her circulatory system (from her diabetes), that the grafts continued to fail and we ended up having to amputate her leg just above the knee.



Is it common for surgeons to specialize in vanity or therapeutic practices or do most of them do both?
Depending on the geographical location, plastic surgeons can specialize in cosmetic surgery, but it's rare for any of them to exclusively do that. There is simply not enough demand in most places (except maybe Hollywood) to not take advantage of the insurance industry.
 


Who were your typical clients? 
Our practice was in a blue-collar Seattle suburb which is a mix of lower-income families, Eastern European immigrants and is beginning to become somewhat gentrified. 


Probably 25% of our patients were fairly well-heeled and could afford 'vanity surgery,' while the rest were people seeking reconstructive surgeries and strippers from the local "airport massage" bars seeking bigger boobs because they translated into bigger tips. 


The doctor I worked with built up a pretty stellar reputation over time, so we did surgery on a former rock star, a professional football player, and some older, well-off women who lived in the waterfront neighborhoods south of Seattle. 


He was a workaholic, though, so he took emergency call nearly every weekend which brought us the hand trauma cases and other reconstructive surgeries which were generally the most colorful ones.

I got to know the patients very well throughout their entire surgical journey, from pre-op to surgery and post-op and met some pretty amazing people. I saw everyone from young women coming in with their husbands and getting breast enlargements to please them to hardened construction workers who stood to lose their livelihood if we couldn't fix their fingers. 



We had a few people over the years who had multiple cosmetic surgeries, but as a general rule the doctor I worked with was pretty reticent to do something that would totally change someone's appearance. He was pretty strong in his moral convictions about making sure that people didn't expect this to change their lives. He wouldn't do liposuction unless someone had been working to lose weight with exercise and diet, for example. 


What kind of expectations do people have about plastic surgery? 
Overall, though, I think most people had been bothered by some particular aspect of their appearance for most of their lives and were realistic about their expectations. I know that the media plays up the extreme cases, but most of the ones we saw were fairly down-to-earth people.
 

I bet you have lots of interesting stories. Can you share any of them? 
We did have a couple of scary surgeries over the years - one of which involved someone who came in from out of town and wanted multiple things done at once, all in one surgery. Because he was a friend of the doctor's and only had a limited amount of time he could be in town, the doctor went against his own instincts and did all of the surgeries. By midnight, the guy was admitted to the hospital with a fat embolism and ended up staying there for a week to treat severe dehydration and recovering from the massive surgeries he'd just had.


We also had a woman in her eighties who was diabetic and came in initially so we could do a skin graft over an ulcerated area of skin on her big toe which just wouldn't heal. We treated her conservatively for several months in an effort to get it to heal on its own and when the doctor thought she was ready, we did a skin graft. Over the next few years, that ulcerated patch grew despite all our efforts, until she ended up having her leg amputated at the knee before it could consume her entire leg.


For those who need reconstructive surgeries, I imagine that insurance takes care of most of the cost. Would that be right? How do people without insurance get help?
Some vanity surgeries can be covered by insurance if you do some fancy footwork. For example, if someone wants a nose job (rhinoplasty), the doctor could document their sleep apnea, snoring, general difficulty breathing, past broken nose, etc. and get the insurance to cover it. Some upper face lifts (blepharoplasty - around the eyes) can be covered for the reason that an older woman's skin is sagging around her eyes and "affecting her sight." Almost all breast reduction surgeries were covered because of back problems, etc, but a tummy tuck or general facelift or liposuction are things we would never even attempt to get covered. In this case, the people who had means would just pay half up front and half after the surgery. Those who didn't would either set up a payment plan with the doctor or, more often, we would direct them to companies who give small loans for cosmetic surgery. Yes, we actually had brochures in our office for companies who would loan people money (at ridiculous interest rates) for plastic surgery. Often, it was the strippers/dancers who had cash and the doctor would give them a cash discount, knowing that they would recommend him to their co-workers. Most cosmetic surgery can't really be done "piecemeal" unless you have multiple things you want (cheek implants, liposuction, breast augmentation, tummy tuck). In any case, it was generally our policy to only do one at a time because of the recovery time and trauma to the body with major multiple surgeries at the same time.

What can go wrong?
Things that can go wrong? Generally, the risks are the same as with any surgical procedure, but specifically I can think of a few I encountered along the way. 



We had women who were like kids in a candy store when choosing their implants and, no matter how much input we gave them, they chose too big and looked a little ridiculous afterwards. We did have at least one woman who came back to get a smaller size a year after her original surgery. 


With surgeries on the face, symmetry is always a big deal, and not always easy to predict. It is possible to have one side of the face heal completely differently than the other or one side pulled tighter than the other. We once did a facelift on a 75-year-old woman who swore to us she was not a smoker but two weeks after her facelift when her incisions still hadn't healed and she had big ulcerations behind her jawline and above her eyes, she admitted that she had smoked her entire life. The circulation in her capillaries was so compromised that it never really healed correctly and she had huge scars. 


We did a skin graft on a man's arm to cover an area with 3rd degree burns and, while it was healing inside a full-arm cast, he got drunk one night and stuck a wire coat-hanger inside the cast to scratch the itch, pulling the entire graft off and we had to start again with more tissue from his other leg. 


We had a professional athlete who I'm sure had taken steroids for years and needed to lose some weight before going to training camp. He wanted liposuction around his ample mid-section and a breast reduction (unfortunate side-effect of the steroid use) and, while we would never normally do two such large surgeries simultaneously, he offered a lot of cash and was a friend of the doctor's and was in a big hurry to heal before camp, so we did it. He ended up having a heart attack on the table due to severe dehydration after having so much tissue removed and spent the following six weeks in the hospital recovering, missing the beginning of training camp. 


We gave a woman a chin implant after she had been in an accident that ruined her jawline and before she could heal completely, she wrecked her car and her face hit the airbag which slid the implant to one side, making her look like she had a huge tumor on her cheek.



Is it common for surgeons to specialize in vanity or therapeutic practices or do most of them do both?
Depending on the geographical location, plastic surgeons can specialize in cosmetic surgery, but it's rare for any of them to exclusively do that. There is simply not enough demand in most places (except maybe Hollywood) to not take advantage of the insurance industry.

  
 



I would suspect that the family or spouse would be more involved with reconstructive surgeries. Does that create problems/difficulties?
Not generally. As long as we were clear about the potential issues and realistic about the outcome, people were generally appreciative of any positive result with reconstruction. They tended to have higher expectations with purely cosmetic surgery.

Have you noticed particular personality types who become plastic surgeons?
The surgeons I worked with were generally perfectionists and tended to be control freaks. They were confident to a fault, sure of their abilities beyond the shadow of a doubt, and fearless. Beyond their scientific minds, though, they also had an artistic sensibility - they were able to see the possibility in things. One woman who was undergoing a tummy tuck asked if the doctor could fashion her a new belly button (she hated her own). His eyes lit up - he puzzled over it for a while and ended up making her the most perfectly exquisite new belly button. I was amazed at the way his mind worked.

What other staff would be involved in a plastic surgery practice?
There are surgical assistants, anesthetists (either registered nurse anesthetists or anesthesiologists - the former are more inexpensive because they haven't had as much school, but are perfectly qualified to do in-office anesthesia), and office staff to run a practice. The office staff would be at least a receptionist/scheduler and someone to do the insurance billing and/or collections. The physician generally has their surgical assistant act as the medical assistant to draw blood for pre-op labs, get informed consent and describe procedures, sterilize equipment, order supplies, and assist with the surgery. In some cases, you need more than one assistant (for example, if it is a particularly involved surgery). Additionally, the doctor will need someone to transcribe his or her notes and they can contract with an outside medical transcriptionist or have one in-house. Most surgeons find that a solo practice is too expensive (and if they take ER call on weekends or evenings, they want to share the load), so often they share a practice with one or two other surgeons.  



Where could one find more information? 
There are lots of professional associations and journals for plastic surgeons. They pioneer new techniques more often and quicker than other surgeons, I think because their surgeries can be done in-office (if you have your own OR setup) and aren't constrained as much by hospital bureaucracies.


What am I not asking that I should be asking?
Plastic and reconstructive surgeons rely very much on referrals from satisfied patients and other physicians. It is important for them to have close relationships with family practitioners, ER doctors, ENT doctors and oncologists who can and will refer patients to them.

Quick bio on me:
I am a 39 year old mother of two daughters and am trying to make it as a writer. I have a bachelor's degree in Biology and one in Philosophy from Pacific University in Forest Grove, Oregon. I worked for several years as a medical/surgical assistant in an abortion clinic, a dermatology clinic, and for several plastic surgeons. I am most interested in medical ethics, however, so when I decided it was time to move on, I ultimately ended up working for the Washington State Mental Health Division as a quality management liaison for the Children's Long-Term Inpatient Psychiatric Treatment Programs. I did this until I had my first child and then spent five years researching and writing my first manuscript. The book tells the stories of fifteen women who faced the agonizing decision of whether or not to terminate a pregnancy for a variety of reasons. It has yet to be picked up by a publisher, but I am optimistic. In the meantime, I am a member of the BlogHer Publishing Network at www.the-writing-life.blogspot.com and am working on a memoir of eight weeks in Europe with two toddlers.





DISCLAIMER (from Suzie): I generally like to include pictures or videos that relate to the career being discussed, and there are plenty available, but they tend to either not show anything worthwhile or they're more graphic than some folks would care for, so I decided that anyone who needs pictures can hunt them down on youtube themselves.


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