We all face the world with our faces. Even for dermatologists, the way a face looks has more than medical significance.
Edgar is 86. His COPD recently caught up with him, and he needs oxygen. The nasal prongs that deliver it are irritating, but what really bothers him about them is that he won’t attend any activities in his Assisted Living facility wearing nasal prongs and trailing a tank.
Recently his pulmonologist allowed him to take breaks from supplementary oxygen, which delighted Edgar. That his oximeter reading drops from 86 to 81 when he moves around is turns out to be less important for Edgar than the fact that he can now leave his room and hang out with other people.
Brenda comes in with a large bandage on her forehead. She takes it off to show me a large, jagged, fully-healed scar. Four months ago she gashed her head on an appliance and didn’t get medical help in time to have the wound properly stitched.
“My bangs aren’t thick enough to cover it,” she says. “My daughter asks why I wear a band-aid all the time,” says Brenda. But Brenda would rather walk around with a large bandage on her forehead. Just as Edgar won’t let anyone see him sick and diminished, Brenda won’t let anyone see her face damaged.
Stella has lymphoma. While she was on chemotherapy, she stayed put at home and avoided crowds to avoid catching someone’s virus. Once chemo was done, she was able to fly to Tallahassee to see her new granddaughter Genevieve.
Unfortunately, her lymphoma recurred sooner than she and her doctors had hoped. Now Stella is on a new drug. This seems to be helping, but it puts her back at risk for infections in crowds.
And on planes. “Will you be able to visit Genevieve in Florida?” I ask.
Her husband Ben interjects. “Her doctors say she can,” he said, “but she would have to wear a mask on the plane, and Stella won’t wear a mask.”
Malcolm comes in now and then for this and that. This time he is here for a skin check. At each visit he brings me up to date on an endless family lawsuit over a contested estate. Its subplots could script a whole Netflix series.
When I’m done with the skin check, Malcolm says, “Also, I’d like Botox on my forehead.”
“OK,” I say. I don’t ask why, but Malcolm answers anyway.
“The lawsuit is finally coming to a head,” he says. “One of the nephews contesting the will is flying in from Indonesia, and the trial gets underway in Kentucky next week. I never would have started this fight, but since my charming relatives did, I’m in it to win it.”
I wish him luck.
“That’s why I want Botox,” he says. “I’m going to testify, and I want to look my confident best.”
While we’re talking Botox, I recall Amy, a well-traveled consultant who gave lectures all over.
“I’m curious,” I once asked her. “What do people say to you after you get Botox? Do they notice?”
“That’s interesting,” she smiled. “When I speak to groups, my face is projected onto large screens. That makes my wrinkles look like the Grand Canyon.
“When I started doing Botox, a man came over to me after a lecture and said, ‘I’ve heard you before, but this time you were, somehow, more cogent and compelling.’
“I thanked him, of course,” said Amy with a smile. “But the speech he was praising was the exact same speech he’d heard the first time.”
When you think about how much most people care about showing the world a good face, it’s striking to contrast them with people who show the world no face at all. Some hide their faces for religious or cultural reasons, out of modesty; others—criminals, terrorists--to insure anonymity or convey menace; still others find the world at large an unacceptable threat, and go about their public business wearing surgical masks for protection. In a primal, visceral way, people who hide their faces are very hard to face.
The rest of us try to put on the best face we can, assisted (in descending order of importance) by: makers of cosmetics, estheticians, dentists, plastic surgeons, and—oh yes—even dermatologists.
Happy to assist!
Dr. Rockoff’s new book, Act Like a Doctor, Think Like a Patient: Teaching Patient-Focused Medicine, has just been published by Medical Education Press. The book focuses on the need for medical providers to know not just how to diagnose and treat disease, but to understand patient and make them feel better. You can order the book on Amazon.