Horowitz The Surgeon

r. Daniel Horowitz's epiphany arrived as he neared the middle of a 400 page biography on Vladimir Horowitz (same surname, no relation), the legendary pianist who with fame grew so fearful of hitting a wrong note in public that he all but gave up performing. How odd, thought Horowitz the surgeon. Throughout his last twenty years of private practice in San Diego, he hadn't once experienced a case of butterflies before starting in on an operation and only now did it even occur to him to wonder why.

Both Horowitz the musician (now deceased) and Horowitz the plastic surgeon (still quite alive and in his prime) were skilled artisans who had mastered their respective trades. Both men lived in the limelight of society-page stardom, and both, God knows, catered to the same spoiled clientele unable to accept anything short of flawless. The burden was heavy.

Each man stood (or at least had stood) at his mature pinnacle – that point in a great career when he is better than anybody else but also as good as he would ever be, that unnerving apex where the only possible next direction is down. But why, Horowitz the surgeon paused to wonder, did he and Horowitz the musician react to this same stress in such different ways?

Not given to pondering the unanswerable, Dr. Horowitz closed his book, a rather odd birthday gift from his oldest daughter who'd probably had no idea what to buy for her one-dimensional father and had likely ordered the title based only on its subject's similar name and fame.

But that's where any similarity seemed to end. Horowitz the musician had been a trembling aesthete afraid of his own shadow, a weak man to be dismissed. Not so with Horowitz the surgeon who reassembled beautiful bodies on a daily basis. Still, while brushing his teeth before bedtime, Dr. Horowitz found himself yielding to a puzzling but building empathy for the celebrated pianist.

He (Horowitz the surgeon) now recalled that he too had experienced a sensation of dread whenever starting in on an especially challenging operation in the earliest years of his career, a vague tightening inside of his chest and a nearly imperceptible although embarrassing tremor in his fingers.

But even these silly distractions had ceased decades ago, replaced at first by a sense of bold confidence that soon gave way to a sense of nothing at all (which, he'd come to believe, indicated either quiet inner peace or raging intellectual boredom, take your pick).

Tired out from a full day of surgery and with a mild headache from too much self-analysis, Dr. Horowitz hopped into bed, turned off the lamp, kissed his wife on the cheek, and snuggled his head into his NASA-foam pillow.

As his mind sucked itself into a tunnel, the realization hit: Horowitz the surgeon was not an artist; he was a technician.

Artists never perfected their craft in a way that he (Horowitz the surgeon) had perfected plastic surgery. The scope of fine art was unlimited, while a surgeon could eventually grow proficient at almost any operation. An artist's challenge was to create yet another challenge, while a surgeon's job was to restore and replicate.

He (Horowitz the surgeon) was actually little more than a specialized mechanic working on the human face, not a sculptor chipping away at flesh but a glorified grease monkey wielding a scalpel instead of a crowbar. Any lesser man might have felt sadly humiliated or even mildly depressed, but Dr. Horowitz experienced an invigorating release of pent-up mental energy that drove his thinking forward at an amazingly rapid pace.

If he were a technician who had perfected a certain specialized technique, that was nothing to be ashamed of. However, he (Horowitz the surgeon) had been around long enough to understand that passing time was most unkind to those of high accomplishment and that his biological clock was ticking fast. He was nearing that point in life when the skill set that had made him a king was self-programmed to abdicate. But did it have to be gradually lost or was there something he might do to preserve it in its fully realized state?

The answer arrived two hours later and aroused him from his deepest sleep.
Why not train a younger technician to do exactly what he (Horowitz the surgeon) could do better than anyone else? Why not strengthen his current reign over his specialty now while simultaneously charting a new course for its future once he'd been deposed?

Because . . . once he'd figured out how to go about training one high-level technician, why not train ten? Or twenty? Or fifty? Why not harness the economies of grand scale to introduce affordable cosmetic surgery to the masses? This would be his legacy – transforming an overpriced luxury into an affordable (but name brand and franchised) commodity.

Why not clone his hard-earned skills at the top of their form and achieve a sort of everlasting presence? Why sit back passively and allow Horowitz the surgeon to pathetically self-destruct as had Horowitz the musician?

or any groundbreaking commercial endeavor to survive and later prosper, the first and foremost necessity is, of course, a revolutionary idea. The second is a supply of cheap talent. The third is a source of working capital, which for most startups requires a carefully formulated business plan. The bright idea was already in place and the business plan could be dispensed with (as Dr. Horowitz was very wealthy).

Deciding exactly who to form into the image of himself, however, was not going to be so easy.

Using other medical doctors seemed not only unnecessary but counterproductive. Even a beginning trained surgeon would come with a salary demand that was high and an ego that was delicate. Besides, a technician did not need to be a full physician broadly trained in every aspect of medical diagnosis and treatment. This technician had to perfect just one single skill but then be better at it than anybody else on the planet. Manual dexterity seemed the primary requirement; intelligence and inquisitiveness didn't even make it into the top ten.

Dr. Horowitz considered the possibility of recruiting a seamstress, somebody now employed in the garment industry who was used to working to tight specifications at breakneck speed under terrible conditions and for very low pay. But asking an assembly-line worker accustomed to repeating just one or two steps to perform an entire operation start to finish would likely be beyond her capacity (and besides he found the concept of replacing himself with a nonprofessional a bit demeaning).

The more groups he considered – nurses, nursing aides, laboratory workers, veterinarians, even the cosmetologists – the easier he found reasons to rule them out. People had personalities and emotions and attitudes and nerves (just like Horowitz the musician). People commanded salaries and benefits and lunch breaks and vacations. Employing people carried with it the hassle of paperwork and turnover and, worse yet, the possible theft of his intellectual if not physical property.

When the solution finally dawned on him, he was shocked he hadn't thought of it at the very start. It struck in a flash of inspiration from out of the blue, the mental image of a relaxed and smiling Horowitz (the musician!) standing next to a player piano spewing out absolutely perfect music, as if the sympathetic dead man had just beamed to his struggling namesake a precious hint from the netherworld.

He (Horowitz the surgeon) didn't need a seamstress; he needed her sewing machine. After all, what more was a technician than a human machine? Robotic surgery was hardly a revolutionary idea and had been successfully applied during operations on the hip, heart, and brain.

Sophisticated scanners and facial recognition software had been highly developed for security applications. Machines to map corneal topography in three dimensions were already in use for laser vision correction. The basic hardware existed as did the software, even if nobody had yet explored its application in the field of cosmetic surgery.

And so while a great deal of adaptation and innovation might be needed to make it happen, the technological jump was not insurmountable. Plus, as luck would have it, Dr. Horowitz's undergraduate college degree had been in biomedical engineering.

ixteen months and 2.2 million dollars later, Dr. Horowitz took delivery of a working prototype, which he quickly came to bond with as a replica of himself. Sometimes he even caught himself referring to it to as if it were a real person. He dubbed it 'Vladimir' over the vehement objections of his daughter, who didn't seem to recognize the name's significance and complained that it reminded her of a tin-can Russian spacecraft.

By then, however, ignoring his daughter's opinion (along with everyone else's) had become routine. Much earlier, he'd learned that nothing was ever going to be accomplished if he first had to consider and then overcome each pessimistic objection offered by every paid consultant, friend, or family member. Minus determination and self-confidence in its innovator, a great concept will remain just that and no more. Besides, his corporation had been structured as a closely-held private company independent of outside venture capital and so he needed to satisfy nobody but himself.

He elected to start off slowly and so focused in on eyelid surgery because it involved an easily accessible small area in a more uniform plane than the full face, breasts, or buttocks. To decrease the number of variables, he limited his initial prospective patient base to women. The process he envisioned entailed four fundamental steps:

First, the patient would be allowed to select a particular look she most admired by flipping through an online gallery of twenty-two CAD-generated illustrations of precisely known proportions.

Second, the patient's eyelid, brow, and upper cheek anatomy would be mapped in three dimensions, a task that by adapting technology used in CAT scanning and diagnostic medical ultrasound could be accomplished with no undue delay. Third, an intellectual database had been generated incorporating all that was known about the eyelids and eyelid surgery. From this, an algorithm would be derived to direct the hardware.

Finally, a fully-automated machine to cut, remove, reposition, and rejoin the operated tissue had been assembled. Cutting and removal of excess tissue would be performed using a combination of radiofrequency and laser energy. Tissue would be manipulated into proper position by a vacuum applied through multiple robotic mini-suction cups. The resulting wound would be closed without sutures using a mechanized application of medical-grade quick-drying superglue.

Step One would be performed entirely by the patient in the privacy of her home, following which she would simply e-mail in the sample number of her desired outcome and a week later receive a small plastic card with her preferences encoded on a magnetic strip along its back.

With Vladimir preprogrammed and waiting, Steps Two and Three would take place automatically in less time than a Google search query. Step Four, again fully automated, would last less than thirty seconds. In essence, the process was to resemble LASIK vision correction, in which the doctor did little more than stick in the card, take a few measurements, position the patient's head inside of a high-tech console, and press a button.

Variability introduced by the human hand (and mind) would be purged from the process, thus allowing for a level of predictability previously unknown in cosmetic surgery. The patient would stroll in, rub on an anesthetic cream, stick her head inside of a well-padded and well-ventilated box, and stare up at a red target looking back at her.

A few minutes, she would depart a new woman. Once perfected, the only way plastic surgery could ever be made more affordable or convenient (or profitable) would be to have the patient press her face against a laserized computer monitor while clicking on a self-service app (an embryonic but fertile idea not lost on Dr. Horowitz, who made a note of it for future reference).

The most challenging and time-consuming phase of development involved design of the algorithm software, the brain inside of Vladimir. Within this complex equation, Dr. Horowitz had incorporated everything he knew about eyelid anatomy and its many variations, surgical techniques and countless options, and precautions designed to promote rapid healing and avoid complications.

It would read like a very long flow chart — if A, then B; if not A, then C; if B, then not C, but D or E or F, and so on almost ad infinitum. Like a brain, it would evaluate its sensory input (from scans and topographical reconstructions), factor in the patient's preferences, and then determine the most appropriate motor output (laser and radiofrequency). From starting point to final result, Vladimir had been designed to leave no imaginable variable to chance.

Truly original ideas will always encounter stiff resistance, and in an over-regulated society, the red tape can prove fatal. Institutional hospital review committees and professional liability issues could easily kill off a novel idea while still in its infancy, which explained why most medical innovation now came from outside the country. 

From his office in San Diego to the border was only a twenty minute drive. A large vacant building was leased, local talent employed, and the work progressed in earnest. For many months, fourteen Mexican computer programmers and engineers toiled almost day and night. Once the specifications were finished, manufacture of a single working model was put out to competitive bid.

Vladimir was now a reality – unpacked, checked over, and installed, sitting in the middle of an obscure but soon-to-be famous warehouse, not unlike the Wright Brother's first plane parked in its dark and lonely hangar, awaiting its fateful moment to make history and change the world.

here comes a time in any wholly original endeavor when one must abandon the drawing boards, computer simulations, and dry runs and proceed forward to actual clinical trials. But testing a new surgical technology was not like testing a pharmaceutical, where bacteria in Petri dishes and small rodents in little cages could provide ready material for toxicology studies. Testing surgery required . . . well, real surgery, and there was no easy way around this. Not only would maintaining a primate laboratory be prohibitively expensive, but the facial proportions of cats, dogs, or monkeys were all wrong (and their skin was fully covered by hair).

Not surprisingly, such limitations were easily overcome. The mere rumor of free plastic surgery drew applications from prospective human subjects on both sides of the border.

Still, there always seemed to be one more last-minute reason to delay taking the plunge. What about this?, what about that?, what if?, what then?– the same hypotheticals that had paralyzed Horowitz the musician.

He (Horowitz the surgeon) felt the dreaded butterflies appear for the first time in decades. His palms felt constantly moist and his chest ached vaguely almost every morning. He wondered whether he should quit and almost did, but then began to have dreams about a glorious IPO followed by a stock price run-up that made the Internet issues of old look like fixed-income investments. He took this to indicate that the time to proceed had arrived.

And besides, after all his careful planning and months of hard work, it was time to quit worrying about what might happen and reaffirm his deep faith in himself.

hose who lack vision and have never undertaken any bold initiative should not dare to pass judgment on one who has.

Okay, so by now you've probably guessed it. I am not some hackneyed creative writing MFA composing this imaginary missive from the implausible third person omniscient point of view. Who I really am is a seasoned journalist of over fifteen years experience commissioned to chronicle the trials and tribulations of . . . oh, hell, why not just come clean with it!

Who I am is the very doctor in question, Dr. Daniel J. Horowitz, and I am writing to you from my dark and dirty dungeon beneath the Tijuana jail. Very little of what you've read so far is fiction (well, apart from the slightly exaggerated descriptions of my own renown as a surgeon and my prior expertise in bioengineering). While I am not seeking your sympathy or forgiveness, I do ask for understanding.

Away from the hustle and bustle of innovation and with ample time to contemplate and reflect in solitude, I now appreciate that artists and technicians are not opposites but only extremes, by which I mean that the two are really the end-points of a continuum along which all doers fall. The best machines – human or mechanical – are neither purely artistic nor purely technical in method. Vladimir might have worked better had I only installed a less restrictive artificial intelligence module that would have allowed him, if necessary, to take liberties from my strict algorithm.

For instance, how was I to ever guess beforehand that when the lights came back on after a brief power failure near the end of one of our earliest clinical trials Vladimir would reset himself and start the entire operation from scratch, only to remove most of the subject's eyelids?

Or, that one of his (Vladimir's, not the patient's) internal sensors might possibly develop a short and confuse right side with left, thus leaving another subject with a most original if not oddly-slanted pair of peepers?

While there was a suggestion of sabotage by colleagues who felt threatened, I could never amass hard proof. Vladimir may, in fact, have been too far ahead of his time, which undoubtedly unnerved quite a few beauty doctors. But the idea of a robot doing surgery was sound, and sound ideas never go away. Researchers who come after me will benefit even more from my setbacks than from my successes. As long as my dream one day becomes a reality, I don't care with whom I must share credit.

But damn!, how could I be expected to know that the big-name Japanese electronics firm I selected to construct our only working prototype had farmed out the project to the same Chinese sweatshop that assembled Barbie dolls and Nike tennis shoes?

Think about it. All progress comes at a dear price, and substantial progress commands a substantially dear price.

How many people had to go blind before the eye doctors perfected cataract surgery? How long does your average recipient live after a heart transplant? A paradigm leap emerges only out of bold experimentation and a good deal of trial and error. Yet here I am, my surgeon's fingers rotting.

But for crying out loud!, how could anyone have guessed that the tiniest dab of leftover superglue could cause Vladimir's laser to jam, then burn clear through the eyelid and into the patient's eye? Like Hal in Space Odyssey, Vladimir the surgeon (now deceased) was a most noble concept as well as a very complex mechanical contraption.

This year for my birthday, my daughter mailed me a box of art supplies instead of (thank God) another book, and I've been working hard at learning to draw and maintaining my dexterity. She also sent me an old newspaper clipping about another great pianist – Van Cliburn – who canceled his comeback national tour following years in seclusion after his very first concert caused a big case of nerves.

So before you're too quick to criticize, at least grant me this. I did not give up after a few minor setbacks and go cower in the shadows. I did not lack the courage and determination to put my talent on full display and dare to push it to its limits. If my attempt at concerto turned into a child mangling scales, well . . . if you never go for a swim, I guess you'll never drown.

And yes, there were several other unfortunate and overly publicized incidents involving Vladimir in which the outcomes were not precisely as expected. But really – there is no need to get gruesome.

For the time being, alas, it seems that cosmetic surgery will remain within the province of the rich (although I am scheduled for release from this rat hole in just another six short years). If only I could escape to Siberia and get on with my work!

My wife shipped me a Yamaha electronic keyboard, and I've been desperately trying to teach myself at least "Chopsticks." Thus far, however, a Vladimir Horowitz I am not.