Saturday, August 18, 2007

A distinction WITH a difference-news story on patients upset with non-plastic surgeons mistakenly featured a non plastic surgeon

I saw a local Dallas new station segment on Plastic Surgery that was unintentionally ironic.

It is introduce with the statement that

"It's a nightmare situation. You've had Plastic Surgery and you don't like the results.....With rapidly rising number of physicians starting to call themselves Plastic Surgeons, (patient)complaints are starting to jump."

The segment features a Dallas doctor doing re-operative surgery on on a woman who 6 years prior, had cheek implants, eyelid surgery, and a brow lift performed and was unhappy. The doctor, takes a not too subtle swipe at how "other Dallas surgeons" don't understand facial aging and aesthetics and have been doing surgery wrong for years.

For some context, you have to understand that Dallas, Texas has some of the heaviest hitters among Plastic Surgeons in the world for facelifts and related procedures. (see my post "Cities known for certain Plastic Surgery procedures" from last spring) Dallas surgeons like Fritz Barton, Steve Byrd, Sam Hamra, Jack Gunter, Rod Rohrich, and others have literally rewritten parts of the vocabulary for understanding the aging face and how to address these changes surgically. Now there's a lot of ways to skin a cat (or rejuvenate a face in this instance), but you dismiss your forebears collective experience at your own peril in Plastic Surgery.

Back to my point! What's the irony of the story about consumer confusion on Plastic Surgery?

The doctor featured isn't even a Plastic Surgeon!

He's an ENT (ear, nose, & throat) surgeon who did not train in Plastic Surgery, but did a loosely regulated apprenticeship with other ENT's in "Facial Plastic Surgery". This type of ENT practice is not equivalent in either training or scope of practice, and most of these fellowships have evolved into tagging along with a cosmetic surgeon rather then actually something resembling training in the full scope of head & neck plastic surgery which is implied by the title.

There is no real standardized curriculum for facial plastic surgery training (as there is for Plastic Surgery) and you can still actually become certified in "facial plastic surgery" without any formal post-graduate training by just submitting a case-log and taking a test if you trained in ENT. I believe that most Plastic Surgeons feel it is a degree not worth the paper it's printed on, but that there's not much that can be done about it (it was actually challenged in court many years ago, but the decisions established that the term "plastic surgeon" could not be trademarked by the American Board of Plastic Surgery).

This in no way means such guys can't do cosmetic surgery well in many instances, but it is just another example of how such titles can confuse and blur distinctions that most patients (and apparently news media) are taking for granted.


DrDiSaia said...

It gets much worse out here with cases in which the doctor has no surgical training at all. Patients just don't know how to tell the difference until after they have been operated and the results look like the corner grocer did the surgery.

Anonymous said...

I'm writing from Sweden, and found your blog when I was googling to find any information on what to do about abnormally high positioned nipples after breast reduction.
At one of your posts you mentioned that one problem with some breast reductions is too highly placed nipples. After a breast reduction I also got this problem. I thought I’d ask you if there is ANYTHING in the world to do about this? Let me tell you my story:
My PS placed the nipples so high that I can't wear any bras or bikinis, and I can't wear summer clothes since the nipples "shine through", and you can see that they are placed really high up and it looks ugly. There is no tissue at the line of the nipple and higher, which makes the countour of the breast (seen from the side) look totally concave and the nipple points straigth up to heaven...
I've got an idea about how to MAYBE solve the problem, and I'm going back to my surgeon later this week and I just hope that he will have mercy about this idea. So here's the idea: You cut out the nipple, so that it is loose from the surrounding skin. Then you cut a "half circle" under the nipple, and move the nipple downwards, and then put the half circle (from the underside of the nipple) to the upper side of the nipple. This will give a scar above the nipple of course, and maybe it will look like one has a "half moon" above the nipple, but in my case as I see it I am willing to live with this scar, as long as the shape of my breasts improves and becomes less of a concave shape pointing upwards and more pointing forwards. Also I believe that if the nipple could be lowered this way, the nipple will be projected forwards by the breast tissue. Because as it is now, the nipple points upwards also because there is no tissue under the nipple, wich would otherwise project it forwards a bit.
What do you think about this idea? Have you heard of anyone having any such operation? Well I'm just hoping my surgeon will think it's a good idea because this is the only solution I can think of, concerning my breasts... I'm just dreaming of that day when I can wear a nice little bikini again...without worrying that the nipples will pop out..

My first reduction was made in January 2004. But the surgeon barely removed any tissue at all, he just put the nipples up high and took away some excess skin. I was really annoyed by this since I wanted them smaller, but when I went back to him to complain he got furious, said that I was "taking up his valuable time". He was so rude to me that I cannot explain it in writing. I didn't know how to handle this situation, he was obviously the one who had failed with the surgery. After a while he accepted to do the surgery over again, so in october 2004 he took away some more tissue. But the nipples were still placed up high. And the tissue down below. After this, I complained again and he accepted to do another try, but this time i would have to pay for it. Well, as you might understand, at this point I was so fed up with everything that I would gladly pay just to get rid of this breast problem. But since I did't have any money at the time, I had to wait, but during the time the PS went and had a stroke... So he wasn't working anymore. Instead, another surgeon had taken over his practice meanwhile the original surgeon was "recovering". But when I finally went back to see the new surgeon (in september 2006), this new surgeon had taken over the practice completely (bought the practice, probably) and so he wanted full payment for correcting my breasts. Well I understand him, since HE was innocent of what the first surgeon had done with my breasts. Anyway. He agreed to correct my breasts by removing some skin under the breasts and "tightening" them, which would make the breast tissue come higher up, which in turn would make it look like the nipples weren't placed so wrongly. I paid 20 000 skr for this (which is about 3000 $ ) and this surgery was in november 2006. After surgery, my breasts looked PERFECT for about two weeks. After that they started sagging again, or how would you explain it. I felt, and saw, the tissue moving downwards again. And now, only 9 months after the last surgery, there is almost NO tissue on the upper side of the breasts and at the level of the nipple. My breasts look like skiing hills!
Now these latest weeks, after thinking so much about what to do about my breasts, I have come up with another idea. Because you see all I want at this moment is to get relieved of this problem. I don't necessarily need to have it done NOW, but I need to know that there IS some way to correct it, that will make it look good not only the first week after surgery... Well what I've thought about lately is wheter it would be an alternative for me to remove the breast tissue COMPLETELY, and instead put in a prothesis in approximately the size that my breasts are now. But a prothesis that is "solid" in shape and that doesn't sink down to a "blob" at the lower part of the breast. Maybe this solution would give me some "fill" at the upper part of the breasts. This wouldn't change the position of my nipples, but maybe the breasts wouldnt look so empty at the upper part. Well I don't know. I've never heard of someone who has completely removed their breast glands. And replaced with protheses. I don't even want to think of what this will cost.
What do you think of these ideas?

Dr. Rob Oliver said...

Dear Anonymous in Sweden,

While I'm a little overwhelmed by your narrative, there are a couple thoughts.

I think the only way to correct your nipple position at this point may be to remove it a replace it as a free graft. That a technique used with large breast reductions or re-do surgeries where blood supply may be an issue.

As to upper breast hollowness, the only way to produce full upper breasts reliably is to use an implant or push-up bra. Breast tissue just has a way of descending no matter how we try to "fix" it in place.

Anonymous said...

I don't know, I think you're being a little disingenuous here. Certainly the scope of ENT facial plastics is limited to the neck up, but quite honestly I would pit recent 5+facial ENT guys against 6 year integrated plastics guys any day. Are you seriously arguing that 3 years of dedicated full body plastics/hand makes for a far better facial surgeon than 4 years of head and neck surgery and then a dedicated facial plastics fellowship? Calling them "not real plastic surgeons" is rather petty - certainly they are not 'whole body plastic surgeons', but they are essentially equivalent when it comes to the face.

Dr. Rob Oliver said...

It's not disingenuous at all. The doctor in that story is NOT A PLASTIC SURGEON .

The scope of training for procedures of the head and neck is somewhat different and distinct for ENT's and Plastic Surgeons. A fully trained ENT would likely have done do a good bit more oncologic resections, functional nasal/airway surgery, and the whole ear tubes & tonsils gig. At most (but not all)programs they'd likely do less congenital pediatric surgery, less reconstructive surgery, less microsurgery, and less cosmetic surgery then Plastic Surgeons.

Facial Plastic surgery fellowships, do not (by in large) train people in "Plastic Surgery" of the head and neck. They're more akin to the loosely regulated group of cosmetic surgery fellowships that also exists after plastic surgery (I did one, for instance).

Again, the fact that you can still get accredited in this with no formal post-grad training speaks for itself.

Anonymous said...

Dear Dr. Oliver

It's fascinating that you don't hear neurosurgeons lambaste or denigrate Orthopedic surgeons about performing spine surgery (or visa- versa)"You should only have your spine surgery performed by a Board certified Neurosurgeon" Nor do I see much in the way of "You should only have your hand surgery performed by a board certified Orthopedic surgeon." Its only when you talk about cosmetic surgery that this becomes an issue....not any type of reconstruction. You actually miss the point with regards to where the problem lies when discussing "who the real plastic surgeons are.." It is reminiscent of article written years ago called "milk masquerading as cream" which
ultimately lead to a law suit over
the term "Plastic Surgeon."
The problem is the Board of Plastic
and Reconstructive surgery which began a heavy handed public campaign to "make sure that your cosmetic surgery is performed by only a Board Certified Plastic and reconstructive surgeon".... under the guise of "protecting the public." Meanwhile otolaryngologists have been trained and practicing (very well I might add) facial plastic surgery since it became a sub specialty (the very first specialty) The American Board of Medical Subspecialies recognizes facial plastic surgery as part of the otolaryngology not requiring ANY further training... this is not new! To reply to your statement that otolaryngology residency "really doesn't train you in facial plastic surgery".... what are you basing that on? My residency in New York surely did. Granted not all residencies are equal... but that certainly is true of plastic surgery residency as well. I personally dislike the term facial plastic surgeon (in which I have trained)- I wish it were enough to say I am a well trained otolarygologist Head and neck surgeon with a extra year of fellowship training for facial surgery... but it's actually the campaign of your Board that requires I use this title to portray my expertise. As for your description of Facial plastic surgery fellowships and specialization.. again what are you basing this on? you knowledge of all the fellowships in the country and what each offers? Moverover, it wasn't that easy to get my certification.... First i needed to be boarded in Oto/HNs... then do a fellowship- take an exam (oral and written)- submit a research project- then practice for two years and develop a suitable case log!
I frequently read and enjoy your blog- I must express my discontent with your comments regarding "facial plastic surgery." It brought to light much of the ignorance regarding the history of medical sub specialty (ie Otolarygology and "plastic surgery")

Let's discuss the history of Plastic surgery. "Plastic" surgery was borne out of the need for reconstructive surgery during WWI. Surgeons (Dentists and surgeons) combined thoughts and experiences into a technique that is plastic surgery. Some of the "Fathers" of plastic surgery were otolaryngologist (Converse and Gilles to name just a few) During the 60's as cosmetic surgery became less a taboo-- people wanted to grab it for themselves. Hence the present day problem.

Dr. Rob Oliver said...

Dear Anon,

I think you're missing the irony and point of the blog post. Again the doctor featured as a Plastic Surgeon was not a Plastic Surgeon. There is no getting around that.

I agree that alot of this issue is semantics, but this new story clearly illustrates the consumer confusion that was deliberately engendered by the "facial plastic surgery" moniker, and was exactly what was envisioned by the American Board of Plastic Surgery when they filed their unsuccessful lawsuit decades ago over this.

I have no issues with ENT's doing head and neck cosmetic surgery BTW, fellowship or no.