Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Do I Need a Full Facelift?

I can’t tell you how many times that I (and every cosmetic surgeon) hear that question.  I think that the word “facelift” has more meanings to people than any other word in cosmetic surgery.  People ask about a “full facelift”, “half facelift”, “neck lift” and so on.  This can be very confusing to patients and some may forego treatment because of preconceived notions that are not true.

A “facelift” by definition is a procedure called rhytidectomy.  A rhytid is a wrinkle and “ectomy” means to surgically remove, so technically it refers to a surgical procedure with incisions removes skin to tighten wrinkles.  A traditional facelift includes hidden incisions in front of and behind the ear.  The skin is then separated from the underlying tissues and the deep layers are tightened.  Then the skin is pulled in a natural direction and the excess is removed.  Traditionally, the platysma (muscles in the central neck) are also tightened.

A traditional facelift does very little (or nothing) for the central oval of the face (brow, central forehead, eyes, nose and mouth).  It also does very little, if anything for tissues above the nostrils.  So, a “facelift” is more for the jowls and neck, in fact, all about the jowls and neck. Now you know what a facelift really is!

The “wrinkle” in this description (yes, pun intended) is that not all surgeons do the same surgery the same way.  Some surgeons omit the platysma procedure.  Personally I think that is short changing the patient, although very young patients may not need a platysmaplasty.  Also, some surgeons “invent” shortcut facelift procedures where they omit the incision behind the ear.  I am always leery about someone who takes a procedure that is 100 years old and puts his or her name on it, or even worse, a corporate name.  Again, facelift surgery has been around for a century and all the tricks have been attempted and abandoned because a short cut in surgery almost always translates to a short cut in result and longevity.  Some surgeons try to avoid several inches of incision behind the ear and end up doing a procedure that will begin to relapse in several years.  These types of shortcuts always claim easy surgery with fast recovery.  Remember, in cosmetic surgery, you always get what you pay for….not in terms of money, but in terms of recovery.  The cosmetic consumer should always be cautious about any surgery that deviates significantly from the standard of care in technique.  Just because something is new, does not make it better.  Obviously, we do make advancements in materials and techniques, but if and when that happens, it becomes widely adapted and the norm.  Any patient that is looking at a “new” or “miracle” procedure should ask the surgeon to see 20 pictures of patients that had this procedure by same surgeon and the pictures should be 1-2 years after the procedure.  If a surgeon can’t show you that (for any procedure) you better think closely about getting surgery that is different from the way most surgeons do it.  Cosmetic surgery patients often get the short end of the stick from hype delivered by companies, media and surgeons.  If it sounds too good to be true, it is!  If someone invents a new and radical improved facelift procedure, it won’t be in TV ads, it will be front page news.

So, back to the“facelift” definition.  Much of the confusion about the definition of the word comes from a patient’s experience.  A patient may have “rhytidectomy” but also have a brow lift, eyelid surgery, cheek implants, chin implant, laser skin resurfacing, etc.  So when this patient tells someone they had a “facelift” the listener may assume that a facelift includes all that additional surgery.  They would be wrong!  Rremember, a facelift primarily addresses the jowls and neck.  The patient merely had other procedures along with their facelift.  When you get your engine tuned up, it may include a wheel alignment at the same time, but technically, an wheel alignment is not part of a tune up.

The best way to keep this all simple is to divide the face into 4 segments:

  • Upper face
  • Midface
  • Lower face and neck
  • Face and neck skin

Each of these regions concerns separate cosmetic procedures to address the aging in that area and the facelift concerns the third item on the list.  Also facelifts come in three sizes; small, medium and large.  It is basically the same procedure in different versions.  Patients in their early 40’s may need a small lift, while patients with more aging need bigger versions of the same operation.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu, III in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


February 27, 2012 Posted by | Cosmetic Facial Surgery Consultation, Cosmetic Surgery Education, Facelift Surgery | , , , , , | Leave a comment

Facial Thirds: a good way to look at the face

I see a lot of patients this time of year who have made a resolution to look better and feel better about themselves.  This is a great time to have cosmetic surgery because you can cocoon in the winter and then the butterfly comes out in the spring!

The best way to decide what procedure is right for you is to divide your face into four parts: the upper face is the forehead and upper eyelids; mid-face is the lower lids, cheeks and upper lip; lower face is the jowls and neck; and the fourth area is the skin.

When patients come in for a complimentary consultation, I look at each of these areas separately and evaluate what kind of aging is there. Together, the patient and I decide whether it requires a surgical or non-surgical solution. All surgeries are performed in my fully accredited, in-office surgery suite.

For the upper face, surgical options consist of either a brow or upper lid lift. These are very effective procedures because the eyes are the first place to show age. Non-surgical upper face options include Botox, Dysport, and Xeomin and facial line fillers for mild to moderate wrinkles.

For the mid-face, lower lid surgery and cheek implants will lift the cheeks and eliminate bags, and can be performed in about an hour.  Injectible cheek, lip and smile line fillers are moderate  non-surgical procedures with no downtime.

For the lower face, surgical procedures include facelifts, liposuction and chin implants. There are varying degrees of facelifts, depending on the patient’s needs, budget and available recovery time. Botox Dysport, and Xeomin and fillers can also be effective non-surgical options.

Chemical peels and laser resurfacing are very effective for skin rejuvenation. Moderate aging and brown spots can be treated with fractional or light laser resurfacing for shorter recovery.  Non-surgical procedures include radio frequency mole removal, spider vein removal, and medically based (prescription strength) lifetime skincare.

If there’s something you’d like to change, 2012 is a good time to do it. I invite you to come in for a free consult and skin scan. You do so much for others. Let this be the year you do something for yourself!

To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

December 14, 2011 Posted by | cosmetic facial surgery, Cosmetic Facial Surgery Consultation | , | Leave a comment

FAQ from Dr. Joe

Click here to view full size PDF

October 5, 2011 Posted by | Cosmetic Facial Surgery Consultation | , , | Leave a comment

Buyer Beware: Cosmetic Facial Surgery

In this day and age of media hype, it is not uncommon to see, hear or read about “miracle” skin and surgery procedures that “can be done awake without anesthesia”, have “little or no down time” and promise to “take years of aging” off of the skin.  BE CAREFUL!  Some general rules to consider are:

• If it sounds too good to be true, it is.
We see so many patients that fell for these “miracle” procedures, spent a lot of money and saw no results.  Do your homework.  Research the procedure you are considering.  You may be surprised how many unhappy patients and doctors there are out there with that specific procedure.  Many of the procedures and devices you see on TV and Doctor shows turn out to be duds.  When you see infomercials on “miracle or revolutionary” facelifts or procedures, stop and think.  If something was truly revolutionary, would everyone be doing it?  Wouldn’t you be more likely to read about this tremendous advance in the mainstream media?  Believe me, if someone invents a facelift that is truly revolutionary and can be done awake with no downtime, they will receive a Nobel price, be on cover of Newsweek, etc.   And no one would do “old style” lifts.  This is called a paradigm shift.  You don’t see horses on the expressway because the combustion engine was such an advancement that everyone drives cars.  If and when we see paradigm shifts in cosmetic surgery you won’t learn about it from infomercials!  Some examples of true cosmetic paradigm shifts include Botox, lasers and liposuction.

• Any skin resurfacing or tightening procedure that can be done without anesthesia is probably not going to do much, especially in a single treatment.
To truly address skin aging, deeper dermal treatment is important and this is simply too painful to be done without sedation.  I see many patients that were treated awake and it was a terribly painful experience.  Remember, in this day and age of safe and easy sedation, there is no reason to suffer for a procedure.  I feel the same way about facelift surgery.  Small facelifts can be done with local anesthesia, but larger lifts, in my opinion, can be done faster and better with sedation.  I recently heard a surgeon discuss how he does facelifts with local anesthesia and his patients take bathroom breaks and have snacks.  Not the way I want to do it, I can do a comprehensive facelift with platysmaplasty and SMASectomy in under 3 hours, but it requires sedation.  Please don’t misinterpret me, some surgeons are very versed at local procedures, and do safe and effective surgery but the average facial surgeon uses sedation.  Patients should have a good idea about the “standard” means of performing surgery and anesthesia and look closely at those surgeons that deviate from this definition.  Does not mean they are bad, maybe just different.  It is the safety and outcome that matters, so do your due diligence, look around.

• How many procedures are required to see a difference?
This is important as I see patients that were treated elsewhere and thought that their “light laser” was a single treatment.  When they saw little or no difference, their doctor told them they need 3-5 more treatments to be effective.  Personally, I think it would be advantageous to have a single Classic laser treatment and take 10 days off of work than to have 3-5 “fractional laser” treatments that take 3-5 days to heal.  Remember, there are no miracle treatments and your result is equal to your recovery.  Procedures with short recoveries have small results.  Procedures with longer recoveries have much more impressive results.

• Don’t be afraid to ask!
Too many times, patients are hesitant to ask their surgeon to see actual before and after pictures of a procedure.  It is important to make sure that the before and after pictures are from your doctor and not from a laser company.  If you are considering a procedure from a doctor and they cannot show you ten before and after pictures, there may well be a reason!  Ask the surgeon how many of these procedures he or she has done and ask for some patient references.

• Every Picture Tells a Story
As digital photography has progressed there should be no reason for any doctor to use poor quality or unstandardized before and after pictures.  Although it is rare that surgeons “photoshop” their pictures to improve the outcome (yes, it happens) it is very common for some doctors to have very poor pictures.  In my experience, surgeons that take pride in their images and pay attention to detail, do the same with their surgery.  Beware for before pictures take without a flash (shadowy) and after pictures taken with a flash.  This always makes the outcome look better because the shadows are gone in the after picture.  Also look for before and after pictures that are not the same size, not the same background, not in focus.  This is just astute observation I have made over the years.  Doctors that have sloppy or misleading before and after pictures may not pay attention to detail.  I always tell young doctors that “your images represent you and your ability”.

What kind of Surgeon Should I have do my Surgery?
This is important and the true answer is that in reality there are many specialties that are qualified to perform cosmetic surgery.  Some specialties are deeply involved in turf battles and would like the consumer to think that only their specialty is qualified to perform cosmetic surgery.  Nothing could be farther from the truth and these arguments are self serving to attempt to capture patients and dollars.  If you are considering facial surgery, you could choose a cosmetic trained dermatologist, oculoplastic surgeon, oral and maxillofacial surgeon, ENT surgeon,  or plastic surgeon.  No one specialty is better than the other and it all boils down to the competency of the individual surgeon.  Their training, ability, patient safety, and clinical outcomes are the most important thing.  Numerous specialties are qualified.  When seeking a surgeon, look for:
• A doctor that you feel good about and that has time for you.
• A doctor that has training in the area that you are considering.
• A doctor that has experience and can show you many examples of his or her work including patient testimonials.
• A doctor that has an accredited facility.
• A doctor that you can easily get in touch with if you need them.
• A doctor with a caring staff.
• A doctor that will back up their work and be able to handle complications.

For more information on cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com


Niamtu, III DMD
Richmond, Virginia

September 7, 2011 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation, Cosmetic Surgery for the Wrong Reasons, Minimally Invasive Cosmetic Facial Surgery, New Cosmetic Surgery Technology | , | Leave a comment

5 Questions to Ask Yourself Before Having Cosmetic Surgery

People turn to cosmetic surgery because they want to look better, feel better and increase their self-confidence. Cosmetic surgery is generally a positive experience that changes lives, but it can become a nightmare if the patient chooses the wrong surgeon or the surgeon chooses the wrong patient—it is truly a mutual relationship. If you are considering cosmetic surgery, first ask yourself the following five questions:

1. Why do I want to have the procedure?

Good reasons to have cosmetic surgery are to look and feel better and boost self-esteem and confidence. Patients who think cosmetic surgery will change their entire life are likely to be disappointed. Having cosmetic surgery to save a failing relationship or vie for a job promotion are not reasonable motivations. And patients who have cosmetic surgery just to get attention will likely remain insecure despite their rejuvenation. The best answer I like to hear when I ask my patients why they want cosmetic surgery is, “I just want to look as good as I feel and look as good as I can for my age.” Whereas a  60 year old woman who brings a picture of Angela Jolie to her consult sets off red flags.

2. Is this the right time in my life to have cosmetic surgery?

Depending on the procedure or procedures, cosmetic surgery can be an intense experience from choosing the right surgeon, to deciding on the best correct procedures, to the recovery process. Your recovery will require your full attention of you and your family and it is not advisable to bite off a big recovery if your life is tumultuous at the moment.  Patients that are grieving, having marital problems or problems with children, etc. can distracted.  you may only do this once in your life, pick a time when it is “all about you”.

3. Can I afford the procedure?

Cosmetic surgery can be expensive, especially if you want multiple procedures. Like any other elective purchase, you should not place unrealistic financial burden on yourself just to look better. Impulsiveness has no place in making medical decisions. Postponing surgery, obtaining in-office financing or limiting the number of procedures may be solutions for some patients. Remember, it takes most of us a half a century get our wrinkles, you don’t have to correct them all overnight.

4.  What is my support system at home?

Recovery from any type of surgery can be intense and, depending upon the procedure, patients may need physical and emotional assistance for several days or longer. There is nothing more helpful than a compassionate, supportive spouse, but this is not the case in some households. I have seen husbands or wives disapprove of their spouse’s decision to have cosmetic surgery.  Sometimes it’s jealousy, sometimes it’s the expense. When you are in bed, bruised and bandaged, the last thing you want to hear is “I told you so.” Support at home cannot be underestimated.

5. Have I chosen the right surgeon?

Patients need to do their homework. It’s important to choose a surgeon who is board certified in their specialty and one who routinely performs the specific procedure(s) you are considering. An experienced surgeon should be able to show a prospective patient many pictures of his or her work and have patient references readily available. An accredited office surgery center and discussion of who will be performing the anesthesia is also important. It is a myth that only doctors of certain specialties are qualified to perform cosmetic surgery. It is the skill of the surgeon’s hands that makes the difference, not what specialty they represent. Finally, you must be able to communicate openly and effectively with your surgeon. Trust your instincts. If you don’t like your surgeon’s personality or demeanor, don’t hesitate to interview another surgeon.

 To learn more about cosmetic facial surgery from Dr. Joe Niamtu in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


February 22, 2011 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation, Cosmetic Surgery for the Wrong Reasons | , , | Leave a comment

Dr. Niamtu Recent Featured Cosmetic Facial Surgery Patient

Name: Brenda Michaels

Age: 61

See a video of Brenda Discussing her Surgery

Procedures Performed:

  • Facelift
  • Upper and lower eyelid surgery


I am a recent widow.  I have two sons and two beautiful daughter-in-laws, and three adorable grandchildren, ages three, five, and seven.


Self employed- buying and selling plastic raw materials.


I enjoy hiking, gardening, reading and playing my piano.

Why you wanted to have cosmetic surgery:

I had wanted a facelift for a number of years as time continued to take a toll on my neck and face.  For me, my neck was the deciding factor in my decision to have a facelift.

Why did you choose Dr. Niamtu:

When I found Dr. Niamtu’s website, I was most impressed with the amount of information that was given about cosmetic facial procedures and I just knew that he was the doctor that I wanted to perform my facelift.

What were you hoping to achieve with the surgery:

I wanted to achieve a more youthful looking face and neck and Dr. Niamtu gave me that.

How did you like the results:

I am most pleased with my facelift.

What advice would you give other women considering cosmetic facial surgery:

Several of my friends have told me that they wouldn’t want to spend the money for cosmetic surgery or put themselves through the surgery and recovery.  Certainly having cosmetic surgery is a very personal decision, but for me the results were worth it all.  I “love my face” and for any woman considering cosmetic facial surgery I would say “Go for It!”

Any special thoughts on your experience:

I feel that I was blessed to have found Dr. Niamtu and to have him perform my surgery.

Comments from Dr. Niamtu:

I think I have the greatest patients in the world and feel very lucky to do what I do for a living.  It just keeps getting better!









To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

November 25, 2010 Posted by | Cosmetic Eyelid Surgery, Cosmetic Facial Surgery Consultation, Eyelid Surgery, Facelift Surgery | , , , | Leave a comment

A Touching Experience: How Doctors Connect with Their Patients


 For 30 years I have been very involved in teaching medical and dental students, residents, interns, fellows and experienced surgeons.  One of the things that younger doctors always want to know is “how do you perform a consult?”  This is a very difficult question to answer as every doctor has his or her own style of communicating with patients.  Some surgeons (usually very successful ones) are great at it and others fumble through the consultation process and never really connect with the patient.  Developing a successful consultation persona is a process that continually matures over decades and most physicians usually learn these things the hard way through trial and error.  Not every doctor can act the same way around every patient.  Some patients are very formal and are turned back by levity or casualness while this is very relaxing and engaging to other patients.  Astute surgeons temper their demeanor and consultation process to individual personalities.

Classical medicine discusses laying of the hands and there is no doubt that a warm and sincere touch is comforting to a sick patient or one who is nervous about discussing their aging face in a cosmetic consultations.  Appropriate greeting and communicating touches with patients put them at ease, introduce a mutual energy, and show a caring physician.  Whether a handshake, a gentle touch on the shoulder or arm or touching the patients face when describing their condition, it makes most patients feel more connected.  Obviously there is a personal space to be respected and with some patients any touch may make them uncomfortable, but if you watch a masterful clinician in consultation with their patients, the chances are you will witness tactile communication.  I have professed this for years and frequently see this confirmed by science.

I rarely post verbatim copy on my blog, but every once in a while, someone says something perfectly and to try to express that without crediting that person detracts from the message.

New York Times

February 23, 2010


Evidence That Little Touches Do Mean So Much


Psychologists have long studied the grunts and winks of nonverbal communication, the vocal tones and facial expressions that carry emotion. A warm tone of voice, a hostile stare — both have the same meaning in Terre Haute or Timbuktu, and are among dozens of signals that form a universal human vocabulary.

But in recent years some researchers have begun to focus on a different, often more subtle kind of wordless communication: physical contact. Momentary touches, they say — whether an exuberant high five, a warm hand on the shoulder, or a creepy touch to the arm — can communicate an even wider range of emotion than gestures or expressions, and sometimes do so more quickly and accurately than words.

“It is the first language we learn,” said Dacher Keltner, a professor of psychology at the University of California, Berkeley, and the author of “Born to Be Good: The Science of a Meaningful Life” (Norton, 2009), and remains, he said, “our richest means of emotional expression” throughout life.

The evidence that such messages can lead to clear, almost immediate changes in how people think and behave is accumulating fast. Students who received a supportive touch on the back or arm from a teacher were nearly twice as likely to volunteer in class as those who did not, studies have found. A sympathetic touch from a doctor leaves people with the impression that the visit lasted twice as long, compared with estimates from people who were untouched. Research by Tiffany Field of the Touch Research Institute in Miami has found that a massage from a loved one can not only ease pain but also soothe depression and strengthen a relationship.

In a series of experiments led by Matthew Hertenstein, a psychologist at DePauw University in Indiana, volunteers tried to communicate a list of emotions by touching a blindfolded stranger. The participants were able to communicate eight distinct emotions, from gratitude to disgust to love, some with about 70 percent accuracy.

“We used to think that touch only served to intensify communicated emotions,” Dr. Hertenstein said. Now it turns out to be “a much more differentiated signaling system than we had imagined.”

To see whether a rich vocabulary of supportive touch is in fact related to performance, scientists at Berkeley recently analyzed interactions in one of the most physically expressive arenas on earth: professional basketball. Michael W. Kraus led a research team that coded every bump, hug and high five in a single game played by each team in the National Basketball Association early last season.

In a paper due out this year in the journal Emotion, Mr. Kraus and his co-authors, Cassy Huang and Dr. Keltner, report that with a few exceptions, good teams tended to be touchier than bad ones. The most touch-bonded teams were the Boston Celtics and the Los Angeles Lakers, currently two of the league’s top teams; at the bottom were the mediocre Sacramento Kings and Charlotte Bobcats.

The same was true, more or less, for players. The touchiest player was Kevin Garnett, the Celtics’ star big man, followed by star forwards Chris Bosh of the Toronto Raptors and Carlos Boozer of the Utah Jazz. “Within 600 milliseconds of shooting a free throw, Garnett has reached out and touched four guys,” Dr. Keltner said.

To correct for the possibility that the better teams touch more often simply because they are winning, the researchers rated performance based not on points or victories but on a sophisticated measure of how efficiently players and teams managed the ball — their ratio of assists to giveaways, for example. And even after the high expectations surrounding the more talented teams were taken into account, the correlation persisted. Players who made contact with teammates most consistently and longest tended to rate highest on measures of performance, and the teams with those players seemed to get the most out of their talent.

The study fell short of showing that touch caused the better performance, Dr. Kraus acknowledged. “We still have to test this in a controlled lab environment,” he said.

If a high five or an equivalent can in fact enhance performance, on the field or in the office, that may be because it reduces stress. A warm touch seems to set off the release of oxytocin, a hormone that helps create a sensation of trust, and to reduce levels of the stress hormone cortisol.

In the brain, prefrontal areas, which help regulate emotion, can relax, freeing them for another of their primary purposes: problem solving. In effect, the body interprets a supportive touch as “I’ll share the load.”

“We think that humans build relationships precisely for this reason, to distribute problem solving across brains,” said James A. Coan, a a psychologist at the University of Virginia. “We are wired to literally share the processing load, and this is the signal we’re getting when we receive support through touch.”

The same is certainly true of partnerships, and especially the romantic kind, psychologists say. In a recent experiment, researchers led by Christopher Oveis of Harvard conducted five-minute interviews with 69 couples, prompting each pair to discuss difficult periods in their relationship.

The investigators scored the frequency and length of touching that each couple, seated side by side, engaged in. In an interview, Dr. Oveis said that the results were preliminary.

“But it looks so far like the couples who touch more are reporting more satisfaction in the relationship,” he said.

Again, it’s not clear which came first, the touching or the satisfaction. But in romantic relationships, one has been known to lead to the other. Or at least, so the anecdotal evidence suggests.

To find out more about Joe Niamtu, III DMD and  cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

March 23, 2010 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation | , , | Leave a comment

Online Cosmetic Surgery Consultation: what’s up with that?

I saw a very interesting article in the New York Times (1-21-2010, page E3) recently about how many cosmetic surgeons are offering virtual online consults for patients.  This article discussed how many cosmetic docs are currently offering online video consultation for patients where the surgeon and patient are connected via web cam and a telemedicine consultation is performed, frequently for a fee.  A group called Surgeonhousecall.com has recruited 55 plastic surgeons to provide online consultation for cosmetic surgery. This got my mind churning about the pros and cons of this technology.

If someone told me 30 years ago that I could take all of my record albums and cassettes and put all that music on my pocket sized telephone I would have thought that was a radical statement.  Admittedly, when I purchased my “100 CD capacity CD player” I never saw the digital music revolution coming.  We can all relate similar stories about the fax machine, email and Internet surfing.  So when someone suggests that cosmetic surgeons may be someday (or currently) performing consultations via a computer screen, I must consider this plausible and possibly a paradigm shift for medicine and surgery, although it somewhat rubs me the wrong way. 

Medicine and surgery are historically based on “the laying of the hands” and for the last thousand years, has been practiced in that manner.  Not being able to actually see and touch a patient probably makes any surgeon feel at a disadvantage.  We use all of our senses to consciously and subliminally formulate thousands of impression about a patient and their diagnosis and treatment.  When you think about it, a flurry of information streams through our brain via sight, touch, smell, hearing, and analysis.  We lose much of this sensory input, staring at a two dimensional picture on a monitor.  Regardless of your surgical discipline, there are many cases where an accurate diagnosis and treatment plan could be formulated via a video conference.  Personally, I could probably perform a relatively accurate consult for blepharoplasty, facelift, skin resurfacing or Botox and fillers by looking at a patient on a monitor and talking to them over the Web, but would I feel comfortable enough with this information to meet them in the operating room the next day?  Probably not!  There is simply not enough sensory input to cover all the minute specifics that are imperative during consultation.  Do they have lower eyelid laxity, how much of the submental excess is fat versus skin, is the skin pigment epidermal or dermal, how many syringes of filler will they need would be information that I would be lacking.

I don’t think that the surgeons who advocate or are currently performing online consultation intend for the consult to be “final or comprehensive” in nature, but rather to serve as a general informational or screening tool in advance of actual personal consultation.  So from that aspect, this process has merit.  Whether we realize it or not, many of us are already performing some form of digital consultation anyhow.  I routinely look at patient’s pictures that are emailed to me for informal discussion.  It is important that I do not render an official medical opinion and I have the following disclaimer on my emails.

Any correspondence should not be construed as medical advice, evaluation, or consultation and should never be considered a replacement for a formal evaluation by the physician in his office and related consultation. Therefore, the information and correspondence that is involved with this email or future emails do not constitute a formal doctor-patient relationship. If you desire to schedule a consultation, please feel free to call the office to arrange for this type of appointment. Please be advised that your own physician should approve any change that should be undertaken regarding to your therapy. Explanation of off-label services and/or products that are mentioned herein does not reflect an endorsement nor promotion and should not be construed as such.

Doctors must be very careful not to construe casual opinion as formal medical consultation for numerous reasons.  First of all, if you do not have a license in the state or country of the recipient you may be in violation of the law.  Secondly, if you offer an opinion that somehow turns out to be incorrect or damaging, you may find yourself named in a law suit.  As farfetched as this sounds, I have a friend in that exact position, so it can and does happen. Also, patient confidentially and HIPPA concerns come into effect as you never know who may somehow obtain this sometimes confidential information or pictures by hacking into your computer.  Given all of these potential problems, we have to wait for medical societies, state boards, and possibly the federal government to set standards of how this activity should or can occur.  Right now, the cart is in front of the horse.

I was a bit surprised to see that there are some pretty well known practitioners that currently have free or paid video consultations available on their websites.  This bothers me because I consider myself and my website to be pretty technologically advanced.  “How did I miss that boat” was my first thought.  My second thought was ” I am not sure I want to be part of that boat at this time”.  It makes me wonder if doctors that offer these online video consultations are hurting for business and need this marketing tool to stay alive.  It also begs the question “if I did this in my practice, when would I find the time to do this”?  I already spend too much free time in the evenings updating my website, blog, etc, so I don’t want to be “seeing patients at home”.  At work, I am too busy with face to face patients to incorporate this technology into an already overly hectic surgery and consult schedule.  Then there is the frank reality that if this kind of thing really becomes popular, I will have to do it to maintain a competitive edge.  This bothers me more than anything as none of us enjoy doing something because everyone else is doing it and now we have to!  Finally, there are so many “tire kickers” out there in cyberspace that are not serious about having a procedure but would relish the opportunity to obtain a free video consult, “just in case” or “just for the fun of it.  I already have too many of those in my real time practice.

So I ask myself if this is a flash in the pan marketing ploy for those that are not already busy enough or is it the crest of a paradigm shift in digital medicine and in the future I will be intentionally leaving open spaces in my schedule for my “virtual patients”.  I have never charged a patient to look at email images and I don’t charge for in office consultations, but if this technology becomes mainstream, I will have to be compensated for my time is some way.

I am one that feels that still feels that accurate diagnosis still requires a hands on approach and that the doctor/patient relationship should remain personal.  I feel that unregulated virtual consultation somehow cheapens the entire relationship.  Having said this, I have always been an early adapter of technology and have in the past eaten words concerning “I will never do that” dogma.  I think telemedicine is a great situation for emergency scenarios and underserved areas or populations that may otherwise not have access to care.  I frequently have out of town patients or even local patients send digital or cell phone pictures to address concerns and have more than once seen an impending problem and was happy to have this early intervention opportunity.  Having said this, I guess I am talking out of both sides of my mouth.  In many ways being able to see a patient before an actual consult may save time for both the patient and surgeons as the proposed surgery may be out of the question and save wasting further time.  Seeing post operative patients that either cannot come in for consult due to geographic, transportation or after hours may in fact head off a potential serious problem such as hematoma, infection, etc.  So there is certainly merit to this technology.

In conclusion, there is no doubt that telemedicine will become a part of contemporary surgical practice.  I am not sure that want to begin seeing online consults just because other surgeons are doing it.  I, again, feel that this entire process needs standardization, regulation and security before it becomes mainstream. Does a patient who gets a plastic surgeon’s recommendation before a face-to-face visit really “win?” Can poor quality video or pictures provide inaccurate diagnosis or misinformation?    Will the “best” surgeons be available or just those who aren’t busy?  . I also fear that virtual consultations may become bidding wars for patients to simply look for the cheapest price.

Supporters cite that shy patients or others may desire a semi anonymous consultation and they want to know cost, and what they get for that cost before they make a commitment, or walk through the office door.” No doubt, some early adaptors will encounter some problematic aspects including lawsuits while this all gets sorted out.  I love technology and gadgets and I am sure that online video conferencing will impact my practice in my working lifetime.  It is an exciting thought but still a bit disconcerting as to when and how I will find time to do this and protect myself and the patient in cyberspace

Time will tell.

To learn more about Dr. Niamtu and Cosmetic Facial Plastic Surgery in Richmond, Virginia visit www.lovethatface.com.

Joe Niamtu, III DMD

January 30, 2010 Posted by | Cosmetic Facial Surgery Consultation, New Cosmetic Surgery Technology, Technology | , | 2 Comments

What goes around…..comes around.

comes aroudn

I had an interesting experience at the office today.  Not my first of this type, but a good one.  I went to a treatment room to see a patient that I have treated many times for Botox and small procedures.  I noticed that she would not make eye contact with me and thought that was odd. I asked her how her summer was and she said “terrible”, again while staring at the floor.  When I asked her why, she said she made a terrible mistake.  She went on to explain that she had consulted me months ago about a facelift, but on the recommendation of a friend, went to another surgeon and the result was a disaster.  I held her hand and reassured her that I am not offended and this happens to all doctors but I was sorry about her result.  Upon examination, she was correct, she had a poor surgical result.  Her incisions were improperly placed and noticeable, her neck still had much laxity, she had lost areas of tissue that healed with scars and had folds on her neck and chin from improper technique, to name the major problems.  She began crying and said she wanted to sue the other doctor.  I asked her who the other surgeon was and she told me.  She also told me that she should have know better than to go to him because when she told him that she had also consulted me, he “went off”.  She said this surgeon went into an embarrassing 5 minute diatribe about how I am unqualified to perform her facelift and many other degrading things about me.  She said that she already had paid a deposit and signed some papers so against her feelings she went ahead with the surgery.  She explained how disappointed she was and how much she suffered and how it ruined her entire summer.  She also reminded me that she asked me one time about this surgeon and I did not say anything negative about him and after his assault on me, she now sees the value of being a bigger person.  She stated “wow, you must really have taken a lot of this surgeons business for him to be that jealous, I am so sorry I did not choose you to begin with.” This was a good reminder of how astute patients really are. 

I again told her not to feel bad and that her actions were in the past and she can’t change that.  She spoke about suing the other surgeon which I totally discouraged, knowing that if the shoe was on the other foot, he would have relished in the process.  We began working on the scars and made a treatment plan to deal with the other problems and upon leaving, she gave me a hug.  I hope a lot of younger surgeons see this blog as there are a multitude of lessons to be learned in a case like this.  First of all, always speak with purpose and never lower yourself to the level of negative, insecure people.  You will always look bigger and patients can see right through an insecure surgeon.  Secondly, many doctors are victims of “competitive insecure bashing” and they should never let that bother them.  If a surgeon treats his or her patients like family and does good work, it will all catch up with the good doc and take away from the bad doc.  A Chinese proverb says “if you sit by the river bank long enough, you will eventually see the bodies of your enemies float by”.  It’s true.  Most doctors that talk trash are identifying themselves to that patient as insecure and intimidated by their competition.  If you can’t say something positive, then simply say “I don’t know anything about him”.  So today I wanted to thank Dr. X for his kind referral of this patient and all her friends.  I actually received patients without any marketing.  What goes around comes around.

To learn more about cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

September 1, 2009 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation, Doctors Badmouthing Other Doctors, Only Use A Board Certified Plastic Surgeon?, Risks of Cosmetic Surgery | , , , , | Leave a comment

How to Choose the Right Cosmetic Surgeon


A  national magazine called me to interview me on the subjecting of “Choosing Dr. Right”or how to pick a cosmetic surgeon.  During the interview, I wrote down some thoughts and here they are!


In reality there are no absolute criteria for selecting a surgeon and some of the surgeons that have the best qualifications do poor work and some simple, unknown, humble surgeons are true artists.  In our society we set standards for picking any service whether it is automotive repair, a school for your children, the place where you purchase your groceries or healthcare. What people look for is a qualified provider.  With consumer goods it may be the seal of approval from the Better Business Bureau, with surgery it is board certification. This does not guarantee proficiency, but is a universal standard for training.


As with consumer goods, the quality of work provided can translate to cosmetic surgery outcomes.  You may favor a certain restaurant because of a clean environment and consistently excellent food.  Surgeons that have consistently pleasing outcomes probably know what they are doing.  Generally the public appreciates this and a reputation for good surgical care and outcome brings a busy practice.  These surgeons are usually “superspecialists” and concentrate on a given procedure, i.e face, breasts, liposuction.  In addition, in my experience, the cosmetic surgeons that are the best, limit their practice to cosmetic surgery.  Not to say that performing other procedures makes a poor surgeon, but if all a surgeon does is cosmetic procedures, he or she would probably have more experience than a surgeon that “dabbles” in facelift surgery.  A surgeon that only does faces may be a better facelift choice than another who does surgery all over the body.  This is not a steadfast rule, but it is hard to be great at everything.


All of us use various service providers because we get treated incredibly well.  Special service is a hallmark of quality.  There is a huge difference in checking into a “W” hotel and a Motel 6.  Concierge service can also occur in the cosmetic surgery office and generally offices that know how to provide the best patient service and communication have quality all the way through the practice.  None of us want to be brushed off when we have a problem or need information and it is a very bad feeling to have a problem after surgery and not be able to readily speak to the surgeon.  Look for excellent patient service and care, the ability to easily reach the surgeon and staff and a clean and contemporary facility are usually good indicators about the quality of a practice.  On this vane, having an accredited facility is another indicator that the office and surgeon are interested in excellence.  Full accreditation can be a task of awesome proportion and is another positive factor in the patient’s decision making process.


Bedside manner is a classical means of rating surgeons.  We all know of excellent surgeons that have personalities like sour milk and we all know very personable surgeons that perform mediocre surgery.  Looking for a surgeon that the patient personally can communicate is very important.  “If you can’t speak to your surgeon, you may have the wrong surgeon” has always been one of my mantras.  If you have a rude, distracted or unfriendly surgeon when you are at the consult process, how will he or she act when the going gets tough?  Astute surgeons realize that a cosmetic surgery consult is actually a job interview for their services.  In addition, being able to reach your surgeon easily is paramount.  When I give my cell phone number to patients they are usually blown away as few surgeons exhibit that level of sincerity. 


Outcome is probably the most important buzz word in this discussion.  Show me any business that produces consistent quality outcome and you will see a successful business.  Providing a consumer with more than they expected is the hallmark of building a business.  Most busy, competent surgeons have a significant volume of cases that are testament to their work.  This is usually very self perpetuating and nothing succeeds like success.  Generally a busy surgeon with good outcomes will be popular by word of mouth.  Also, an experienced surgeon should be able to show prospective patient examples of his or her work.  If a surgeon can’t show you 50 before and after facelift pictures, something is not right.  Obviously, it may be a young surgeon with less experience and may do good work, but seasoned surgeons should have voluminous amounts of their work to help guide patients in the decision process.  Also remember that ever the best surgeons have occasional outcomes that are less than expected, but it is the general “gestalt” of a surgeon’s work that is important to the patient who is shopping for the correct surgeon.


Backing up one’s work is also a huge thing to look for with any consumer service.  If I pay thousands of dollars for a big screen TV and it does not work correctly, I expect the seller to stand behind their product.  Although cosmetic is not as simple as an appliance warranty, there are daily occurrences where a superlative surgeon will “back up what they do”.  The patient is always right should be a way of life and compromising for the effects on patient relations is something that is viewed with a very positive note.  It is impossible to guarantee a surgical result, but meeting reasonable patients half way when problems occur is positive marketing that money can’t buy.



Practice or Passion?  Another means of judging a surgeon is to evaluate their total involvement in their profession.  Like anything else, show me a person with a passion for what they do for a living and I will generally show you some that is good at what they do.  Doctors that publish, lecture, give courses and teach other doctors, have university appointments and are active in community service generally love what they do or they would not be so involved and these surgeons are generally “a cut above”.  No pun.



Things to avoid?  Beware of a surgeon who speaks negatively against their competition.  Remember that a surgeon that slanders his competition may also talk negatively about you as a patient.  Also, in most cases, surgeons that discredit their competition are usually hurting or jealous of the person they defame.  This is an unfortunate quality of many humans, to try to look good by making someone else look bad. This is especially true for those surgeons that attempt to mislead the public by saying only “their” specialty is qualified or better trained to perform cosmetic procedures.  This is like Ford saying that their car is the only choice and that all other cars are inferior and unsafe.  We all realize that turf wars exist between sports fans, restaurants, politics, religions and yes, surgeons.  The competent surgeon and savvy patient should never get caught up in these petty indifferences.


In conclusion, the above points, each taken separately, can serve as concrete facts when selecting a competent surgeon.  Collectively, the more of the above attributes that a given surgeon has the better a patient should feel when making a decision.  Show me an enthusiastic, board certified surgeon, who has many successful cosmetic cases from their accredited facility that is easy to communicate with and that backs up their work, and I will generally show you Mr. or Mrs. Right.


For more information on cosmetic facial surgery in Richmond, Virginia go to http://www.lovethatface.com.


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


April 2, 2009 Posted by | Choosing A Cosmetic Surgeon, Cosmetic Facial Surgery Consultation, Doctors Badmouthing Other Doctors | Leave a comment