Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Please Don’t Call Me a Plastic Surgeon

The field of cosmetic surgery has increased at an exponential rate over the past several decades.  Many paradigm shifts have occurred and this has changed the entire landscape of aesthetic surgery.  If a practitioner that performed aesthetic surgery procedures 40 years ago were to spend a day in my office they would be amazed by the new changes and technology.  Botox, lasers, endoscopic surgery, injectable fillers are just a few of the changes that have improved the profession.

Also among the changes is the fact that numerous specialties include aesthetic surgery in their core curriculum.  These procedures are taught in most residency programs to ophthalmologists, dermatologists, ENT docs, plastic surgeons, oral and maxillofacial surgeons and gynecologists to name a few.  In most of these specialties, cosmetic surgery procedures are part of the resident’s training, they are part of the board exams for those specialties and they are covered under the malpractice policies for those specialties.  Contemporary educators will freely admit that aesthetic surgery is well within the accepted scope of numerous specialties.  No single specialty owns the body or the face and each of these specialties have brought advancements to the collective table of aesthetic surgery.  For instance, dermatologists pioneered laser surgery and invented tumescent liposuction.  The current American Society of Plastic and Reconstructive Surgeons were originally founded by oral surgeons and physicians and was called the American Society of Oral Surgeons until 1931. Oral and maxillofacial surgeons also made significant advanced in aesthetic skeletal surgery and facial implants.  Ophthalmologists have contributed many techniques for cosmetic eyelid surgery and gynecologists have introduced or improved cosmetic vaginal surgery.  ENT physicians have advanced the field of cosmetic nose surgery on a continual basis. The list goes on and anyone that disagrees with the fact that contemporary aesthetic surgery is a multispecialty realm simply has their head in the sand or has intentions of secondary gain, such as limiting the competition, turf battles, and the desire to control patients and dollars.

So…what is “plastic surgery” and how does it differ from “aesthetic surgery” or “cosmetic surgery”?   A Plastic Surgeon is a noun (or could be an adjective) that describes a surgical specialty of medicine.  When used as to describe a type of surgery it has a much broader definition.  Any surgery that is intended to improve form, replace or restore missing or damaged tissue can also be called “plastic surgery”.  So, having said that, if one calls them self a plastic surgeon, it should indicate that they performed a general surgery residency and then a plastic surgery residency and they would be considered a plastic surgeon.  There are, however, exceptions.  Otolaryngologists (ENT’s) changed the name of their specialty to “facial plastic surgery” and ophthalmologists developed a specialty designation of “oculoplastic surgery”.  These practitioners often refer to themselves as “plastic surgeons”.  Other specialties will surely follow this lead in the future to represent their contemporary scope.

In my situation, I am a board certified oral and maxillofacial surgeon.  I am very proud of my unique qualifications to provide aesthetic facial surgery.  My early dental training (I never practiced general dentistry, but had to have a dental degree to enter a maxillofacial surgery residency) gave me excellent dexterity and artistic perspective as well as four years of studying facial anatomy.  My oral and maxillofacial surgery residency provided me not only with medical and surgical training, but also with an unparalleled level of head and neck anatomy and expertise in that region.  I feel that my specialty has an intense level of head and neck training (if not more) than any specialty.  As with any specialty, a surgeon can decide to focus on specific areas that he or she likes to do or excels in.  My true love is cosmetic facial surgery and over the years it became a bigger and bigger part of my practice and in 2004, I limited my practice to only cosmetic facial surgery.  If a doctor does nothing but cosmetic facial surgery then I believe it is practical to refer to them as a cosmetic facial surgeon. 

One huge misconception is that “plastic surgery” is synonymous with cosmetic surgery.  This could not be further from the truth.  Some plastic surgeons have excellent cosmetic surgery training and do a lot of cosmetic surgery.  Others have very little cosmetic surgery training and do very little cosmetic surgery.  Remember, plastic surgery is not necessarily cosmetic surgery.   I have some plastic surgery friends that are excellent at cosmetic procedures and do a bunch and others that are not so proficient and do more reconstructive and wound surgery instead of cosmetic procedures

 In reality, it is not about the specialty, it is about one’s training and expertise in what they do.  A poor cosmetic surgeon does not stay in business long regardless of the specialty.

Why don’t I want to be referred to as a plastic surgeon?  The reason is simple.  Number one, that is not my specialty and I have no need to feign credentials.  Number two and most important, I limit my practice to cosmetic facial surgery and “plastic surgery” is not necessarily cosmetic surgery, so if I did attempt to call myself a plastic surgeon, it would be detrimental to my practice as it would indicate that I do not spend 100% of my time doing cosmetic facial surgery.  The third reason that I do not want to be called a plastic surgeon is that I have many plastic surgery friends on a local, national and international level and it would be an affront to them and their training.  Most plastic surgeons are pretty sharp people and do some amazing reconstructive procedures all over the body, but having that specialty designation does not automatically imply proficiency in aesthetic surgery.

The real bottom line is that numerous specialties perform competent and safe cosmetic surgery.  That can’t be disputed.  Some competitive practitioners who are still fighting the worn out turf battles will attempt to say that other specialties have more complications, but again, the people that usually are saying this are the ones with the most complications.

So, I am not a plastic surgeon, but no one can dispute that my practice is limited exclusively to cosmetic plastic surgery procedures of the head and neck.

I am quite happy and secure being a board certified oral and maxillofacial surgeon and a DMD that only does cosmetic facial surgery.  It is very difficult for any practitioner of any specialty to limit their practice solely to cosmetic surgery and very few ever get to that point.  It is even more difficult to limit a practice to cosmetic procedures of the face and neck because not doing body surgery significantly reduces available surgical options.  I am proud to be one of the few surgeons of any specialty in my state to have a practice limited to cosmetic facial surgery, as well as one of the busiest.  I am also proud to be a fellow of the American Academy of Cosmetic Surgery and the American Society of Laser Medicine and Surgery.  I am proud to have published and lectured on cosmetic surgery more in the last decade than most of my naysayers will in their lifetime.  I am proud of my most recent textbook, which has set sales records and has sold well to all the recognized cosmetic specialties.  Cosmetic facial surgery is my passion, my life’s work, my job and my hobby.    I teach cosmetic facial surgery (to all specialties including plastic surgeons) at over 20 venues a year.  This sounds like bragging, but it isn’t; instead it is passion. I love cosmetic surgery, I love going to work, I love the patients and I love operating. Finally, this is how I feed my family and take care of the numerous expenses required by being the father of two severely handicapped children.  This I take the most seriously.

I do what I do well.  It is not a problem to call me a cosmetic facial surgeon because all I do, all day; every day is cosmetic facial surgery.  But please don’t call me a plastic surgeon.  It does not accurately describe a practice that exclusively performs cosmetic surgery.

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

 

Joe Niamtu, III DMD

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March 18, 2011 Posted by | Academic Cosmetic Surgery, Choosing A Cosmetic Surgeon, Cosmetic Surgery Around the World, Cosmetic Surgery Education, Doctors Badmouthing Other Doctors, New Cosmetic Surgery Technology, Only Use A Board Certified Plastic Surgeon? | , , , , , , | Leave a comment

Choosing the Right Patient

It takes a long time to become a surgeon and when it is all over and the shingle gets hung, all physicians must spend a great deal of energy for the rest of their working lives soliciting patients.  Some surgeons do this very aggressively with marketing, TV, Radio, etc. while others do it more subtly while still others merely join a busy group.  Whatever route a doc takes while he or she to put time and effort into pleasing current patients and procuring new ones. With all this focus on “getting patients and getting busy”, young surgeons are very attuned to accepting almost any case.  “you go into practice, you are not busy, you need patients and bang, here is one sitting in front of you with a check book and surgical request” .  It can be really hard to say no, especially for those surgeons just beginning their surgical journey.  “If someone walks into a car dealership and wants a car and has the cash, no one would ever consider saying no; but patients are not commodities and lives can be affected (doctor and patient) by accepting the wrong patient.

Any surgeon that has been in practice for a decade or longer at some time or another knowingly or unknowingly accepted a surgical case that, in retrospect, they shouldn’t have.   This is how we learn.  Unfortunately, it is not easy as there is not frank quantification.  I have always said that if someone could invent a device that you touch on a patient and it says “good patient, average patient, or bad patient”, our lives would be easier.  Too bad for us, that is not possible.  “I really think it takes years and unfortunately, getting burned a few times for the average doc to realize, wow, I will never do that again, on that type of person!”  Even experience docs sometimes miss the mark.  I have accepted patients that I thought were extremely stable, only to see them become noncompliant and problematic.  I have, likewise, hesitantly accepted some patients that had questionable stability and they turned out to be model patients.  “we will never get it right 100% of the time, but realizing the “red flags” can make our lives easier.

Surgeons can have red flags too.  No surgeon should ever do any case “just for the money”.  We all know this but in tough economic times, some surgeons may relax their principles.  Apparently unstable patients should also be another red flag.  As much as we may want to do this surgery, this type of patient can make our professional and personal lives miserable as these patients can be very litigious and in some cases violent. A number of cosmetic surgeons have been murdered by disgruntled patients.  My advice to novice surgeons, pretend the board of medicine is sitting in the room when you evaluate this patient, follow you surgical instincts, (they got you this far), if something does not feel right, “just say no”!

Saying no sounds very easy, but in reality can be quite difficult.  Most of us are polite people and are running a business.  Most of us are honored when chosen by patients to be their surgeon and most importantly, most of us want to help our patients and please them.  So, when a patient presents to your office, requests your talents, has the situation that you know you can improve and has the financial ability to pay for it, saying no can be difficult.  Sometimes the patient makes it more difficult as they don’t want to take no for an answer.  They keep pushing and sometimes begging.  Then they pull out their tricks and begin ingratiating the surgeon.  They speak poorly of previous surgeons and over complimentary of you.  They may point out that they traveled a long way to see you or that “no one else understands them”.  Most of these people are experts at getting what they want (or think they want, or want at this second) and can be extremely persuasive.   I have been in practice for 27 years and have at times accepted the wrong patient.  These are the people that want their money back, will defame you with other people and surgeons, will call you 24 hours a day, and can be very disruptive.  It has  been said that 1% of your patients cause 99% of your problems, well, this is the 1%.  I have noticed a huge increase of this type of patient as the Internet has developed.  I, like many surgeons, went from seeing patients from all over my city, to all over my state, to all over other states, to other countries.  This increase in the patient pool can bring proportionally more unbalanced patients to the office.  Also, manipulating patients feed of off the Internet as it can find them more prospective “hits” as many surgeons in their geographic may have turned them down or know their M.O.  By the same token, I have had some of my best patient experiences with out of town patients.  There is not guarantee either way.

What are some of the signs that should alert a surgeon of a potentially problematic patient?  Much has been written on this subject and this list is never ending.  Here are some

Red Flags during the consultation.

  • Patients with known Body Dysmorphic Disorder or psychiatric condition.
  • Any overly narcissistic or immature patient.
  • Unfriendly or impersonal patients
  • Patients that don’t smile or may eye contact.
  • Patients that are too busy or too important for surgery
  • Patients that speak negatively about previous patients be are complimentary to you
  • Patients that won’t listen and just talk.
  • Patients that are having surgery for the wrong reason such as a failing marriage, promotion or in the midst of a loss.
  • Patients that cannot decide on a surgical plan or say “do what you think I need”.
  • Patients that are overly impulsive, want to book surgery at first evaluation appointment.
  • Patients with unrealistic expectations.
  • Patients the “know” more about a procedure than the surgeon.
  • Patients that tell the surgeon what procedure to in extreme detail.
  • Patients obsessed with online cosmetic surgery bulletin boards or cosmetic surgery sites.
  • Young patients that have already had numerous surgeries or request surgeries generally performed on older patients.
  • Patients over reacting to a small flaw.
  • Patients that complain about financial arrangements or are pushy about discounts or are otherwise “shoppers”.
  • Patients that insist on absolutely no photographic documentation or are resistant go give important information such as cell phone numbers, etc. and insist on “secrecy”. 
  • Patients desiring surgery with intense familial disapproval.
  • Patients that are rude or pushy.

So, how does a doctor say no to a patient?

Good surgeons frequently say “no”! This sounds easy but in reality may be difficult.  The best means I have found in doing is to simply tell the patient that I have considered their request and looked at everything carefully and “I don’t think I can make them happy”.  I do not get into details that may lead to arguments.  Although many surgeons may ask a patient to see a psychiatrist, I never do, that is not my job, and if a patient is in need of that much evaluation, it is probably a mistake to operate on them at this point.  Also, many patients are offended by such a request.   I am always polite and stay away from issues that may be offensive or insulting.  A patient can argue with me if I question their mental stability or motivations for surgery, etc.  No one can argue with my appraisal that “I don’t feel that I can make you happy”.

My advice to novice surgeons is to try to learn these pearls without making these mistakes themselves.  Speak to older colleagues that have experience with this type of patient.  Sharing others “war stories” can assist in optimizing the surgical experience.  An ethical surgeon and balanced and compliant patients are a rewarding experience.

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

http://www.lovethatface.com

October 16, 2010 Posted by | Choosing A Cosmetic Surgeon, cosmetic surgery addiction, Cosmetic Surgery Around the World, Cosmetic Surgery for the Wrong Reasons, out of town cosmetic facial surgery, Risks of Cosmetic Surgery, Surgeons Picking the Wrong Patient | Leave a comment