Dr. Niamtu’s Weblog

….on cosmetic facial surgery

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


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

When all you have is looks; what happens when your looks are gone?

It is human nature to appreciate physical attributes.  Most people have some physical attribute, i.e. nice teeth, great hair, awesome breasts, big biceps that they are proud of.  Some people are really lucky and have it all; doesn’t it seem that college quarterbacks and cheerleaders always seem to?

You can pretty much tell when someone is infatuated with their own attributes.  These are the women with large breasts that always wear revealing tops and blouses, the guys with big arms that always wear short tight sleeves, etc.  Again, this is a bit human nature; if you’ve got it, flaunt it!

The problem is that some people become so stuck on their given attributes, it becomes the defining portion of their life.  We all know people like this.  Women whose world revolves around their bust line, men who are obsessed with muscles.  Some are obsessed with several body parts so that they are simply “into themselves”.  I read (with sadness) the other day that the woman with the world’s largest breast implants (Sheyla Hershey) had to have them removed.  She also lost much breast tissue and is despondent because she will no longer be able to have M size breasts.  Really……….M cups!  The insanity of someone that would actually want breasts bigger than basketballs is startling.  The fact that a surgeon would oblige is sad.   This lady was all over Google Images with insane pictures of insanely huge breast implants.  This was her life and that is sad.  Now her sole asset and claim to fame is also gone which is even more sad.

Again, there is sometimes a fine line between a great physical asset and a personality defect.  Many individuals that are overboard with a physical attribute are actually masking some personality deficiency.  They may be using their breasts, hair or biceps to overshadow insecurity.  The big boobs gives them the security.  Some people simply are insecure and need the attention and hence the low cut blouse, tight jeans or short sleeves gives them just that.  Some are so obsessed that they may move to a warm climate as not to cover their body with bulky clothes.  We are all a bit narcissistic or none of us would own a mirror, but most people pull it all off with a balance and they know that what is here today may not necessarily be here tomorrow; and that is the crux if this story.

If one’s life revolves around big, firm breasts, what is going to happen when these breasts become droopy and wrinkled?  Guys that live in a world revolving around their arms or abs, guess what?  You are not going to look like that forever.  Many of the body builders that I worked out with in college (and I am talking about some big boys) look pitiful now.  The are big and fat and out of shape.  For those of you who attend your high school reunions, it gets pretty scary after year 20.  Most people get old, fat and out of shape.  Their great breasts, etc. provide no crutch to their personality.  Fortunately, most of us (even those who were over the edge) figure this out and adjust appropriately.  Some try to chase it.  Bigger breast implants every decade or tricep implants.  They will never catch up, you can’t out race time.

Individuals whose world revolves around a body part or those who use such to compensate for psychologic or personality defects are setting themselves up for a lifetime of insecurity and unhappiness.  Bottom line?

1. Be happy with what you have.  There are a lot of unfortunate people out there with birth defects and other significant problems. 

2. We are not all movie stars.  Get used to this.  Some people are born with “gifts”.  Some have great voices, some can run fast, some have great body parts.  It may not be you, that is life.

3.  It is OK and not unnatural to be proud of you body and it makes great sense to take care of it and fight aging as youth is the best gift of all.

4. Having cosmetic surgery is fine if it is for the right reasons.  If you are trying to outrace age or cover up personality defects, you will lose the race.

5. If you are one of the lucky people that get a lot of attention because of your physical attributes, keep in mind they are probably temporary.  You need to plan for the future.  People used to comment on my great hair, now I am bald!  You need to understand that what may get you through today may not be there tomorrow!  It is similar to having a 401K, you need to plan for the future.  Again, most people mature out of the severe narcissistic phase and can laugh at the way they were.  Some don’t  and as a cosmetic facial surgeon, I see this type of person every day.  They are desperate and trying to hold on to the only thing that has kept them afloat.  Some should be working on their personality instead of their face.  Fortunately this is a small percentage of most practices, but trust me, they are out there.

6. We need to make sure our children and friends understand this and someone has to have this talk with them sometime.

Poor Sheyla Hershey lost her M cup breasts.  I have the feeling it will change her life. I hope she has something else that keeps her going.  The story is sad to me.

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

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

September 23, 2010 Posted by | cosmetic facial surgery, cosmetic surgery addiction, Cosmetic Surgery for the Wrong Reasons, How We Feel After Cosmetic Surgery, Risks of Cosmetic Surgery | , , , , , , , | Leave a comment

Botox Customization and the Droopy Brow

The discovery of neuromodulators to treat hyperfunctional lines was the cosmetic shot heard around the world and ushered in the most popular cosmetic procedure in the world.  When I began injecting Botox in 1996, it was a pretty much unheard of cosmetic therapy and the “pretty poison” was only used by those early adapters.  Back in the day, patients wanted paralysis, plain and simple.  If I injected a patient and they had even minimal muscle movement, they considered it a failure and wanted a refund.  It was not hard (still isn’t) to pick out those patients with mask-like expressions from total upper facial paralysis.

Things have changed greatly in the past decade.  Botox (and now Dysport, and soon to be others) has become an everyday procedure and the fear from “the toxin” has diminished.  What has also diminished is the desire for patients to look “done”.  Contemporary cosmetic surgery patients desire the ability to retain positive animation while stopping negative animation such as scowling.  After being injected for years, most patients now have an appreciation for exactly what they want their Botox to do.  Whereas in the past, they came in for injection and said “do what you think I need”, now they come in with their own tailor made request of units and injection patterns.  Although this bothers some surgeons, I welcome this “Botox customization”; after all, we are here to please the patient.

It is now common for patients to stretch or disperse their Botox units to achieve what they want.  I also feel that the sour economy we have seen over the last several have added to this where patients are trying to get more for their buck.

The most common customizations I see are in the glabella and frontalis.  Whereas the traditional 5 point glabellar injection is still the most common treatment, numerous patients present and request a more central glabellar treatment because fear of “lowering their eyelids”.  The same thing has occurred in my practice with the frontalis.  First of all the frontalis was the second most requested treatment in my office for over a decade, but has fallen to number three with the lateral canthal regions (crow’s feet) now being second.  The main reason for backing off of the frontalis is the fact that when coupled with glabellar treatment, a significant loss of animation can occur.  Again “my eyelids get droopy” (the real truth about this later) is a complaint from aggressively treating both glabella and frontalis.  This trend has led to my frequently injecting the glabella and using “half the units” on the frontalis.

Cosmetic surgery patients are finicky, but when patients feel that they have “droopy lids” from Botox, they can become livid and rebellious.  Proportionately, it seems patients can get madder about this condition than most other “real” cosmetic surgery complications.

Patients must understand the pathology of the “droopy Botox brow”.  Botox cannot make extra skin, but it can prevent patients from elevating their brow.  Many females, especially those with excess lid skin, perpetually elevate their brows.  It is subconscious and they cannot help or control it, they simply spend their waking hours with their brows elevated.  Ask any surgeon who performs brow lifts and they will confirm that it is impossible to take a before picture on many women with their brows relaxed.  Herein lies the problem.  When patients with excess upper eyelid skin raise their brow (via the frontalis muscle) they have the appearance of having less excess upper eyelid skin because the skin is stretched.  In some cases, they can also see better as the obstructing skin is elevated, hence improving vision.  If these patients are aggressively treated with a neuromodulator and cannot elevate their brow, they notice the extra eyelid skin (usually about 3 days after injection while applying eye makeup) and can become quite upset.  They think that the Botox gave them extra skin (impossible) or that they have true upper eyelid muscular ptosis (extremely rare).  What they frequently fail to understand is that they are chronic brow elevators and now they cannot elevate to their preinjection level.  The picture below is of your truly.  Admittedly, I need blepharoplasty or a brow lift.  I am bald, so the brow lift is out the window and I am simply too busy fixing everyone else to have my own blepharoplasty.  In the top picture, I am raising my brow and I look better that the bottom picture with my brow relaxed.  This picture tells the story!

It is imperative (especially for novice injectors) to recognize patients (usually older females with excess upper lid skin) who may be at risk for the “low brow”.  In these patients, especially those who are getting Botox for the first time, it is best not to inject the glabella and frontalis at the same time.  If the patient has a low hairline, the glabellar injection can deactivate a good portion of the frontalis.  If the frontalis and the glabella are to be simultaneously injected, it is better to use only 10 units of Botox (or 30 units of Dysport) over the entire frontalis to lessen the effect.  Also a good idea on any person is to taper off the Botox units and injections over the lateral brow.  Having a good central effect with a lateral tapering effect will still allow brow elevation.

Unfortunately, we cannot reverse neuromodulators so an unhappy patient may be unhappy for several months.  Fortunately, the lateral brow elevations seems to return before all the toxin is worn off.   The inventor of a botulinum toxin reversal agent will be a wealthy man or woman!

My advice to novice injectors is to include discussion of the above in the consent and to treat lightly with the frontalis.  My advice to patients is to be conservative as more Botox can always be added and to realize they may be in need of a browlift or blepharoplasty.

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

April 25, 2010 Posted by | Botox, Brow Lift Surgery, Minimally Invasive Cosmetic Facial Surgery, Risks of Cosmetic Surgery, Uncategorized | , , | Leave a comment

Heidi Montag Addicted to Plastic Surgery: How much is too much?

The tabloids have been ablaze about a 23 year old B list reality show star who had 10 simultaneous cosmetic surgery procedures.  How could a 23 year old have any cosmetic surgery, let alone 10 procedures on the same day?  Ms. Montag responded that she is in the entertainment business and she needs these assets to ply her trade.  I have to give her credit in that she actually responds quite intelligibly to the sharp pointed questions from her interviewers.  She seems to see the situation no less different that an athlete who comprehensively trains in all aspects of physical demands to become and remain competitive in their sport.  The difference here after all is that thousands of athletes train and that is normal, but few 23 year olds have 10 cosmetic surgery procedures in a day.  Heidi, this is unusual! 

Heidi certainly got more than her proverbial 15 minutes in the spotlight so from a media aspect, her decision paid off.  Does she look better?  Well, she looked pretty darn good before her surgery so the improvement was minimal by my eye, but for Heidi, it was night and day.  What really looms here is the bigger question; why does our society place so much emphasis on physical attributes that young people feel a need for major body alteration to pursue perfection?  Being a cosmetic surgeon this trend is in my best interest, but it is nonetheless disturbing and I witness it first hand on a weekly basis.  Over the past decade, the Internet has thrust my business from a local to a global platform.  Where in the past, I rarely saw patients from out of town, I know see many from out of state and out of the country.  Although I consider this an honor, it also brings many young patients to my doorstep with extremely unrealistic expectations and accompanying psychological problems.  I have young men and women (in their 20’s and 30’s) that have had 5 and 6 cosmetic facial procedures and are bent on a quest to emulate a celebrity or starlet.  I recently saw a 19 year old who wanted a browlift, a mini facelift and cheek and chin implants!  I obviously refused this surgery but I really felt bad for this guy because he has severe body dysmorphic syndrome and is headed for a lifetime of unhappiness.  With my big old bald head, I am no double for Brad Pitt, nor aspire to be, but I continually see male and female patients that bring in celebrity photos and want Arnold’s jaw, or Johnny Depp’s cheeks or Brittany’s eyes.  They bring in pictures and have also taken the time to Photoshop their own face into an anticipated outcome.  Some surgeons may relish this opportunity, but I cannot in good conscious or ethics get sucked or trapped into this situation for several reasons.  One, they usually don’t need the surgery.  Granted I have performed facial implants or ear pinning on younger patients, but these were procedures that could be reversed or that truly had merit.  Another reason not to operate on this young age group is that they aren’t happy now and won’t be happy in the future.  They will be unhappy with themselves and I will by default become the next “bad” surgeon and get assassinated on the cosmetic surgery chat sites.  I have seen numerous healthy younger patients that have been disfigured by Dr. Givemeadollar and they look extremely unnatural. Don’t get me wrong, some young patients will benefit aesthetically and gain self esteem by having a nasal hump reduced or enhancing a weak chin, but these young patients are not the problem.  It is the patient who is seeking aesthetic enhancement for the wrong reasons.  Some people think they are ugly and are not.  Others see it as a way to gain attention and yet others have a serious issue with other aspect of their life and are attempting to compensate.

It is difficult for a surgeon to say no, but good ones do it weekly.  Unfortunately there are many cosmetic surgeons with open schedules and when a patient is standing in front of them waving money, they can’t say no.  Most younger surgeons will make this mistake once or twice until they see comprehensive picture of this unfortunate cycle.  I have patients get mad at me because I refused to operate and have seen others who I turned down return several years later begging for correction of disfigurement from the surgeons that said yes.  With experience, a surgeon can “feel” the legitimacy or lack thereof associated with patients.  Like good detectives who can tell if a suspect is lying by body language or appropriateness,  experienced surgeons can tell if a prospective case is a good fit or not.  Again this may be more difficult for the novice surgeon but after several unfavorable experiences they become savvy.  I love cosmetic surgery and I love the energy and exuberance of young patients and for years performed a lot of reconstructive surgery on this population.  I feel a responsibility for what I do and I don’t want to bear the burden of pointing a young patient down a path that I would not want my own family to follow.

Back to Heidi.  I frequently see patients that have their hair colored, wear colored contact lenses, have fake eyelashes, dental veneers, tanning bed tans, breast implants and artificial nails.  Now they are seeking cosmetic surgery at an age too young.  We all like to look good and believe me if I could get hair as easy as some patients get surgery, I would be combing it now!  There just needs to be a basis of acceptance of one’s real self, we all need to be somewhat grounded and here is where the biggest problem lies.  Heidi may look hot now, but someday, she is going to be saggy and wrinkled.  We can’t avoid it.  It is all a result of having birthdays.  When a person puts their entire self esteem in physical attributes, it is a losing game because they are not always going to be attractive.  They are going to age and there will be other beauties out there stealing the limelight.  When all you have is artificial beauty, there is nothing to fall back on because, your happiness will be temporary.  Look at yesterday’s icons.  We are harsh on our celebrities and idols because we expect them to be eternally youthful and when they age, the same media that put them on a pedestal crushes them for being wrinkled, grey or overweight.  They have been cast from one end of the beauty scale to the other, very often with severe psychological determent.  Beauty is youth and youth is temporary.  This is not to say that we cannot be attractive seniors, we all know men and women in their 60’s and 70’s that are truly beautiful people.  That beauty however is usually well coupled with non physical attributes such as self confidence, personality and simply staying fit.  High school reunions can be brutal testament to prom queens and quarterbacks that bear no resemblance to the popularity that embraced them year ago.

My message to younger patients that are wondering too far in cosmetic land is to find peace within.  Sure, it is OK to improve minor distinct deficiencies, even at a younger age, we all want to feel good about ourselves.  But remember, beauty is only skin deep and 20 cosmetic surgeries won’t make up for psychosocial deficiencies.  It is hard to undo bad or unnecessary cosmetic facial surgery and I have seen too many people that were unhappy with their appearance regret their actions and wish they could revert back to their natural look.  It wasn’t really that bad.  For younger surgeons that may be struggling to keep a full schedule, always remember that the best way to become busy is to make the best decisions for your patients.  Be ethical, treat them better than anybody else and say no to those who seek cosmetic surgery for the incorrect reasons.  That reputation will catch up to you and you will become busy the right way…….by serving your patients in their best interest.

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

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


February 1, 2010 Posted by | Can Cosmetic Facial Surgery Change Your Life?, cosmetic surgery addiction, Risks of Cosmetic Surgery | , , , , , | Leave a comment

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

Anesthesia and Cosmetic Surgery


One of the biggest humanitarian innovations in the history of civilization was the discovery of anesthesia.  Prior to the discovery of ether anesthesia in the 1840’s, people were pretty much tortured during surgical procedures and “bitting the bullet” had a very literal meaning.  The best Civil War battlefield surgeons were those who could most rapidly remove a limb.  Fast surgery was very important at one time.  The first part of the 20th Century ushered in the discovery of local anesthetics with Novacaine being the first agent.  This was another huge advance as it made anesthesia “portable” safer and provided patients with another surgical anesthetic option.  Prior to this, having a mole removed or a tooth worked on was a tough deal!

We are lucky to live in an era of multiple anesthetic options for cosmetic surgery.  General anesthesia is the deepest form of surgical anesthesia.  This technique is defined by an unresponsive patient that cannot follow commands and requires assistance with life support.  Although the lighter anesthetic procedures allow the patient to breath on their own, the deeper techniques “breath for the patient” by using a ventilator on the anesthesia machine.  A breathing tube is frequently placed through the mouth or nose and through the vocal cords to enable the oxygen and anesthetic gases to enter and the carbon dioxide to be exhaled.  Although some cosmetic procedures are better performed with general anesthesia, there has been a giant trend to not use such deep anesthetic techniques.  Many surgeons feel that general anesthesia adds additional risks with cosmetic surgery.

The second type and most common anesthetic technique is IV sedation or M.A.C. (monitored anesthetic care) anesthesia.  With IV sedation the patient does not need a breathing tube and breaths on their own the entire case.  IV sedation can be light, where the patient is relaxed and can respond to commands, or deeper where the patient is totally unconscious.  MAC anesthesia is a very safe technique and is “fast on and fast off” meaning that the patient quickly is sedated then quickly wakes up when the drugs are stopped.  Many patients have had experience with this type of anesthesia from wisdom tooth surgery or colonscopy.  Newer drugs decrease the post anesthesia sickness, nausea and vomiting seen in the past.  For general anesthesia and IV sedation the patient must refrain from food or water for about hours before surgery.

Oral sedation is another option and involves taking a sedative pill before the procedure.  Although this relaxes the patient, it does little for pain control so local anesthesia must be used as well.

Tumescent anesthesia involves mixing saline with the local anesthetic Lidocaine and very small amounts of epinephrine.  This is most frequently used for liposuction and facial surgery procedures.  This mixture enables pain control and reduces bleeding.  Tumescent anesthesia has revolutionized cosmetic surgery anesthesia as many procedures may be done with this type of anesthesia, totally awake.

Local anesthesia is another popular form of awake anesthesia and is the same mechanism as going to the dentist.  Eyelid surgery and other cosmetic procedures are sometimes performed with only local anesthesia.  Local anesthesia or tumescent anesthesia is also frequently used with general anesthesia and IV sedation to enhance pain control.  This also reduces the amount of anesthetic agents necessary to keep the patient asleep as well as keeps the patient numb for a while after they awake.

Most anesthetic techniques are very safe and statistically patients have a higher chance of being in a motor vehicle accident than having a serious anesthetic problem or death.  Obviously there are risks of undergoing any type of anesthesia and all cosmetic surgery and anesthesia patients must be thoroughly evaluated by a doctor prior to having anesthesia.  Smoking, obesity, diseases and allergies can all put patients at increased risk for anesthesia.  Fortunately, most patients desiring cosmetic surgery are  usually healthy enough to undergo some type of anesthesia.  For those whom aren’t, staying alive is a better option than looking better.

If you are considering cosmetic surgery discussion your anesthesia with your surgeon is an important part of the informed consent process and should be given serious consideration by all patients. It is important to know what type of anesthesia you will be getting and who will be administering it.  Some surgeons are trained and experienced in ambulatory outpatient office anesthesia and along with their staff provide the anesthesia and surgery.  It is important that in this situation, the doctor’s office has the same level of monitoring, emergency drugs and devices as a hospital.  For more complex anesthetic or medically compromised patients, nurse anesthetists or physician anesthesiologists usually provide anesthetic care.

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

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


September 28, 2008 Posted by | Risks of Cosmetic Surgery | , | Leave a comment

Cosmetic Surgery Addiction

The first question of this article is “can a patient become addicted to cosmetic surgery?”  The first answer is absolutely!

Cosmetic surgery is a means of artificially enhancing or reversing the aging process.  First and foremost is the fact that “no one needs cosmetic surgery, it is totally elective.”  So, here we have an entire specialty built around procedures that no one really needs!  We are not saving lives or healing (with the notable exception of reconstruction, and the like) but rather adorning ourselves to look better or younger in our eyes or in the eyes of others.  Pretty vain when you truly consider it.  Being a cosmetic surgeon, I am obviously a proponent of cosmetic facial surgery but like anything else in life it needs to be performed with a balance.  You don’t have to travel far to see patients whose faces and bodies scream “I am addicted to cosmetic surgery!  I have seen this in New York City, Canton, Ohio, Dubai, Venice and Athens.  Some people smoke too much, some people drink too much, some people gamble too much and some people have too much cosmetic surgery. 

I can write an entire text on the changes that the Internet has brought to cosmetic surgery.  Most of them are very positive but it has also brought some negatives.  One of the positives has been patients from out of town or out of the country.  In my practice I now operate on many patients from out of town and out of the country.  It is a joy and an honor and I have made friends from all over the world.  On the other hand I have evaluated many patients that seek surgery outside their domicile because no local surgeons will operate on them or already have.  Many of these patients have unrealistic expectations and are bothered by small physical flaws that are actually manifestations of a larger psychological disease.  A small percentage of these patients are not happy, have not been happy and will never be happy with their physical self.  Their quest is to change their life by having the next cosmetic procedure, in the same vein that a compulsive gambler puts his or her last dollar into a slot machine in the remote hope of a big payoff that may change their life.  Don’t get me wrong, as the vast majority of my out of town patients are very realistic in their wants and desires, but having a high profile practice also brings its share of unreality.  To operate on a realistic patient is a joy; to operate on an unrealistic patient only makes you the next surgeon that “didn’t do it correctly.”  When I lecture to young surgeons (as I frequently do) I tell them that one of the main ways to be successful is to operate on the “right” patients.  By this, I mean that the correct procedure on the correct patient is a reward for both the doctor and the patient and the inverse of this can spell disaster for both.  Unfortunately, there is no means to measure the psychological stability of a prospective patient and due to this sometimes the surgeon and staff are fooled.  The patient can get a good idea of the skill of a surgeon by looking at their credentials, before and after pictures, talking to other patients, etc., but it is pretty hard for a surgeon to garner the status of a new patient.  Most surgeons learn this the hard way by a series of misadventures throughout their early career.  “I will never operate again on a patient like that” is a common mantra among seasoned surgeons.  Each time that a surgeon experiences such a patient (or hears a story from a colleague) they pick up on the “red flag”.  After getting a little grey in the temples, these red flags become more easily recognizable and hence avoidable.  A good surgeon says “no” frequently and will not operate on any patient that comes through the door.  The doctor and staff become more adept with experience in picking up on these “red flags” and avoiding the wrong procedure on the wrong patient.

I do want to say that there are also “red flag” surgeons of which patients must beware.  These include surgeons that over promise, promote “miracle” treatments, do not offer their availability, and cannot produce substantiation of their results.  Doctors are not exempt from reality.

A patient that wants breast implants, a hair transplant or a facelift to look and feel better is a great thing.  A patient that wants one of these procedures to change their life or make up for personality defects or other psychological issues is not a good thing.  Some people crave attention.  They have ungodly loud stereo systems in their cars that scream “notice me, please”.  Some people do the same with their homes by decorating them ostentatiously and some people do it with their body by trying to look like something they are not.  These patients stick out like a sore thumb and are not a good testament to cosmetic surgery or advertisement for that surgeon.  It is said that quality cosmetic surgery should “whisper, not scream”.  In the quest to look natural, some patients become more unnatural.  For a surgeon, happiness comes in operating and it is difficult to turn down a patient who presents with that ability.  Every surgeon has had the situation where they say “I am so sorry that I operated on that patient.”  It is not a fun situation to be in and you become an additional cog in the wheel of unhappy experiences for that patient.  Sometimes it is even rewarding to say no.  When you see a patient in your chair with breast too big, lips to big, skin too tight, a perfect tan and make up too excessive you feel you are doing a favor to them and to your reputation by denying further surgery as they are addicted and you are enabling their disease.  By not operating on them, you may be actually helping them.  Every cosmetic surgeon is a part time psychologist and must be to be competent.  A surgeon must truly listen to what the patient is saying and council them on their decision process.  Once in a while, these patients simply need someone to listen to or bounce ideas off of about their physical appearance.  I have told many a patient to appreciate their inner beauty and focus less on their acne scars, lose skin or other physical appearance.  I have told them about other patients who are much more ravaged or afflicted and how happy those patients would be to look like the patient sitting in my chair at this moment.  I believe that sometimes they leave my office relived that they don’t need a cosmetic procedure, feeling better about themselves and thankful for the candid insight.  Other times I see that they have talked a surgeon down the street into the procedure and after having it, are still unhappy.

Again, there is no more rewarding feeling for a cosmetic surgeon than performing a successful procedure on a happy patient.  It is the essence of what we do and how it should be.  Hopefully most encounters will be like this, but we don’t live in a perfect world.  One way to make it better is to appreciate the fact that some patients are and can be addicted to cosmetic surgery and avoiding operating on these patients can enhance your practice and their life.


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia


July 24, 2008 Posted by | Risks of Cosmetic Surgery | | 1 Comment

Cosmetic Surgery Bulletin Boards: Can you believe everything you read?


One of the true joys of being alive in this day and age is the Internet.  For those of us that are older than 20 years of age it is hard to imagine life without it.  The Internet has empowered us and made encyclopedias and dictionaries obsolete.  It seems that you can find out anything with just a few clicks.  To Google has become a common verb!

Information is definitely power, but if that is true, misinformation is then weakness.  The decision to have cosmetic facial surgery and the ramifications that go along with it can be tasks of awesome proportion.  There are many surgeons to choose from, many procedures to have done, there are also considerations of patient health, recovery and budget.  When you think of all of this at one time (as most patients do when walking blindly into a consult) it is a miracle that a decision can be made.  So much information, so little time!

Bulletin Boards have become common and popular forums for humans to share information….or misinformation.  I have picked up some great tips on various bulletin boards like how to repair my 1965 Jaguar, how to tune my boat engine, what fishing lures to use on the James River, the best abdominal exercises, etc, etc.  Sometimes I have to wade through some incorrect or opinionated data and it can vary from confusing to dangerous.  With the Internet you have to take the good with the bad.  Cosmetic surgery bulletin boards are numerous, frequently factual, sometimes entertaining and frequently misleading.  On a positive note, these bulletin boards allow patients to discuss and compare data and experiences on various procedures, products and surgeons.  I have seen a lot of very good comments, ideas and advice on these bulletin boards, but I have also seen downright false, mean spirited, confusing and doubtful information as well.  Cosmetic facial surgery is not only my job, but it is my passion, so I am basically consumed with it during my waking hours.  It is my profession and my hobby.  At work, I see patients and operate, at home I work on my website and blog and for leisure I read cosmetic journals and text books.  For fun, I write journal articles and textbook chapters.  My wife thinks I am crazy, but she understands a man driven.

It was my honor to find out that I came highly recommended on several of these bulletin boards.  It is downright flattering to have your passion reflected by nice comments and appreciation of your work.  Sooner or later, however, I (like many compassionate surgeons) may be maligned by an unhappy patient with an ax to grind.  No one likes to hear negative comments about themselves, if they are serious about what they do for a living.  I have one friend who is truly a world class surgeon and is very good at what he does.  He had an unhappy patient (as all doctors will from time to time) that made it their hobby to assassinate this surgeon on virtually every forum that would accept a post.  Due to this, this surgeon has been very discredited for what was not really his fault.  To his defense, he did not deserve it.  There may be others that do.  Some doctors are complacent and are not patient oriented.  They may have consistent poor outcomes and unhappy patients.  A person like this may warrant the bad publicity, but we should all stop and take a deep breath before we discredit someone.  We have all gone to a great restaurant and had a bad meal, or gone to a famous vacation destination and had poor service, etc.  The same can happen with cosmetic surgery.  Because one patient had a bad experience or outcome may not mean that all patients would have the same.  A complication may be the surgeon’s fault (we are human too) or it may have been the patient’s fault.  Some patients refuse to follow pre or post op instructions, others use medications they are warned not to.  Some patients smoke and lie about it and some patients just had bad luck. 

I have been very fortunate that I have been able to have positive dialogue with 99.9% of my patients from the time I meet them.  I always try to personally answer emails on a timely basis, I give all my patients my cell phone number and I am surrounded by a great compassionate and caring staff.  It is not that we never have problems because if you have a very successful and busy practice, you will have problems from time to time.  The most critical thing is how they are handled.  Sometimes it is merely the fact that the patient does not understand, or they are anxious and communication, hand holding and compassion go a long way.  Sometimes, they feel that the surgeon is not responsive or has done something wrong.  Sometime it as simple as the surgeon saying “I am sorry”.  Sometimes the patient is totally unreasonable and sometimes the doctor may be unreasonable.  Fortunately, most successful surgeons have good people skills and are able to smooth out the things that happen.  Sometimes a good surgeon gets a bad patient and vice versa.  Successful surgeons become good at “picking” the right patients.  Over the years, the surgeon and staff develop a sixth sense about patients that may be problematic.  These include patients that are know it alls, patients that don’t listen, patients that talk bad about previous surgeons and patients that are not dependable.  Many patients also have a sixth sense about surgeons, offices and staffs and can tell a genuine proficient and caring surgeon from someone who is faking it.  Having said all of this, usually the patients choose the correct surgeons and the surgeons choose the correct patients.  Everything works out well.  When it does not, it takes responsible communication from both sides to try to make things better.  The problem with some bulletin board postings is that they only tell one side of the story.  If I said that one specific hospital had a high mortality rate, it may cause many people to speak badly about it.  If I said in the next sentence that it was a hospital that only treats terminal cancer patients, you hear the other side of the story.  Some patients will never be happy no matter whom they see because they are not happy with themselves.  Cosmetic surgery requires a stable, rational and psychologically secure patient for the best outcomes.  Some patients have psychological and or image problems and have no business having cosmetic surgery.  The surgeon that operated on them has made a mistake before the first scalpel cut.  Don’t get me wrong, there are surgeons with these issues as well, most of them aren’t busy or popular.  The more good work you do, the more good press you get.  Unfortunately, it only takes one bad apple to spoil the whole bunch and we all should keep that in mind when things get sticky.  Doctors should not talk bad about other doctors or patients, that is a matter of ethics (by the way, doctors that talk bad about other doctors probably talk bad about their patients and that should be a warning sign).  Patients should not go out of their way to demonize a well meaning surgeon who may have been a victim of circumstance.  There are no official ethics here, just the Golden Rule…”Do unto others”.  Just great words for which to live ones life.

I see many patients each day and those whom have visited my website (or other sites and bulletin boards) usually have an advantage of education about what we do and how we do it.  Occasionally, I see a patient that has been brainwashed with misinformation to the point that they feel they know more about the technique than I do.  Obviously that would be a poor choice to operate on that patient.  A know it all or a patient that tells a surgeon how to do a procedure is a gamble and a set up for problems.  It is fine to ask about a given technique or discuss options, but it should be the surgeon that directs the care.  I may present the patient with 4-5 options (filler vs laser vs facelift, etc) and by providing them information such as before and after pictures, patient references, brochures, etc. they can make and informed decision.  I have heard many patients discuss things that they saw on a bulletin board and were not true, or at least not true the way I practice.  Discussion should be two way. The patient and surgeon should both talk and listen.  A bullheaded patient (or doctor) is hard to deal with. The beauty of it all is that no one “has to have” cosmetic surgery, it is totally elective.  If they don’t have a good feeling about a surgeon, they should find another one.  Same for the doctor.  If a certain patient has personality traits that do not blend in with the way you practice, then they should not operate on that patient.  One thing every patient and surgeon should evaluate between each other is “how will he or she act if there is a problem”.  That goes for surgeons and patients.

Education and bulletin boards are great things when they are factual.  You can’t believe everything you read or hear.  Remember, there are Liberian Bank schemes, people trying to steal your identity and a host of other examples of misinformation on the Web.  Be rational, fair, consider the source, hear both sides and most importantly, as you parents told you…………….if you can’t say someting nice………

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

July 8, 2008 Posted by | Cosmetic Surgery Bulletin Boards, Digital Technology and Cosmetic Facial Surgery, Doctors Badmouthing Other Doctors, Risks of Cosmetic Surgery | | 1 Comment

Kanye West’s Mother and Surgical Risks.

Earlier this year the life of rapper Kanye West’s mom ended tragically after undergoing a cosmetic surgery procedure.  This is an unfortunate and tragic event and besides the personal tragedy it also brought light to many other aspects of cosmetic surgery.

First of all, it shows that there is risk with any surgery.  Every year, patients die during or after surgery and anesthesia.  Some patients are sick and the high risk of surgery and anesthesia was known.  Some patients were perfectly healthy and some very unusual event occurred.  Some of these events are the fault of the surgeon, anesthesia personnel or hospital staff.  Some of these events are the fault of an undiagnosed health problem.  I recently read of a completely 16 year old patient who had a rare and undiagnosed cardiac condition and died during a tonsillectomy.  No one, the patient, hospital or surgeon had any idea that such a problem existed.  The bottom line is that any surgery, cosmetic or otherwise, carries some risk of complications including death.

When Mrs. West passed away the night of her surgery, every news station and tabloid show hovered tightly over “the dangers of cosmetic surgery”.  Allegations flew faster than speeding bullets and finger pointing started early.  Dr. Jan Adams, the celebrity plastic surgeon on TV was the biggest target.  This famous surgeon was used to being in the limelight and was suddenly cast into cold darkness.  The finger of blame pointed directly at Dr. Adams even though not official cause of death was determined.  He was tried, sentenced and executed by the media.  What’s more, his own people turned on him.  Organized plastic surgery, who has long been tooting the horn of “only board certified plastics surgeons” should do surgery”, condemned him for not being board certified.  Instead of sticking up for their own and coming out with a statement that no surgeon should be condemned until the facts are discovered, they simply turned on him.  By the way, saying that only a “board certified plastic surgeon” should do cosmetic surgery is as silly as saying that only Fords are safe cars and that you should not drive any other car.  There are many talented board certified plastic surgeons and there are many board certified plastic surgeons that have very little, if any cosmetic training.  On the other hand, there are thousands of very qualified board certified surgeons in ophthalmology, dermatology, oral and maxillofacial surgery, ENT, facial plastic surgery, general surgery and other specialties that have extensive cosmetic training.  It is the surgeon and his or her training that is important, not what specialty they come from.

Dr. Adams was getting pounded by everyone that had an opinion.  Former patients came out of the woodwork with accusations of malpractice.  Entertainment Tonight showed bad scars caused by Dr. Adams and women stood in line to denigrate Dr. Adams.  Funny they did not complain prior to the West tragedy.  In addition, other cosmetic surgeons in the area where Dr. Adams practices also got their 15 minutes of fame by condemning the actions of Dr. Adams, even though not one single person had the facts. I have no idea if Dr. Adams is a good or a bad surgeon, but I would bet that he is pretty talented to be selected for a national show and I bet when he wakes up and goes to work in the morning he has the main goal of performing his specialty in a safe and effective manner and to do his best to help his patients.  I am sure that he received many benefits from being surgeon to the stars, but I guess being famous has a big downside as well.

Fast forward six weeks.  The coroner released the official cause of death report.  Preexisting cardiac conditions and nondescript post operative problems.  Guess what?  Nary a mention of Dr. Adams was made.  Not a single sentence in the report detailed a single problem during surgery or any wrong doing of Dr. Jan Adams.  Too bad his career has been ruined, too bad that the media and detractors could not hold their tongues for six weeks to find out the truth.  In this age of sensational journalism, people do anything to sell a show.  We were all tired of the Anna Nicole Smith and Paris and Lindsey scandals, so we were hungry to feast on the new meat of Dr. Jan Adams.

Apparently Mrs. West had some preexisting heart problems and there may have been other non surgery related problems like over dosage of pain medications.  Yes, once the patient leaves the surgery center or hospital, there are many potential problems that could lead to complications.  Sometimes it can be from patients not following directions, sometimes it can be from unforeseen coincidence, and sometime things just happen.

The bottom line is that all medical procedures, including cosmetic surgery carry risk.  Fortunately, the risk is very low for elective cosmetic surgery procedures.  Fortunately, you have a better chance of dying from falling out of bed in the middle of the night than you do from dying from cosmetic surgery.  It is important to know that all procedures carry risks.  It is also important to discuss the informed consent with your surgeon before the procedure.  Don’t be afraid to ask questions, I actually love it when my patients have questions about complications, as it means they are educated.  Also, the patient and surgeon should have a plan in place if complications do occur.  Good questions to ask are how will these potential complications be managed, when will they be treated and who will pay for the treatment.

Although it is impossible to prevent post surgical complications, you can do some homework to insure standard of care treatment.  Some good points to follow are:

  • Choose a surgeon who is experienced in your procedure.  There may be a big difference in a surgeon who performs 2 facelifts a year and a surgeon who performs 2 a week.
  • Insist to see your surgeon’s work.  Experienced surgeons should be able to show you many before and after images and allow you to talk to patients that have had that specific procedure.
  • Your surgeon should be board certified in his or her specialty
  • Your surgeon should operate in an accredited facility.  Stringent rules apply in order to have an accredited facility in ones office and this means that the doctor has met these qualifications.
  • Your surgeon should be available.  If you cannot reach your surgeon when you have a problem, you choose the wrong surgeon!  I personally give all of my patients my home and cell phone numbers and it is my privilege to assist them when they have questions.
  • Choose a surgeon you can communicate with.  A great surgeon with poor communication skills may not be as good as an average surgeon who is personable, approachable, available and affable.
  • Is the surgeon’s practice limited to cosmetic surgery?  Although there are many fine surgeons that dabble in cosmetic surgery, those who limit their practices obviously have more experience.
  • The standard of care prior to many cosmetic surgery proceudres is a history and physical as well as lab work and sometimes EKG and chest X-ray.  Very simple procedures my not require these tests, but longer or multiple procedures or medically comprimsed patients need a thorough pre surgical work up.


Many patients spend more time picking out a pair of shoes than they do researching a cosmetic surgeon.  Fortunately, most times everything works out well but heeding the above points can make your choice easier.


Joe Niamtu, III DMD

February 29, 2008 Posted by | Risks of Cosmetic Surgery | , , | 7 Comments