Drive-thru Plastic Surgery and Michael Jackson

Like many people around the world, I've been giving some thought to all the coverage of the recent untimely death of pop superstar, Michael Jackson. Among the controversies in his life has been criticism of the number and extent of facial cosmetic procedures Mr. Jackson endured over his career. What's bothered me, though, is that most often the scorn and ridicule has been directed at Michael Jackson himself. Surprisingly little of it has been directed at his surgeon(s) and dermatologist(s).

Remember, Michael Jackson did not do this to himself. Never once did he himself operate on his own nose, or eyelids, or chin. He had to find willing accomplices in his doctors. Which brings me to the following point:

Plastic Surgery is not a McDonald's Drive-Thru!

Now, I don't mean any disrespect to the McDonalds restaurants [as my staff will attest, I probably eat there more often than most Americans]. My point is that as doctors we have a different responsibility to our patients than simply filling their order. If a 400 pound person orders a couple of Big Mac Meals at McDonalds, when he pulls up to the drive through he'll be given two Big Macs, large fries, and drinks. It is not the duty of the McDonalds staff to say, "Wait a minute, buddy. We're not going to give you these Big Macs. You're overweight and you really would be better off just having a small side salad and a diet soda."

As surgeons, however, our duty is to evaluate whether patients will be properly served with what they're requesting. If we feel that their desires are inappropriate or their expectations are unrealistic, we need to advise them against surgery, against an injection, against a prescription.

Body Dysmorphic Disorder

In fairness, I have never examined Mr. Jackson as a patient, so my analysis is necessarily limited by what I've seen in the media about him. But in all likelihood, the pop star suffered from Body Dysmorphic Disorder, a psychiatric condition in which patients imagine themselves as ugly and obsess about minor or nonexistent flaws. Its treatment is medication and psychotherapy, not plastic surgery. It's like the anorexia nervosa patient who thinks she needs to lose more weight.

Why Michael Jackson's surgeons didn't say no to him is beyond me. Money is a reasonable guess. Physicians and surgeons—regardless of speciality—need to be the guardians of reality for our patients, lest the Oath of Hippocrates become regarded by the public as the Oath of Hypocrisy as far as plastic surgery is concerned. Again, Michael Jackson didn't act alone.

Latisse™ for longer, thicker eyelashes!

Did you know that the quest for beautiful eyelashes dates back at least 6,000 years! But if you'd asked us a couple of years ago about the best way to get longer and thicker eyelashes, the answer would have been uninspiring: apply mascara or false eyelashes.

Now patients have a new option for lash enhancement: Latisse^®. Just approved by the FDA, Latisse is a topically applied prescription medication that actually helps you grow longer eyelashes!

The story behind it is interesting. The prescription medication in Latisse, bimatoprost, was originally developed to treat glaucoma (a condition of increased pressure of fluid in the eye). A side-effect noticed by many patients and their physicians was that the eyelashes of patients using this eye drop became longer, thicker, and darker. In subsequent clinical studies of Latisse™, 78% of patients saw significant increases in these three measures after 16 weeks of use.



So what's the catch? Although Latisse is applied with a small applicator brush, patients should avoid getting it in the eye itself as it may also cause the iris to hyperpigment (darken) in some patients, thus adding some brown to those baby blues. Now, in fairness, the clinical studies of Latisse did not show an increase in iris pigmentation, but the same drug when instilled directly into the eye has shown this side-effect.

You can read more about Latisse or watch a video on how to apply Latisse on our website here:

Latisse^®

Better yet, give us a call to see if Latisse could help enhance the beauty of your eyelashes: 904-215-PFPS.

Protecting Your (Digital) Image

While the public often considers "before and after" pictures to be the stock-in-trade of plastic surgery, there are few things more personal and than one's picture. That's why we take data security very seriously at Pearson Facial Plastic Surgery™.

In fact, before and after photos are an important part of the medical record even for patients who do not consent to have their photos displayed. We use them to document the success (or failure) of our procedures, to learn from, to teach from, and even to protect ourselves legally. And digital pictures offer many advantages over traditional film when it comes to clinical photography: we like that digital images are immediately available, are readily backed up, are searchable, and take up very little physical space. They don't fade, or warp, or scratch.

But digital data of any sort is also potentially vulnerable to theft, deletion, data corruption, crashes, and loss...any of which could be devastating to both patient and practice.

With that in mind, we think that we've implemented a best-practices system for our patients' pictures. Here's a snapshot (no pun intended) of what we do to keep your pictures safe:

• The memory card and camera are never left in the office over night.
• Only the most reliable memory cards are used (e.g., Sandisk Extreme III SDHC, at the time of this posting).
• All images are stored on a hard drive off site.
• The hard drive itself is backed up automatically to an external drive every hour.
• Images on the primary drive and the backup drive are strongly encrypted with AES-128 encryption (a standard strong enough for U.S. government encryption of classified data).

Of course, in medicine and surgery we never say never. Data loss is always possible, and no practice can guarantee data security, but we'd like to think that we've done better than most to protect our patients' images.

As you consider which plastic surgery practice you'll trust with your personal information, you might want to find out how they'd protect your pictures.

More Bogus Botox in Florida

I think Botox is terrific. I really do. But like any powerful tool, it's critical that it be administered by someone who's properly trained...and actually licensed to practice medicine!

Just last week I received this email alert [see copy below] from the Florida Board of Medicine about a man in Coral Gables, Florida who has been injecting people with Botox in his home (!). The problem? He's not a doctor...or any other kind of licensed practitioner, for that matter:

FOR IMMEDIATE RELEASE Contact: Communications Office

August 11, 2008 (850) 245-4111

FLORIDA DEPARTMENT OF HEALTH INVESTIGATION LEADS TO ARREST IN CORAL GABLES

TALLAHASSEE— The Florida Department of Health’s (DOH) South Florida Unlicensed Activity (ULA) Unit announced that their joint investigation with the Coral Gables Police Department Special Investigations Section (CGPD) has led to the arrest of Juan J. Aguirrechu in connection with the unlicensed practice of medicine, a third degree felony and punishable by up to five years in prison.

A CGPD investigation that was initiated from an anonymous tip indicated Aguirrechu was practicing medicine from his residence located at 5627 Granada Blvd. in Coral Gables. Specifically, it was alleged that Aguirrechu was representing himself as a doctor and was providing Botox injections to “patients” he would see at his home. A ULA investigation determined that Aguirrechu holds no form of licensure from the Florida Department of Health. The joint investigation ultimately led to the issuance of an arrest warrant. On Tuesday, August 5, 2008 CGPD detectives contacted Aguirrechu at his house and took him into custody without incident.

DOH has several resources to combat unlicensed activity:

· Consumers are encouraged to use DOH’s Web site www.flhealthsource.com where they can conveniently view the license information of their health care practitioner.

· Complaints may be filed anonymously by completing and mailing the complaint form on the DOH Web site or calling 1-877-HALT-ULA to have a form mailed to you.

The Florida Department of Health’s (DOH) unlicensed activity program protects Florida residents and visitors from the potentially serious and dangerous consequences of receiving medical and health care services from an unlicensed person. DOH’s Division of Medical Quality Assurance (MQA) investigates and refers for prosecution all unlicensed health care activity complaints and allegations. The unlicensed activity unit works in conjunction with law enforcement and the state attorney’s offices to prosecute individuals practicing without a license. In many instances, unlicensed activity is a felony level criminal offense. More importantly, receiving health care from unlicensed people is dangerous and could result in further injury, disease or even death.

The mission of the Department of Health and MQA is to promote, protect and improve the health of all people in Florida. Working in conjunction with 22 boards and seven councils, MQA regulates six types of facilities and more than 40 health care professions. MQA evaluates the credentials of all applicants for licensure, issues licenses, analyzes and investigates complaints, inspects facilities, assists in prosecuting practice act violations, combats unlicensed activity and provides credential and discipline history about licensees to the public. Visit http://www.doh.state.fl.us/mqa/ for additional information about MQA.

You can read the news reports about this guy here, for example.

Here are some questions that come to mind, though, that aren't answered in the email or the news reports:

• Was it even real Botox? Botox Cosmetic can only be legally purchased through Allergan, the company who manufactures Botox here in the U.S. Allergan requires proof of our medical licensure before they'll open an account. Recall that in 2004 several people in south Florida ended up on ventilators with acute botulism after being injected with an unapproved and illegal bulk research-grade botulinum toxin.
  
  On the otherhand, we routinely receive offers (via fax) from companies outside the U.S. to purchase cut-rate supplies of Botox, Juvederm, Restylane, etc. much less expensively than by ordering through the authorized distributors. This, too, is illegal under FDA rules (despite claims to the contrary on those companies' web sites). I presume that further investigation will uncover Mr. Aguirrechu's source of "Botox."
• Why in the world would you trust a guy to inject your face with Botox when he doesn't even have an office? Shouldn't it raise a few red flags when he's treating people out of his home? [It's a nice home, by the way, valued at just under a million dollars] Have gas prices gotten so high that people need to save a few bucks on Botox by going to this guy? (I'm presuming he was inexpensive, but I haven't found any news reports that have uncovered what he was charging).
  

This guy, of course, isn't the first person to illegally practice and he won't be the last, unfortunately. Who can forget, for example, the recent reports that Priscilla Presley had been the victim of an unlicensed practitioner who injected her face with industrial-grade silicone?

As usual, though, caveat emptor and please be sure to check into the credentials of the person wielding the needle or the knife.

Artefill and FUD?

One of my favorite products for minimally-invasive, in-office cosmetic procedures is an injectable filler called Artefill. It's a product used for the correction of deep facial folds, such as smile lines, and for contouring other areas of the nose and face as well. It's chief advantage is that it is permanent. So I was surprised to find that a few of my colleagues across the country have been suggesting that Artefill is a not such a good product.

I couldn't disagree more. Now, reasonable physicians will disagree about treatments and techniques from time to time. Our regional and national meetings are filled with such debates and discussions. The problem here, however, is the way in which Artefill is often being attacked—through "FUD."

"FUD" is a marketing term that stands for "Fear, Uncertainty, and Doubt." It's a technique used to attack a competing product or service, often when there is no real basis for the attack. So lets address the most common claims head on:

.............................................

Claim 1: "This product is too new to know what it's long-term safety is."

Answer: Although Artefill is new to the United States, its sister product, Artecoll, has been used in Canada since 1998 (nearly ten years ago) in thousands of patients. I, myself, first treated patients with Artecoll in 1999 during my fellowship training in my home town of Toronto and have been very pleased with its performance. And Artecoll's predecessor, Arteplast, was used in Eupore earlier still. And PMMA (poly-methyl-methacrylate), the chief component of Artefill, has been used in other applications in humans for decades. This is not to say that it has no risks. Local complications of nodule formation and other skin reactions are known risks and are somewhat technique dependent.

But the broader point is that new products, techniques, and technology are constantly being introduced and refined. That doesn't mean that I jump willy-nilly on every new thing that comes down the pike (far from it), but do we really want to practice medicine the way it was done decades ago? Plus, long-term data from the Canadian experience with Artecoll has been published in peer-reviewed medical journals reviewing just such risks of complications.¹ Similar data exists for the U.S. experience during Artefill's FDA-approval process.


Claim 2: "It's permanent. I'd have to always worry about the long-term changes to my patients' faces."

Answer: Of course! But as a facial plastic surgeon I routinely have to take that into consideration. Whenever my colleagues or I perform surgery (e.g., a rhinoplasty, an eyelid lift, or an otoplasty) we are creating permanent changes that have to take into account long-term changes. This is why it's serious stuff and why I harp on having the right training to do these cosmetic procedures.

Now, the cynical side of me has another theory about why some practitioners are opposed to using something permanent on their patients. Permanent products don't require continual re-application (or continual payments to the doctor). I sometimes wonder if those patients are simply seen as an annuity that will keep paying dividends year after year!

Dr. Arnold Klein, for example, a dermatologist in Beverly Hills, has asserted that Artefill will "destroy" the soft-tissue augmentation field. But consider that Dr. Klein has been paid for years to consult for Allergan and Medicis, makers of the competing and non-permanent products of Juvederm and Restylane, respectively. [FYI, Juvederm and Restylane are also excellent products, and I use them in areas of the face that are not as well suited for Artefill, such as lip augmentation and fine wrinkle correction]. And in case you're wondering, no, I do not have any relationship with any of these companies.

Claim 3: "There's too much guesswork in the volume of Artefill needed."

Answer: This claim, I think, simply comes from ignorance of the proper technique for this product. Artefill is not placed the same way as other fillers. Full correction with Artefill is achieved gradually over two or three (maybe more) sessions separated at least two months apart. I counsel patients that perfection lives at the edge of a cliff. We want to ease toward that goal, not rush toward it where we might overshoot it. I purposely under-correct facial folds with Artefill since it's easy enough to add more, but difficult to take it away.

.............................................

In summary, Artefill is just another tool in our armamentarium for the correction of facial folds and other contour problems of the face. It is not for everyone. And like all procedures in facial plastic surgery, there is risk involved. To put it in perspective, I would put Artefill below surgery in terms of risk, yet above other temporary fillers like Radiesse, Restylane, and Juvederm.

Hopefully this information will be helpful to you as you consider your choices with injectable fillers and other cosmetic procedures.

---

¹Bagal A, Dahiya R, Tsai V, Adamson PA. Clinical experience with polymethylmethacrylate microspheres (Artecoll) for soft-tissue augmentation: a retrospective review. Arch Facial Plast Surg. 2007 Jul-Aug;9(4):275-80.

Free Consultations for Plastic Surgery(and why we don't offer them)

Not infrequently, prospective patients will ask whether we offer a free consultation. With the rare exception of special promotions from time to time, we don't. But it might be worthwhile to explain our decision against complimentary consultations for plastic surgery, since some other cosmetic practices offer them (including some in Jacksonville and even in Ponte Vedra Beach).

To put this in context, as of the date of this blog entry, we charge $100 for a full cosmetic consultation—e.g., a rhinoplasty consult, an aging face consult, etc. [some consults may be less, depending on the issue at hand].

However, for this you reserve an hour of time where my staff and I are at your disposal. It includes an in-depth review of your concerns, your medical history, my examination of your features, and a discussion of my analysis and recommendations. None of that should be rushed.

And, as it turns out, for those patients who are good candidates for facial plastic surgery and who book surgery within 30 days of the consult, the entire consultation fee is deducted from the surgical fee—in essence, making it a free consultation after all.

So why do we have a consultation fee? Perhaps surprisingly, it's not to make money from the consultation, but rather for the following reasons:

• First and foremost is the issue of seriousness. Reshaping the face is serious business and the decision to have cosmetic surgery (or even a non-surgical procedure) is an important one. By having even a modest barrier of $100 for the consultation, we help ensure that only individuals who have given this issue considerable thought come to see us.

• Secondly, data has shown that when a practice does offer free consultations, the no-show rate for those consultations is very high—typically because those prospective patients weren't serious to begin with. In response to this, many practices will then go to double-booking those free consult slots. But then, on the occasion that two patients do show up for the same appointment, the doctor faces a difficult problem: cut each appointment short or make the other patient wait a long time. Not exactly a luxury experience, is it? In our office, we know your time is valuable so we never double-book and we never cut the appointment short.

• Lastly, we feel that it's important for patients to realize that there is real value in the consultation itself. Even if a patient decides to see another plastic surgeon, they take with them my advice, suggestions, and warnings. There are even times, for example, when my best advice is that a patient should not have surgery. [And if you don't think that that is valuable, look no further than what happened when Kanye West's mother, Donda West, did not heed that advice.]

So why do some plastic surgery practices offer free consultations? I suppose it's because price is the only thing they have to sell.

We, on the other hand, prefer to offer quality and our unique advantage: a Mayo Clinic training, specialization in the face and neck, and board certification specifically in facial plastic surgery. Fortunately, our patients seem to appreciate the value in that.

FDA Update on Botox Safety

Last month I posted a blog entry about the recent media reports of death from Botox. Just today, the Food and Drug Administration (the FDA) released a report in response to these claims. Fortunately, but not surprisingly, my suspicions about what had occurred in these Botox cases were confirmed. Here are the highlights of their conclusions about the Botox deaths:

•None of the cases involved adults. •None of the cases involved injections in the face. •None of the cases involved the cosmetic use of Botox.

According to the FDA investigation, the most serious cases—those that included hospitalization or death—occurred mostly in children treated for cerebral palsy-associated limb spasticity, which is not an FDA-approved use of Botox.

Below is a highlight of the FDA's conclusions today from their "Early Communication about an Ongoing Safety Review":

"What does FDA know now about these data?

The FDA has reviewed post-marketing cases from its Adverse Event Reporting System (AERS) database and from the medical literature of pediatric and adult patients diagnosed with botulism following a local injection with a marketed botulinum toxin product.

The pediatric botulism cases occurred in patients less than 16 years old, with reported symptoms ranging from dysphagia to respiratory insufficiency requiring gastric feeding tubes and ventilatory support. Serious outcomes included hospitalization and death. The most commonly reported use of botulinum toxin among these cases was treatment of limb muscle spasticity associated with cerebral palsy. For Botox, doses ranged from 6.25 to 32 Units/kilogram (U/kg) in these cases. For Myobloc, reported doses were from 388 to 625 U/kg.

The reports of adult botulism cases described symptoms including patients experiencing difficulty holding up their heads, dysphagia and ptosis. Some reports described systemic effects that occurred distant from the site of injection and included weakness and numbness of the lower extremities. Among the adult cases that were serious, including hospitalization, none required intubation or ventilatory support. No deaths were reported. The doses for Botox ranged from 100 to 700 Units and for Myobloc from 10,000 to 20,000 U.

This early communication is in keeping with FDA’s commitment to inform the public about its ongoing safety reviews of drugs. FDA will communicate to the public its conclusions, resulting recommendations, and any regulatory actions after the review of the data are completed. "

Needless to say, Botox is a powerful drug that should only be administered by doctors properly trained in the use of these medications. In my office, we take Botox seriously. For example, the injections are personally prepared by me so that I can be assured of the exact concentration. I personally inject the patients. And all of our patients are evaluated for neuromuscular and other conditions that may be risk factors for adverse outcomes. Patient safety is paramount. Fortunately, Botox's safety in terms of its cosmetic use in the face remains well-established.

For more information, you can read the full FDA report here and review my original blog entry on this subject here.

Botox Deaths (and the real story)

The news reports from January 24, 2008—in typical news fashion—are shocking: Death from Botox! [<--see the Reuters article] As always, though, the devil is in the details and those are conspicuously absent from these news articles. Just today I had a patient in the office expressing her fear over the idea of getting "botulism" from injections for her forehead wrinkles. "It's all over the news," she exclaimed, which is what prompted me to post this quick blog entry. Here's my take on the story and what you should understand about these news reports. Botox (botulinum toxin type A) from Allergan is used for much more than just wrinkles. For many years, and long before it was approved for cosmetic use, Botox was and is used for the treatment of muscle tension disorders. Prominent among these are its use in a vocal cord disorder called spasmodic dysphonia and for a neck muscle disorder called cervical dystonia ("wry neck"). In both instances, Botox is injected into these hyperactive muscles to weaken them, generally to the suffering patient's great satisfaction.

So I suspect, based on the reports, that none of these tragic deaths were among patients receiving Botox Cosmetic for their facial wrinkles. Rather, I would bet, those who died were patients receiving injections on their neck muscles and vocal cords.

Take, for example, the case of vocal cord injections. Most people think their vocal cords are primarily for speaking, but their most important function is protecting the airway (the windpipe and lungs) from food, liquids, saliva, etc., from going down the wrong way. We all have experienced when that critical reflex doesn't work, such as when we're eating and laughing at the same time: we choke and cough violently.

But imagine the patient who's received a little too much Botox in their vocal cords during treatment for their voice disorder. As the paralysis kicks in, they become unable to protect their airway. This provides the perfect setting for conditions known as aspiration pneumonia or chemical pneumonitis from food, liquids, secretions, etc. getting into the lungs. These are potentially fatal complications.

Or consider the situation where a child with cervical dystonia needs his or her neck muscles relaxed: a small neck, a big muscle (the sternocleidomastoid muscle), and distorted anatomy from the twisted neck. In addition, larger quantities of Botox are needed to relax a big muscle like this. But just fractions of an inch from it lies the esophagus though which we swallow...and which is basically a long tubular muscle.

If enough Botox is injected around the esophageal or pharyngeal muscles of the throat, the resulting paralysis can make swallowing difficult or impossible. And where does that food go when it won't go down the esophagus? It obstructs the esophagus or spills into the airway, possibly choking the patient.

So could Botox migrate from the forehead muscles (frontalis muscle), frown lines (corrugator supercilii and procerus muscles), or crow's feet (orbicularis muscle) far enough and in sufficient quantity to cause death? The short answer is "No."<sup>*

*</sup>Of course, there's always a caveat. If the person injecting you is using illegal botulinum toxin and accidentally injects about 100,000 times (!) the usual dose, you could end up on a ventilator for a few months.

[FYI: the LD₅₀ of botulinum toxin for adult humans is estimated at about 3000 units (LD₅₀ is the "lethal dose 50%", or the dose required to kill 50% of subjects receiving a given toxin). Typical cosmetic doses are about 5 to 40 units of Botox...a pretty safe margin, I must say.]

Are you a gambler?

Changing your appearance is never without any risk. Often, the greatest factor affecting the odds of a safe outcome versus a disastrous one is the doctor you choose. Many times, though, patients aren't sure how to research a doctor's qualifications. In this blog entry, I'll review some of the issues patients need to bear in mind as they make such a decision.

[Obviously, any doctor writing an article like this is going to argue favorably for choosing him. I'm no different—but all the same, I think you'll find my argument compelling.]

The Reality

It's a fact that payment for medical services is decreasing: doctors are getting paid less for what they do—less by the insurance companies and less by the government (e.g., Medicare & Medicaid). As a result, many healthcare practitioners are looking for ways to supplement the bottom line. Unfortunately for the public, that means that all too many doctors with essentially no real training in the plastic surgery disciplines are hawking cosmetic procedures to the public.

Just here in Orange Park and the surrounding areas of Jacksonville and St. Augustine there are "cosmetic medicine" practices whose doctors are family practitioners (general practitioners), obstetrician/gynecologists, emergency room doctors, and even dentists! All are trying their hand at cosmetic specialties.

Would you trust me to do your Pap smear? So why would you trust an OB/GYN to inject your forehead with Botox? And I don't think you'd want me filling your cavities, yet a dentist—someone who's never been to medical school—offers facelifts and eyelid surgery to the unsuspecting public. His office is only thirty minutes from mine. A family practitioner whose office is only blocks from mine claims to specialize in "cosmetic medicine"—whatever that is—with no formal residency or fellowship training beyond her residency in family practice. An ER doctor performs cosmetic procedures at his local medispa (medical spa) in Jacksonville.

I can assure you that none of their residency programs emphasize cosmetic procedures. None of their boards extensively examine competency in plastic surgical procedures. Weekend courses do not a plastic surgeon make.

Can pediatricians perform liver transplants?

The short answer is yes. You may find it hard to believe, but in the United States when a doctor is licensed to practice medicine, the state license is an unrestricted license. That means that it is perfectly legal for a pediatrician to perform a liver transplant, or for a radiologist to perform brain surgery, or for a psychiatrist to perform a heart bypass.

Of course, most of us in medicine generally know better than to do such things and so we stick to our areas of expertise. And if they don't know better, the traditional checks and balances have been the securing of hospital privileges. That is, while it's perfectly legal for me, a facial plastic surgeon, to do a hip replacement (for which I have no training), no hospital in the country would allow me to do that—they would never grant me privileges to perform orthopedic surgery...and no amount of weekend courses I may claim to have taken will convince them otherwise. But what if I build my own surgery center? Well, I can do anything I want there. And office-based procedures? Same thing. Anything goes...and it does.

Staying safe...How to avoid The Big Gamble

I fully understand that it's hard for the general public to make sense of our credentials. Some are meaningful and some are not. To become a member of the American Academy of Aesthetic Medicine, for example, requires only that you pay $175.00 (for doctors). Less scrupulous practitioners are capitalizing on such confusion...at the expense of your money and your safety. Here are some tips:


• Check what that doctor really trained in

By "really trained in," I mean what residency and fellowship training did they receive...what is their actual specialty? Was their residency in a field that includes plastic surgery? General surgery does, otolaryngology/head & neck surgery does, ophthalmology sometimes does, dermatology sometimes does. And that's pretty much it.

Most specialists also do further fellowship training in their more narrow area of expertise. For example, most facial plastic surgeons will have completed a five-year otolaryngology/head & neck surgery residency and then an additional year of an accredited facial plastic surgery fellowship, as I have. General plastic surgeons typically have spent five years in general surgery followed by two years of an accredited plastic surgery fellowship. Someone whose residency was in family practice, or obstetrics and gynecology, or emergency medicine is not a specialist in plastic surgery. Sure, a family practitioner may call herself an "aesthetic physician" but that has no official meaning (and is backed by no official training or board exams).

You can look up our training on the Florida Board of Medicine's license lookup free of charge. Just type in our name and then look at our Practitioner Profile by clicking on our license number. My medical license is ME 80556. There you can verify our education and specialty certification as well as any criminal convictions, malpractice history, and reprimands by the Board of Medicine.


• Don't confuse an Academy with a Board

Academies are our academic organizations, but boards are our certifying authorities. Legitimate certifying boards are recognized by state medical boards and state legal statutes.

So, while I am a member of the American Academy of Facial Plastic and Reconstructive Surgery, I am also certified by the American Board of Facial Plastic and Reconstructive Surgery (and am furthermore certified by the American Board of Otolaryngology...whose exam also encompasses facial plastic surgery).

Becoming a member of an academy is much easier than becoming certified by its corresponding board which requires passing rigorous written and oral exams...and in the case of facial plastic surgery, also submitting for peer review the operative notes from at least a hundred cosmetic and reconstructive plastic surgical cases performed after completion of one's training (nope, Botox and all those non-surgical treatments don't count one iota toward that case log).


• Look for appropriate board certification

If someone's ad mentions, "board certified," what exactly are they boarded in? Although the American Medical Association's Ethical Advertising Guidelines suggest that when doctors proclaim board certification that it should be in the specialty for which they're advertising, many times this is not the case. A common trick is to simply claim, "Dr. Wannabe is a board-certified doctor." Fine. They probably are, but in what? OB/GYN? Family practice? My personal opinion is that the following board certifications are reasonable indicators of competence in cosmetic and reconstructive procedures:

• American Board of Facial Plastic and Reconstructive Surgery (ABFPRS): for advanced surgical procedures of the face, head, and neck.


• American Board of Otolaryngology (ABOto): also for surgical procedures of the face, head, and neck.


• American Board of Plastic Surgery (ABPS): for surgical procedures of the body, face, head, and neck.


• American Board of Ophthalmology (for surgical procedures of the eye).


• American Board of Dermatology (for surgical procedures limited to the skin and hair).

I am boarded by both the ABFPRS and the ABOto. Here's an easy way to check my certification: http://www.abfprs.org/certified/index.cfm and http://www.aboto.org/cert_search.aspx.


• If someone is touting membership in one of the less well-recognized organizations, it may be because they lack membership in more prestigious organizations

Being a member of one of these lesser categories isn't by itself a bad thing—but it's suspicious if that's all they have.


• Make sure the doctor has privileges to perform cosmetic surgical procedures at a hospital

Let the old system of checks and balances work for you. Even if the doctor does most of his or her procedures at a surgery center, a good indicator of competence is to ask if he or she has privileges at a hospital to perform these procedures. Note that having admitting privileges at a hospital does not mean having surgical privileges for cosmetic and reconstructive procedures.


Confused now? I hope not. In the end, even putting yourself under the care of a doctor with legitimate credentials from reputable organizations who's well trained, is no guarantee of success...but you've certainly improved your odds.

I try never to forget that at the end of medical school I took an oath as a physician. So while I am also a businessman, I am a businessman second and a physician first. Isn't that what you want?

The Beauty Vector™ and Patient Satisfaction

From time to time any of us who perform cosmetic surgery have to face a patient of ours who is unhappy with his or her result. And when an operation has hasn't gone as well as we'd liked or has suffered complications, a patient's dissatisfaction is justified and understandable.

Some patients, however, are unhappy despite having a technically perfect operation. How can this be? In such cases, the usual reason is the patient's unrealistic expectations about what surgery can do. This underscores one of the most important tasks we have as cosmetic facial plastic surgeons: properly setting patient expectations.

Needless to say, there is no perfect way to do this, but in addition to the usual techniques we're taught in our training, I've recently begun using a concept that I call "The Beauty Vector™".


Figure 1.

Imagine a graph where the vertical axis represents beauty along a scale from "unattractive" to "gorgeous". (see Figure 1.) Pre-operatively, the patient imagines herself (or himself) as lying somewhere along that spectrum—labeled here as "Pre-op". Represented along the horizontal axis is a scale of surgical results, with the extreme right edge representing the theoretically most technically perfect surgery imaginable.

It follows, then, that a patient's appearance will increasingly improve the closer the surgeon comes to executing a technically perfect operation.


Figure 2: a steep Beauty Vector™.

And while it's true that the better the surgery, the better the result, there's another critical factor over which neither the patient nor the surgeon has any control and that's the slope of the line (see Figure 2.).

In figure 2, the patient's Beauty Vector™ is fairly steep. This means that a lot improvement in the patient's appearance is possible—even with surgery that falls short of perfect execution.


Figure 3: a shallow Beauty Vector™.

Some patients, though, have a much shallower Beauty Vector™ such as in Figure 3. What accounts for these differences in slope? The simple answer is: fundamental aspects of a patient's anatomy that are impossible or impractical to modify. These are not limitations of the surgeon's skill, but rather limitations of technology.

Here are a few such examples: we cannot usually modify the position of the eyeball relative to the shape of the eye socket, and yet this relationship helps dictate the height of the upper eyelid; we cannot generally modify skin thickness and yet such factors determine how skin redrapes after rhinoplasty; the position of the hyoid is unalterable and yet it greatly determines how nice a neckline we can create with a facelift.


Figure 4: perception vs. reality.

Problems arise when a patient imagines her (or his) Beauty Vector™ to be a steeper than the surgeon knows it to be (see Figure 4). As the angle widens between medical reality and patient perception, the likelihood that the patient will be unhappy skyrockets, as demonstrated below.


Figure 5: the consequences.

The result for a patient with a shallow Beauty Vector™ is that even a perfect surgical procedure performed by the best surgeon in the world will produce only a modest improvement in appearance (gold and grey dotted lines in Figure 5). But the patient will believe that this modest improvement is the result of mediocre surgery or a mediocre surgeon (blue and grey dotted lines in Figure 5).

As a facial plastic surgeon, the challenge for me is not only to try to come as close as possible to technical perfection with each surgery, but also as importantly to make sure that the patient understands his or her Beauty Vector™, particularly if it is a shallow one.

I want to emphasize that this is not to say that someone with a shallow sloped Beauty Vector™ is never a good candidate for plastic surgery. Rather, a patient is a bad candidate only if his or her expectation of improvement is greater than what is surgically possible.

At Pearson Facial Plastic Surgery™, we're beginning to include a formal estimation of a prospective patient's Beauty Vector™ into the pre-operative evaluation. This helps with our own "quality control," so to speak, and helps create that unique and satisfying experience for our patients.

First Anniversary of Pearson Facial Plastic Surgery™

Wow! I can hardly believe how quickly this year’s passed. October 1st marks the one-year anniversary of our new practice. Of course, the growth we’ve been so fortunate to have experienced is thanks to the wonderful support of many groups. None of this would have been possible without my former Mayo Clinic patients who continue to see me, my former Mayo Clinic physician colleagues to continue to refer to me, my colleague in the building, Dr. Carreno, and the positive word-of-mouth that’s brought us so many new patients from all over north Florida.

The other key ingredient has been our excellent (and growing) staff who’ve been so dedicated to the practice and our patients. I’ve also appreciated their humoring me through my endless tweaks and revisions to everything from our forms, décor, electronic systems, logistics…you name it…all in an effort to create that unique experience for our patients.

As we move into our second year at this location we’re looking forward to our continued growth, getting the Pearson Facial Plastic Surgery™ name out there, adding new services and procedures, and probably even some additional staff. The one thing that won’t change is our focus on quality and safety, and never forgetting that I'm a physician first and businessman second.

Thank you to everyone who helped make this such a good year!