“INSIDER’S INFORMATION FROM THE NASAL SURGERY SUPERSPECIALIST”

I would like this report to be precious to you.  I want this to have value such that you will say to yourself, “It’s a good thing I read this, I sure didn’t know that.”

Today I want to discuss with you issues that other MDs may not necessarily be as forthright or open about.  I am going to tackle a somewhat controversial subject. But I do this from the vantage point of having been a board-certified specialist for 36 years and having over 4,000 nasal surgery cases under my belt. My career included serving a fellowship in cosmetic facial surgery following my residency as well as a military career which gave me enormous experience and depth. 

Is Every Plastic Surgeon Qualified to Do Nasal Cosmetic Plastic Surgery?

The issue that I want to share with you is that not all “plastic surgeons” or head and neck/ear, nose and throat surgeons are equipped by training, talent or experience to perform cosmetic and reconstructive nasal surgery.  It’s an inconvenient truth that needs to be told.

What I’m telling you is based on my observations and my involvement over the years in the academic community and in acting as a consultant to the Medical Board of California and to insurance companies and even the City and County of Los Angeles Medical Departments.  Nasal surgery is unquestionably the most complex and challenging of all the surgeries within the world of cosmetic plastic surgery.  You can understand why.  The operation is typically done through the nostrils.  While it can be done through an external incision, even that still yields a very limited opening through which surgery is done.  Contrast that with surgery inside the abdomen, chest or even skull where the exposure or opening is quite generous.  In abdominal surgery, three or four surgeons could put their hands inside.  You can barely put your little finger inside the opening of the nose when operating. 

The other issue is that the nose has complex anatomy and the structures each are interdependent on each other and the room for air is very minimal.  It won’t make much difference if there is a little bit of tightness or a little extra scar tissue inside your abdomen after you have your gallbladder removed or your hernia repaired but you sure don’t want to have any scar tissue that shows on the outside of your nose after having cosmetic nasal plastic surgery.  So the standards for excellence have to be high.  With little room for error in appearance and the need often to make sure that the patient breathes well, there is a lot of responsibility that comes with picking up the instruments to do cosmetic nasal surgery or rhinoplasty as well as the surgery to improve the airway known as nasal septoplasty and turbinate resection.  Sometimes, it is even necessary to do some limited sinus surgery if in fact the patient’s breathing problems are so bad as to impact upon sinus function.

My point is that just like in orthopedic surgery, where not all orthopedic surgeons are experts in arthroscopic knee surgery, you must make sure that you narrow your search beyond just having a board-certified specialist in either head and neck surgery or plastic surgery because both of those fields are huge.  In plastic surgery, for example there are 137 operations that the American Board of Plastic Surgery considers within its domain and expects its graduating residents to have familiarity with and be capable of performing.  But there is no way any plastic surgeon could master all those operations.  Certainly rhinoplasty, as difficult as it is technically to perform, cannot be fully mastered in just a couple years of residency.  It takes many more years.  But the route to excellence comes from great teaching, proper training and broad experience.

  Current Problems with Training and Education of Cosmetic Surgeons

Speaking of training, you need to understand the current state of American post-graduate medical education, the residency system.

Nearly 100 years ago, the U.S. established the world’s premier and most sophisticated postgraduate physician training system.  All this was the result of recognition of specialties which began in 1916 with the formation of the American Board of Ophthalmology.  My specialty, head and neck surgery, was the second certifying board founded several years later.  Since then, there have been 23 recognized specialties, each conducting its own residency programs leading to credentialing known as “board certification.”

In the golden era of medical education which in my opinion began at the end of World War II and continued into the early 1980s, surgeons in training, particularly, had ample opportunity to amplify their skills since there were many patients who would come to the university hospitals and be willing to have their surgical procedures done by the surgeons in training under supervision of the professors and other faculty members.  This was possible because universities had large budgets to allow teaching and would, in fact, absorb the cost of the operating room times.  And as you can imagine, residents in training take longer to do procedures than sophisticated faculty or other veteran specialists in practice.  The system worked very well for many, many years.  This large inflow of patients allowed young surgeons to feel quite comfortable with their skills when they graduated from the residency programs.  I know that teachers in our program felt that way. 

Further heightening the abilities and talents of today’s senior surgeons was that nearly all of us served in the military.  For many of us who were fully trained specialists, it was a rich and rewarding opportunity to hone our skills and at the same time, of course, serve the country in a meaningful manner.  Most of today’s young surgeons have not had the privilege and honor plus the benefits of the experience that come with military service.

In the 1980s, the complexion of medical practice changed as insurance companies began to alter their manner of payment.  The bottom line is that over a period of time, teaching hospitals – like all hospitals, became financially squeezed as insurance company payments were continually ratcheted down and as the expense of providing care went up.  What that meant was that budgets in university hospitals were under such a tight rein that the residency programs began to suffer from it.  Some hospitals even gave up training certain residents and fellows (fellows are post residency subspecialty trainees) because government stipends were diminishing parallel to the decline in insurance reimbursements. 

So how did this all affect the training of residents?  The answer is that the opportunities to perform elective surgery drastically diminished.  Residents today graduate form some training programs with a very poor background in cosmetic surgery.  They are stronger in reconstructive surgery, whether in the head and neck or the rest of the body.  The reason is that reconstructive surgery is medically necessary and patients come to the hospitals with some form of insurance and, therefore, the hospitals still keep the welcome wagon out for them.  But hospital administrators are loathe to tie up an operating room for an entire day for a young surgeon to learn how to do a facelift which would take him eight to ten hours as compared with an experienced surgeon taking five or so. 

As usual, economics trumps all.  The consequences for today’s patients are significant in that if residents graduate from a residency program with little experience in performing nasal surgery, for example, they have to learn it on their patients in private practice.   We hear of surgeons who go into practice and proclaim that they perform cosmetic nasal surgery and yet have done two or three in their residency.  Their web site shows one or two cases. 

You need to think about all these things when you make your decision particularly concerning nasal cosmetic surgery which is by far the most technically demanding and sophisticated of all the cosmetic surgery procedures. 

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Dr. Kotler:  “This is dictating an addition to a previous piece that was entitled ‘A Dr. Kotler Special Report’, so we’ll just plug this in.  Let me see here, current state of American postgraduate and the residency system – paragraph”  . . .

America established the world’s premier and most sophisticated postgraduate physician training program.  All this was the result of recognition of specialties which began in 1916 with the formation of the American Board of Ophthalmology.  My specialty, head and neck surgery, was the second certifying board founded several years later.  Since then, there have been 23 recognized specialties, each conducting its own residency programs leading to credentialing known as “board certification.”

In the golden era of medical education which in my opinion began at the end of World War II and continued into the early 1980s, surgeons in training, particularly, had ample opportunity to amplify their skills since there were many patients who would come to the university hospitals and be willing to have their surgical procedures done by the surgeons in training under supervision of the professors and other faculty members.  This was possible because universities had large budgets to allow teaching and would, in fact, absorb the cost of the operating room times.  And as you can imagine, residents in training take longer to do procedures than sophisticated faculty or other veteran specialists in practice.  The system worked very well for many, many years.  This large inflow of patients allowed young surgeons to feel quite comfortable with their skills when they graduated from the residency programs.  I know that teachers in our program felt that way. 

Further heightening the abilities and talents of today’s senior surgeons was that nearly all of us served in the military.  For many of us who were fully trained specialists, it was a rich and rewarding opportunity to hone our skills and at the same time, of course, serve the country in a meaningful manner.  Most of today’s young surgeons have not had the privilege and honor plus the benefits of the experience that come with military service.

In the 1980s, the complexion of medical practice changed as insurance companies began to alter their manner of payment.  The bottom line is that over a period of time, teaching hospitals – like all hospitals, became financially squeezed as insurance company payments were continually ratcheted down and as the expense of providing care went up.  What that meant was that budgets in university hospitals were under such a tight rein that the residency programs began to suffer from it.  Some hospitals even gave up training certain residents and fellows (fellows are post residency subspecialty trainees) because government stipends were diminishing parallel to the decline in insurance reimbursements. 

So how did this all affect the training of residents?  The answer is that the opportunities to perform elective surgery drastically diminished.  Residents today graduate form some training programs with a very poor background in cosmetic surgery.  They are stronger in reconstructive surgery, whether in the head and neck or the rest of the body.  The reason is that reconstructive surgery is medically necessary and patients come to the hospitals with some form of insurance and, therefore, the hospitals still keep the welcome wagon out for them.  But hospital administrators are loathe to tie up an operating room for an entire day for a young surgeon to learn how to do a facelift which would take him eight to ten hours as compared with an experienced surgeon taking five or so. 

As usual, economics trumps all.  The consequences for today’s patients are significant in that if residents graduate from a residency program with little experience in performing nasal surgery, for example, they have to learn it on their patients in private practice.   We hear of surgeons who go into practice and proclaim that they perform cosmetic nasal surgery and yet have done two or three in their residency.  Their web site shows one or two cases. 

You need to think about all these things when you make your decision, particularly concerning nasal cosmetic surgery which is by far the most technically demanding and sophisticated of all the cosmetic surgery procedures. 

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                        A  Word about Before and After Photographs. 

There is no better telescope into the nature of a cosmetic surgery practice than the volume and quality of the before and after photographs that are made available to prospective patients.  I almost giggle when I see some surgeons with such a limited number of rhinoplasty or neck sculpting cases on their website.  They may have more breast augmentations or liposuctions but even those numbers are very small.  So if a surgeon has such a small library of before and after pictures, doesn’t it seem that their surgical experience would also be limited?

I love websites that have hundreds of before and after photographs because it is much easier for the prospective patient to identify someone, somewhere on that site that had similar needs and aspirations that they have. So don’t forget to ask about before and after photographs when you go for consultation and if there are no photographs that can be shared with you, I would suggest that you say “Oops, I think I have a call. I must leave now,” and graciously head for the door.

Should You Go to a Teaching Hospital?

Thanks to the Internet, today’s patients are very sophisticated. They know a lot and they also know that perhaps the teaching hospital is not the place to go for their surgery because that is where the surgery is done by trainees. So that keeps people from going to the hospitals and that diminished inflow reduces the surgical load for the surgeons in training.  In addition, teaching hospitals offer little privacy and personalized service. Further, of course, there is a greater risk of infection and other complications that are such an anathema to the surgeons.  

So what I’m suggesting to you is that if you are considering having nasal surgery, you must search for the superspecialist.  A surgeon who has narrowed his practice down to a very limited number of procedures among which is nasal surgery and who has the focus such that he has excluded other procedures from his practice that he may have even once been quite capable of well- performing. The educational background that one seeks is to have graduated from a residency program and passed the board examination and then gone on for additional fellowship training in facial plastic surgery which will always have nasal surgery as a key component. That is what you look for on paper.   After you glean that from the doctor’s resume, you need to ask how long the doctor has been doing nasal surgery and how many cases he has done over a period of years and do the calculation that shows how many are performed each year. Any surgeon who is performing fewer than 100 nasal cases per year is probably not at the top of the totem pole.

Remember, you have the right to ask these questions, you have the means to do your homework. As you know from seeing patients who have had unsatisfactory nose surgery, the stakes are high. 

You want to do it right the first time.

I hope this helps you.

Robert Kotler, MD, FACS