How to choose a surgeon, advertising, promotion and the internet

The General Medical Council and the Royal College of Surgeons of England have produced booklets entitled ‘Good Medical  Practice’ and’ Good Surgical Practice’.  These are the basis for consultants’ annual appraisal and are based on five areas, 1)  good clinical care which includes providing  evidence of the number and type of operations you perform and their outcomes, 2) maintaining and improving good surgical practice which includes continuing professional development and learning, 3) teaching, training and supervising particularly of surgical trainees and in advanced practice of other surgeons ,4) relationships with patients and, 5) working with colleagues.  Probity in professional practice and personal health are also included.  The Independent Health Care Association has also produced a booklet on good medical practice in cosmetic surgery which is based on the same areas.  Your surgeon should be able to provide evidence of the quality of their practice in all these areas. 

 In the modern world it is often possible to find evidence to support a surgeon’s commitment to these areas.  Your surgeon, particularly if they have a significant teaching commitment, will look to present their work at national and international meetings and will have published book chapters and scientific papers.  Evidence of these activities is often to be found from reliable 3^rd parties on the internet such as publishers, universities and specialist surgical societies and teaching course organisers.  Often invitations to national and international meetings to teach and publications in the scientific literature and in books is evidence of recognition by peers in the field.   I have performed surgery on teaching courses in the UK and abroad and there is no greater audit of one’s practice than being watched closely by one’s peers when invited to demonstrate surgical techniques in front of them and a large audience.  I have blogged about the value of teaching and training previously not only with regard to helping others learn surgery but also because I believe teaching is a strong motivating force driving one to reflect with discipline on one’s own practice and improve.

Surgeons should be able to show you examples of their previous work, in particular that are relevant to you and should have a body of work rather than just occasional cases.  Asking about revision rates for rhinoplasty surgery does provide some useful information but again as I have blogged before figures alone do not give the whole picture and a surgeon with higher revisions rates may have more complex cases to operate on and may have patients who request refinement procedures more than others. 

Personal patient and colleague  testimonials can be very  helpful and ideally your surgeon should also be able to put you in touch with previous patients who can talk to you and help you if you wish.  These patients are not anonymous and are happy to be accountable.  You are able to personally  judge them and the truth and value of their opinions and advice.  Their full personal story will give you context.  This in my opinion is much more valuable than using internet forums where posts are anonymous and when it is difficult to judge the writer and their motivation for writing. The General Medical Council states that if a surgeon advertises any information it must be factual and verifiable.  These same standards cannot be applied to anonymous posts on the internet .

In light of the PIP breast implant problems a call has been made for cosmetic surgery marketing to be more about helping patients make informed decisions not selling http://tiny.cc/g4xgt.

I completely agree and empowering patients so that they have the confidence to make their own decision about what is right for them has always been an absolute and fundamental aim of our practice.  You should be thinking about all the above factors and the professional goals of your surgeon and his team when reading their literature, when preparing for your consultation and during your consultation to make it truly valuable.

Rhinoplasty and implants

There is a lot of discussion and concern in the UK at present regarding PIP implants in relation to cosmetic breast surgery. Implants are sometimes required in primary and in secondary rhinoplasty. One of the commonest places to use an implant in rhinoplasty is along the bridge of the nose to build it up if it has been damaged by injury or too much bridge had been removed in a previous surgery or the patient was born with a low bridge. It is more common for patients from Asia to request building up of the nasal bridge. It is very tempting in these cases to use an artificial implant such as Gortex or Silastic which is a type of plastic. These are easy to use as they don’t require extra surgery just the opening of a packet! They can work well but carry an increased risk of infection or rejection. This is a major difference compared with patients own tissue which can’t be rejected and has a much lower chance of infection. Therefore, in the nose if an implant is required I always aim to use the patient’s own tissue. It may take extra time to remove from elsewhere in the body like the rib or the scalp or ear and longer to shape and carve but I feel it is worth the extra effort. Using a patient’s own tissue to build up their own nose is the best principle to follow.

Art and science in plastic surgery

I am taken by and like very much Jonathan Yeo’s latest series of paintings “you’re only young twice” featured in The Sunday Times Style section today. They have an element of Francis Bacon in the flesh tones and a remarkable feel for tissue tensions and textures which are so important for the surgeon to be sensitive of. He portrays the play of light and shadow on curves beautifully. Extraordinarily he also brings in a reference to Hollywood 50′s glamour and Pan Am or Ad Men aspiration particularly in Endobrow lift. He is right that as plastic surgeons we should have artistic sensitivity but only partly right, perhaps with a romantic hope, that we can leave our own signature. Patients are not a blank canvas.

Cosmetic rhinoplasty, happiness & VAT

Some interesting tweet conversations yesterday which made me think. Suggestion made to me was that non life saving surgery should attract Value Added Tax just as other non-essentials in life do. The wonderful reward of well performed aesthetic rhinoplasty in well chosen patients is a profound improvement in self-confidence and happiness as illustrated by the comments of a mother of one of my patients recently http://t.co/1JLMc6dt. As Paddi Lund, a dentist in Brisbane discussed in his book Building A Happiness Centred Business, making our patients happy and the privilege of gaining in return an increase in personal happiness is an example of what being human beings is all about. Happier, more confident individuals will contribute more to society too. I think therefore that society should have as a fundamental goal increasing profound happiness in each other. This is a different happiness than is transiently found from buying a new pair of shoes or a bigger, flatter TV. Society through it’s elected government should then encourage activity that helps people develop real increases in happiness. So VAT on aesthetic surgery misunderstands the motivations of those seeking it and the rewards it provides to individual patients and society as a whole.

Are you thinking about a consultation?

The consultation you have with your surgeon is to my mind such an important part of having a rhinoplasty.  If you set out on a journey the preparation you make for this journey to take the right route should never be underestimated.  Meeting with the surgeon should be much more than the traditionally termed consultation which suggests a one-way request for an operation.  It should be a partnership in which your hopes and worries are listened to and understood and in which guidance and advice is offered to help you ultimately make your own right decision.  Your time is very valuable particularly in current difficult times.   We want you to be able to receive everything you want  from one visit with us without feeling the need to take more time off work to travel again.  We’ve therefore put over an hour aside for you.  Reflecting on our extensive experience of  what patients want to know, we have specifically structured the time we offer you to anticipate and answer all your questions – even things you might not have known were important before we mentioned them!

Why working in the NHS & in cosmetic practice helps both

I consider it a privilege to have an NHS Consultant appointment. I am an expert in complex rhinoplasty and septorhinoplasty. Other surgeons kindly send me cases of severe nasal trauma and cases when the nose has badly damaged by cocaine abuse. I often have to rebuild these noses using rib cartilage. They are lengthy cases taking several hours. It is very rewarding to help these patients to make a new start. I also have gained considerable experience in secondary or revision rhinoplasty helping patients who have had previous operations. The lessons learnt in my cosmetic surgery practice can be applied to these cases and vice versa.

Why we don’t put before and after photographs on our website

Photographs are personal and precious. We are proud of our rhinoplasty results. We do not want their personal, precious value to our patients trivialised by appearance on our website to be used like flicking through a catalogue. One of our desires is to educate our patients and to help them understand what might be right for them and what can be achieved. We think that photographs of our previous results can be very helpful in this respect when carefully chosen examples that are relevant are chosen. We don’t want everyone seeing our work and our patients photographs.  We prefer to offer viewing our patients photographs to those who will understand and appreciate their real value and who will respect our patients. It is then a privilege and a pleasure for us to show patients we have a good relationship with and who like us and want to have surgery with us examples of our work that are helpful and relevant to them. This we feel is best done in the privacy of our clinic face to face with our patients. Interestingly some of our patients after surgery don’t want to see their before surgery photographs anymore as they’ve moved on with greater self-confidence and their earlier photographs are part of a ‘previous life’. We understand and respect this and recognising what’s personal, precious and in the past and being proud of our work we don’t want to detract from this by providing open access to our patients photographs to everyone.

Analysis of nasal tip aesthetics.

Firstly I think of the size of the nasal tip is it normal big or small.  Then I think of the site of excess size, if present is it a vertical excess or a horizontal excess. Then to explain these two aspects further I think of the position of the lateral crus, is it malpositioned more vertically as in the perenthesis tip or is it excess horizontal width because the right and the left tip cartilages are widely spread or divergent.  Thirdly I think of the shape of the tip cartilages to explain a problem with size and the site of the size problem.  Are they excessively convex and if so where is the site of that convexity, which margins of the tip cartilages are involved the caudal or the cephalic margins and in which access or direction does the curl run.  In summary I think of surface aesthetics in terms of size and shape of the tip and then try to see through the skin to explain and anticipate the size, site and shape of the tip cartilages themselves.  This careful analysis then enables me to make an individual operation plan.

Thoughts on Open Approach Rhinoplasty

I’ve been thinking about why for difficult tips I favour the open approach.  There are three main reasons for me.  One is that it enables a very precise assessment of the shape of the tip cartilages and their relationship to each other.  This is not a substitute for very careful analysis of the shape of the nose and the contour of the skin but I feel we can not truely understand what makes the nose the shape it is until we see the underlying cartilages.  In closed approach bringing the cartilages down into the nostrils distorts them and makes it very difficult to really understand their true shape and relationships.  It’s also true to say that after using a surgical technique sometimes during surgery the shape of the nose changes in a way we weren’t expecting and the open approach enables us to see and understand this directly and so correct it.  Secondarily during surgery it enables accurate precise performance particularly fixing grafts into place.  And thirdly I do believe that to get good definition and good shape into a nasal tip we often need to build a really strong structure in the cartilages that supports the overlying skin very well and introduces some tension into the tissues just as a really good framework on a tent keeps the material of the tent in the right shape and position.  I don’t think this is as possible in the closed approach. 

Of course not all nasal tips need an open approach and experience leads us to understand when the open approach is best and when the closed approach is best so it’s definately not a one operation fits all.

Reflections on Teaching and Training

I am off soon to lecture on the Milan Rhinoplasty Masterclass on strategies for treating the bulbous nasal tip and considerations in 3D for surgery to humps on the nasal bridge. Preparing for these meetings is hard work but very rewarding. One of the greatest benefits of a teaching commitment is that it forces one to reflect on ones own practice. This means carefully examining why one chooses certain surgical techniques and carefully assessing the results of these techniques. Reflection and an enquiring mind are part of the responsibility of a profession. I’m sure I’m a better surgeon for the time spent on teaching and training. The feedback one gets from young surgeons and from the audience also stimulates one to think and to constantly to try to improve.