It's Just a Needle, Right?

Upfront biases: I am a formally trained ENT surgeon with significant training in facial plastic surgery. I trained with two of the best facial plastic surgeons in the country (Ted Cook, MD and Tom Wang, MD) for 4 years.  My views are skewed to side with what's best for the patient.  Furthermore, my views are based on the fact that cosmetic surgery/treatments make up a big part of my practice.  Obviously, those who agree with the opinions in this blog post would be more likely to end up in my office.  Regardless, I think my points are valid, so I will write this post anyways.

Facial rejuvenation can obviously be surgical, but given the current trends in the United States, most people aren't interested in surgery.  Instead, the focus is on nonsurgical rejuvenation techniques like:

• Botox or Dysport for dynamic wrinkles
• Facial fillers like Restylane, Juvederm or Radiesse for volume restoration
• Skin resurfacing techniques with laser treatments or chemical peels
• (I don't include laser hair removal here as that has little to do with rejuvenation)

 So who's qualified to do these treatments?  In my opinion, it's:

• ENT/Facial Plastic surgeons
• general plastic surgeons
• dermatologists
• a PA or nurse who works with one of the aforementioned physician specialties who has experience performing these treatments. 

Who should NOT be treating your face:

• ER doctors
• Internal medicine doctors
• Family practice doctors
• OB/GYN
• Naturopaths
• Any other doctor that isn't formally trained
• Medical assistants
• "Someone your friend knows who will come to a Botox party"
•  Estheticians or other MedSpa "injectors"

So why do I have this opinion?  The reasoning is quite simple.  We are talking about your face.  Some of these treatments can have devastating complications.  But let's dive into this a little more:

1. The people in the "should not treat" category did not go to residency to learn cosmetic surgery.  They trained for their specific board certified specialty.  At some point afterwards, they decided that "cosmetic facial treatments" would be more lucrative.  It is only about money here.  Doctors don't go to residency for Internal Medicine, practice for some period of time, and then suddenly think "My real calling is in the rejuvenation of the aging face". Let’s not kid ourselves.
2. The treatment of the face has more to do with the analysis of what the face needs than it does where to inject and what to inject.  I can train almost anyone to inject a product.  But the art of facial rejuvenation is in looking for subtleties, asymmetry, and what the patient desires.  Too often, people give their faces up to untrained hands, only to suffer a complication or, more commonly, no effect at all.  This can occur because the analysis of the face was incorrect from the start.  
3. Who can own a MedSpa?  The requirements differ from state to state, but in Oregon, it can be anyone with an MD/DO doctoral degree or a naturopath.  Thankfully, dentists are not yet allowed to perform these treatments although they are seeking approval. I recently spoke against this idea at the Oregon State Dental Board, but keep in mind that some states allow it.

If your MedSpa director is not an ENT/facial plastic surgeon, plastic surgeon or dermatologist, then their training consists of courses.  Courses that are often run by other untrained professionals, sometimes over a weekend or an evening, and often without live demonstrations or hands-on training.  That means that the ER doctor turned cosmetic guru who would like to inject $1000 worth of Botox and Restylane in your face could have JUST LEARNED how to do it.  Some analogies will help drive this point home:

“Hey dad, I just saw a show on TV about car repair. Mind if I have a look at that leak?”

“Ma’am, I know you’re experiencing chest pain, nausea, lightheadedness and left arm pain.  I’m an ENT surgeon by training, but I’ve seen this several times before and I’m pretty sure I can treat you just like a board-certified cardiologist would.”

“Land this plane? No problem. I’ve done flight simulation on my Xbox a million times.” 

Etc. Etc. 

The final argument is the most valid, in my opinion.  The biggest problem with having an ER doctor or internist as your cosmetic MD is that surgery can NEVER be an option.  That means that every single patient can only get the non-surgical option, even if the surgical option is the only one that would achieve a particular effect.  That leads to patients getting treatments that would have never worked in the first place.  Because that doctor isn’t allowed to do surgery, they try something that they have in their possession.  Every cosmetic problem gets the same exact treatment.  That’s not good medicine, and it’s not fair to our patients.  We cannot look at every cosmetic patient as the same nail that only needs a hammer.

Comments

[Gwenny]

There is no effing way I would let someone unqualified remotely come anywhere near my face with a sharp instrument! Are people truly that stupid?

P/s last analogy made me lol so hard I almost fell off the bed.

[Cosmetic Surgery India]

You made a few great points there. I did a seek out on the issue and learned the majority of people will concur with your blog.

[Cosmetic Surgery India]

You made a few great points there. I did a seek out on the issue and learned the majority of people will concur with your blog.

[Captive Medical Solutions - Michael Allen]

This is a great post and highlights the importance of educating the "should not treat" set you describe by marketing what the "should treat" set does and generating appropriate referrals. Patients certainly deserve to have all options presented and qualified guidance to undersand when surgery is appropriate. Similar scenario in pain management.