Dr. Scott Miller is an attending surgeon at Scripps Hospital, assistant professor at UCSD and runs his own surgery center.

A big part of reconstructive surgery is cosmetic. What has been discovered and perfected in the operating room has become standard practice to enhance looks and improve a person’s daily life.

Crossover of reconstructive surgery and cosmetic surgery is common. Dr. Scott Miller says many of the procedures used by plastic surgeons are reconstructive and cosmetic at the same time. Miller is an attending surgeon at Scripps Hospital, faculty assistant professor at UCSD and runs his own surgery center. One of his more unusual cases involved a young woman who as a young child had a tumorous growth removed from her spinal cord. As she grew into a young woman, the resulting scarring and defect was something she became uncomfortable with and something that kept her living within a social shell. “Going in and doing surgery was something that allowed her to blossom socially,” Miller says. Using a combination of flaps common in reconstructive surgery the area was masked. Today that woman is very successful and engaged to be married.

Another procedure that is cosmetic and reconstructive is the brow lift, something Dr. Richard Bodor frequently performs. Sometimes the brow is so heavy that the patient’s visual field is hampered. Bodor says he had one patient at the V.A. Hospital who removed the doors to his kitchen cabinets as he kept bumping into them because he could not see above his brow. Another patient used matchsticks to prop open his eyes so he could read to his granddaughter. Bodor performs the procedure through a hairline incision that heals nicely and is hidden cosmetically. Patients return home the same day with a little swelling.

Even sutures have come a long way. From staples to removable thread to dissolvable stitches, today’s physicians are using Contour Threads to hold some skin in place. Developed by a reconstructive surgeon, these are barbed sutures based on the same principle that makes burrs stick to socks. Today they are used as a minimally invasive surgical approach for “skin lifts.”

As technology simplifies procedures it is important patients understand not all shortcuts are improvements. “People are always looking for shortcuts,” says Dr. Gary Nobel, a plastic surgeon in private practice. Among the practices he questions is the stringlift, a mini facelift that involves a string attached at the corner of the mouth and tacked up to the temple. “It doesn’t really do anything,” Nobel says. “It makes you look like a marionette in cases where you can see the pull of the string.” And not all procedures can improve the way a person looks. “Everyone is a candidate for plastic surgery,” Nobel says. But, he cautions, not all patients will have good results. A good doctor knows how to select patients who are going to get good results from a procedure. And it is up to the doctor since there are no restrictions on what surgeries can be done in a private office.

Dr. Gary Nobel, a plastic surgeon in private practice, questions the stringlift, a mini facelift that involves a string attached to the corner of the mouth and tacked up to the temple. ‘It makes you look like a marionette...,’ he says. (photo/alandeckerphoto.com)

Patients should get to know the doctor and understand the procedure. Some physicians have added plastic surgery to their practice for financial reasons. “With the change in the medical climate in regards to reimbursement from insurance companies, money has been a big incentive of people wanting to do things that pay better,” Nobel says. “Of all the things that are done out there, probably cosmetic surgery pays the best because the price is not dealt with through the insurance company, it’s a negotiation between (doctor) and patient.”

Because of the economic freedom, many of the specialists, like ophthalmologists, have changed their designation to include plastic surgery. Instead of working just on the eye itself, they will do eyelid surgery. Some expand to do face lifts and other things. It’s not as bad as it seems, Nobel says. At least these are surgeons. They have more than the general schooling and focus on corrections of problems that may evolve from poor plastic surgery. “I’m not saying that is all wrong,” Nobel says. “The biggest conflict throughout time is the ear, nose and throat physician. They change their designation from the ears and larynx to facial plastic surgeon. Many of these people have extended their scope, working on the head and neck area, to include the breast, liposuction and tummy tucks.”

These physicians may have done no more studying than a weekend course or, in extreme cases, observe while a surgeon performs the procedure, says Bodor. He says the public should know there is no formal residency program teaching surgeons to become “cosmetic surgeons.”

“The best plastic surgeons have also done years of reconstructive surgery and continue to refine their skills at optimizing a patient’s anatomy, whether it is considered a reconstructive or a cosmetic defect,” Bodor says. “The best-trained continue to build upon their many years of formal plastic surgery residency training, by an ongoing surgical practice of tackling both cosmetic and reconstructive problems.”

There are physicians with different board certifications in different fields, who overlap in various cosmetic surgery procedures. The American Association of Medical Colleges designates the major specialist residency training programs, and one of those is plastic surgery. Only those surgeons who have successfully completed the typical six to seven years of required formal residency training can claim the title Board Certified Plastic Surgeon. “That specialty has the longest years of required formal training (in cosmetic and in reconstructive surgery all over the body) before even starting practice,” Bodor says. “It is important to ask your surgeon what formal residency training was completed out of (medical school), thus designating their primary AAMC Board specialty. Even if you are having a procedure done in an outpatient surgi-center or in an office, you should also still ask whether your surgeon has qualified for local hospital privileges in that very procedure.”

Local hospital privileging committees scrutinize all surgeons’ training and performance, closely reviewing their skill levels before granting hospital privileges for each specific procedure. This hospital endorsement helps patients choose local surgeons who have already been locally screened by their peers, and it allows the surgeon to admit patients and operate, if there is a complication.

— Maria L. Kirkpatrick