The Value Of Board Certification In Cosmetic Medicine?

Is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week?

In Cosmetic Surgery, the term "Board Certified" is the most highly used term for marketing purposes today. Thirty years ago, many doctors were "Board Eligible" or non boarded and their value came from their training and their experience and their expertise, not just a label. Today, doctors are expected to be board certified in something. That something is the topic of heated battles and debates and many of our colleagues are just as confused about it as are our patients and the public and the media. Insurance companies and third party payor and even hospitals require board certification and may use it for determining reimbursement. 

The American Board of Plastic Surgery (ABPS) and The American Board of Facial Plastic Surgery (ABFPRS) have had many decades of heated nasty all out warfare. For the most part, on the surface at least, the war is over but small battles and skirmishes are still waged amongst these two specialties here and there around the country. But cosmetic surgery is no longer being offered purely by Plastic Surgeons or Facial Plastic Surgeons, Oculoplastic surgeons, Oral surgeons, otolaryngologists, & dermatologists are a significant part of the cosmetic surgery providers. More over, family physicians, ER doctors, Radiologists, OBGYNs, and other doctors whose specialty is not traditionally associated with cosmetic surgery are now the fastest growing population of cosmetic surgery providers with Botox and fillers and lasers as their entry to the more involved mini facelifts and blepharoplasties and liposuction. The American Board of Cosmetic Surgery and the American Board of Laser Surgery has given this large heterogonous group of non-cosmetic surgeons an umbrella to gather under and a label to use for marketing and validation.  

The American Board of Plastic Surgery and The American Board of Facial Plastic Surgery have now joined forces in order to "protect the public" and inform the media and public about the lack of proper residency or fellowship training by many of these new non traditional providers.  Protecting the public is a noble endeavour and a great cause but I ask who is going to protect the public from less inept members of the American Board of Plastic Surgery and the American Board of Facial Plastic Surgery?  There is no doubt that the vast majority of poor cosmetic surgery with bad outcomes are being performed by Board Certified doctors, most of which are actually certified by these two esteemed Boards (ABPS and ABFPRS). 

Then what is the true value of "board certification" and how will the public be protected? We must police and control our own profession as a whole before we are controlled by outside forces. In Ontario Canada, a deal between the society of Plastic Surgeons and the Department of health posed a new regulation where no one other than a plastic surgeon could use the term "plastic surgery" in their advertising! So, is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week or even from a nurse who works at a plastic surgeons office? This is a tough question that needs to be answered by us doctors before it gets settled for us by external forces. 

Radiofrequency Assisted Liposuction (RFAL) - A new technique for adipose tissue treatment & 3D-skin tightening

The new technique using radiofrequency assisted liposucion (RFAL) from Invasix is based on bipolar radiofrequency energy which is applied to the subcutaneous adipose tissue and subdermal skin surface.

Preliminary clinical trials, histologic biopsies of the treated tissue and thermal monitoring demonstrate a rapid liquefaction of the adipose cells, coagulation of surcutaneous blood vessels and uniform sustained heating of tissue.

The dramatic rise in liposuction procedures, the aging “baby boomer” population, with decreasing skin tone and advanced laxity are seeking new body contour procedures.

The traditional tumescent, suction-assisted liposuction (SAL) is a mechanical disruption of adipose tissue through the openings in the cannula with induced negative pressure and can be quite traumatic to the patient.

 In seeking to improve the postoperative patient recovery of swelling, bruising, pain and to enhance skin contraction as well as to diminish physician effort, newer generations of energy-assisted liposuction technologies have been developed.

Preliminary studies with the RFAL technique reported faster treatment, improved safety, reduced tissue trauma, liquefaction of adipose tissue, blood vessel coagulation and uniform heating of the skin and subcutaneous tissue as well potential 3D-skin tightening. Due to histologic observation of connective tissue in the treatment area there is a significant change in its structure with coagulation of the deep, dermal collagen. After treating the subcutaneous fibrous and dermal matrix with RFAL the results are impressive in 3D-soft tissue contraction and contours.

Dr. Bratani has no disclosures and interests with Invasix Ltd.

American Cosmetic Surgery Numbers By Region

American cosmetic surgical procedures in the U.S. by region.

North East: 302,000 cosmetic surgeries

• 29% Nose Reshaping
• 20% Facelift
• 18% Eyelid Surgeries
• 17% Liposuction
• 15% Breast Augmentation

South East: 289,000 cosmetic surgeries

• 23% Liposuction
• 23% Facelift
• 22% Eyelid Surgeries
• 16% Breast Augmentation

South: 258,000 cosmetic surgeries

• 17% Breast Augmentation
• 17% Nose Reshaping
• 16% Tummy Tuck
• 15% Liposuction

Midwest: 242,000 cosmetic surgeries

• 31% Dermabrasion
• 17% Breast Augmentation
• 14% Nose Reshaping
• 13% Eyelid Surgeries
• 13% Liposuction

West: 485,000 cosmetic surgeries

• 36% Breast Augmentation
• 34% Eyelid Surgery
• 32% Liposuction
• 31% Facelift
• 27% Nose Reshaping

* Percentages may aggregate to more than 100% do to the same patient having multiple types of treatments.

Laser Liposuction & Skin Tightening - Emperor's New Clothes?

Does laser assisted liposuction really provide all of the skin tightening benefits that the manufacturers claim?

We are in pursuit of many Holy Grails in plastic surgery, from scarless post-surgical healing, non-invasive liposuction and implant-free breast augmentation to non-invasive skin tightening. With the advent of laser-assisted liposuction (LAL) came the promise from the manufacturers that we have finally achieved a way of combining "minimally invasive" fat removal with skin tightening, sensationally treating two maladies with one procedure.

I been involved with LAL for many years, and it has been the primary revenue driver in my practice for nearly five years running. I began to perform the procedure when the machines became powerful enough to actually generate enough subdermal heat in a timely fashion to potentially create significant collagen remodeling and hopefully result in skin tightening. My case load quickly became large enough that I was asked to be a national speaker for one of the dominant laser companies educating other physicians on the use of LAL. As such, I delved into every published paper even remotely relating to heat-generated skin tightening and laser assisted liposuction. Over the years, I have been able to merge a huge surgical experience with the science behind the procedure and draw some fairly clear and simple conclusions on the issue of skin tightening.

Setting up a patient for potential skin tightening is fully dependent on generating ample subdermal heat to initiate collagen denaturation and subsequent remodelling. Generally, this temperature is felt to be between 40 to 45 degrees celsius.  At around 47 degrees celsius, skin blistering and burns occur.  With proper time, temperature-monitoring devices, and careful technique, adequate temperatures can be achieved. Getting the skin to this temperature range takes time and significantly prolongs the procedure. Additionally, the risk of seroma escalates the longer you spend with the tissues in this temperature range in my experience.

In about 15% of cases, I see clinically visible skin tightening which I don't feel I would have seen using other techniques. This skin tightening is not the equivalent of excision techniques, but typically limited and subtle. This is obviously purely my subjective opinion to be clear, and I cannot say that these same results may not have occured witht the same frequency had I used other liposuction techniques.

The science of LAL and skin tightening is clear that some tightening does occur and is quantifiable. But this does not predictably translate into clinical relevance. I have now performed nearly 1000 LAL's and no longer educate my patients that LAL is a good method of tightening skin. The limited degree of tightening I credit LAL for is not enough to call it a clinically relevant skin tightening procedure. The majority of new LAL consults in my practice present with the impression that LAL is going to tighten up their loose skin while removing fat. The notion is dominant on the internet and even in print ads. I politely educate them that although there may indeed by some skin tightening, this will be subtle at best. In my opinion, the advantages of LAL lie elsewhere, particularly in a somewhat easier recovery.

I continue to hear from colleagues who also use LAL that they believe in the skin tightening.  I don't know if this is a case of "The Emporers New Clothes" or not. I have pushed the envelope in terms of thoroughly heating up the skin to appropriate temperatures and length of time, but only see minimal tightening and an increase number of seromas. I continue to use LAL heavily but no longer tout skin tightening as being an expected end point.