Cosmetic competency

Dr. Niamtu's CounterPoint article in the July 2007 issue of Cosmetic Surgery Times("Max Factor: No Specialty Owns the Face") is interesting, entertaining and shows the intellect of its author. However, Dr. Niamtu is quite defensive of his lack of medical training, justifying dentists with oral and maxillofacial surgery (OMS) training as competent and safe practitioners of cosmetic surgery. Most of us who have dental backgrounds and who have participated in the training of oral surgeons would disagree with many of his arguments. One cannot argue with Dr. Niamtu's personal achievements; generally speaking, however, oral surgeons are poorly trained in soft tissue aesthetic surgery. My assertions and opinions are based on having a dental degree myself and having taught for five years in a plastic surgery residency program as a full-time faculty member at the University of Southern California (USC). We would interface and operate with the oral surgery residents in maxillofacial cases. One cannot argue about the reputation of the USC Dental School or its excellent OMS faculty. However, it was obvious that even chief residents in OMS were quite uncomfortable with soft tissue surgery and the anatomy anywhere else away from the jaws. Turning oral surgeons "loose" on the public without a full aesthetic facial fellowship, in my opinion, is not protecting the public. There is a big difference between exodontia and facelifting.

TRAINING IMPERATIVE The majority of OMS training involves the mouth and jaws. Facial fractures and simple soft tissue injury management are taught in teaching hospitals. How much time in the residency program is spent teaching the complexities of rhinoplasty and facelift? In plastic surgery and facial plastic surgery residencies, a minimum number of aesthetic procedures by category are required prior to completion of training. If dentists with OMS training wish to perform aesthetic surgery of the face, I believe it is imperative that they have the same requirements. They should perform primary and secondary rhinoplasty, oculoplastic procedures, brow lifting, facelifting, etc. in sufficient number and with the appropriate supervision to warrant being given the privilege to operate on patients. It is critical that OMSs performing cosmetic surgery do not rely on learning how to do these procedures in weekend courses.

POLITICAL POSITION Dr. Niamtu's counterpoint article is just as political as the original article in CSTthat he was accusing of being political and biased (November/December 2006). He is a good spokesperson politically for single-degreed dentists who are oral surgeons; however, he underplays the value of a medical education. Many of us who also have dental training will agree that a medical degree by itself does not insure competency as a cosmetic surgeon. However, medical training greatly expands the knowledge base allowing for better decisions in patient selection, management of complications and overall care. One of the reasons that OMS doctors often strive to achieve a medical degree is to expand their medical knowledge and training to better care for patients.

QUI BONO? Also left out of Dr. Niamtu's article is the real reason that oral surgeons want to perform cosmetic surgery — the pursuit of money. As reimbursements for insured dental procedures have fallen, OMSs have become interested in pursuing more lucrative endeavors. There appears to be a direct correlation and timeline between the dental specialty pushing for cosmetic procedures and falling dental reimbursements. Quite interesting?

Finally, Dr. Niamtu partially justifies his arguments regarding the competency of OMSs based on the California Medical Board agreeing to allow OMSs with a permit to perform cosmetic surgery. What he did not elaborate on was the manner in which this was achieved. The American Dental Association (ADA), the California Dental Association (CDA), and OMS members poured massive amounts of money into lobbying efforts in California. According to records of the California Secretary of State, lobbying efforts of the CDA alone in 2005-2006 were in excess of 1.2 million dollars; a significant percentage of these funds were applied to dental scope of practice issues. State records show that groups opposing dentists performing cosmetic surgery including the California Society of Plastic Surgeons and Facial Plastic Surgeons spent less lobbying against this legislation.^{1, 2, 3} Despite Dr. Niamtu's arguments, I am worried about the safety of cosmetic surgery patients in the hands of OMSs who do not have extensive training in facial aesthetic surgery. I would suggest that all OMSs who wish to perform cosmetic facial surgery should have additional formal fellowship training in aesthetic surgery. If not, I am confident that patients will suffer.

Dr. Bresnick is a board-certified plastic surgeon in private practice in Encino, Calif., an active member of ASAPS and ASPS, and has served as Assistant Professor in the Division of Plastic Surgery, USC, and Childrens Hospital Los Angeles.

For more informationStephen Bresnick, M.D. [email protected]

References

1 California Secretary of State, Public Records 2005 - 2006, 2007 - 2008

2 American Society of Plastic Surgeons, Records for 2005 - 2007.

3 Los Angeles Times, Published article: "A Knife Fight in Capitol: Oral surgeons want the Legislature to allow them to perform cosmetic surgery." Jordan Rau, May 27, 2004.