Is It Adviseable to Consider a Facelift with an Oculoplastic Surgeon?

Trust. It is the basis of why patients come to us as surgeons. This trust is undermined by putting self interest and political agendas before the interest of the patient. Many of the physicians answering this question are using fear and partial information to inspire fear rather than to inform. When physicians sling mud like politicians, the profession and more importantly, the patient suffers.
The question is “is it advisable to consider a facelift with an oculoplastic surgeon?” These colleagues quickly fired back with phrases about training and board certification without knowing anything about the Oculoplastic Surgeon in question. If one were to review malpractice cases and settlements, there would be no shortage of Board Certified Plastic Surgeons listed as defendants. Board Certification in any specialty means the doctor completed a residency and passed an examination. Board certification does not measure surgical skills, artistry, judgment and ethics.
As a practicing Oculofacial Plastic Surgeon in New York City for the past 15 years and as an instructor in Cosmetic Surgery, I would answer this question posed by this individual differently. “Is it advisable to consider a facelift with an oculoplastic surgeon?“ My answer is “It Depends”.
Cosmetic Surgery is not the exclusive domain of one specialty. Cosmetic Surgery is distinctly different from Plastic Surgery. Specialization and even super specialization has led to great advances in the disciplines of Cosmetic Surgery which everyone benefits from. One can argue that a 2 year hospital based residency (standard for Board certified Plastic Surgeons) with limited experience in Cosmetic Surgery is inadequate for the complexities and art of Cosmetic Surgery. This does not mean that the general Plastic Surgeon is not qualified to perform Cosmetic Surgery but rather like any surgeon, must focus on particular areas to achieve excellence.
The exposure during residency and fellowship varies between programs and when you think about it, no matter how many years of training a doctor has, it takes many years of practice before one becomes proficient in a specialty. What does it take to excel in Cosmetic Surgery? It takes a foundation of surgical experience combined with technical skills, aesthetic sense, judgment and ethics. Does one specialty have this combination exclusively? The answer is no. Physicians are individuals.
A local Board certified Plastic Surgeon who advertises heavily and performs high volume surgery has so many poor outcomes that he has a full time attorney to handle all the malpractice suits. I personally have revised many of his facelifts and eyelifts. Some facelifts were done so poorly that there was not enough skin for me to work with. Is it fair to now say that all Board certified Plastic Surgeons are just like him? No. On the other hand, I personally have witnessed excellent liposuction performed by Ob/Gyn doctors and excellent breast surgery by Ear, Nose & Throat doctors.
Why are these doctors exceptional at what they do? The answer is training, experience, technical skills and aesthetic/artistic vision and commitment to provide the highest level of care for their patients. Personally, as a facelift surgeon, I have been impressed by and learned much from 2 colleagues who do excellent facelift surgery who are Oral & Maxillofacial Surgeons (original specialty – dentistry). The greatest contribution to the field of liposuction surgery was made by Jeffrey Klein, M.D. – a dermatologist.
Performing facelifts for the past 15 years, I have kept up with new developments in the field and have seen facelift surgery being routinely performed by general plastic surgeons, dermatologists, oral/maxillofacial surgeons, otolaryngologists, and yes oculoplastic surgeons. Inter specialty rivalry generates endless accusations of who has more experience during training and who is more familiar with an area of the human anatomy. Once again, patients become confused and judge physicians negatively as self serving.
Based on the answers to this question in this forum, a board certified plastic surgeon who graduated 1 week ago from a 2 year residency is more qualified than an otolaryngologist specializing in facelift surgery for 20 years. The logic used here is flawed and inflammatory. In fact, by the logic used in this forum, Oculoplastic Surgeons are more qualified to perform eyelid surgery then any other specialty. I doubt if these colleagues would stop doing blepharoplasties (eyelifts) for the good of their patients and refer these surgeries to their local Oculoplastic Surgeon.
Unfortunately, it comes down to money. One specialty believing another specialty will “steal” their patients and therefore their right to revenue. It is only beneficial to the consumer to have choices and for specialists to compete in a healthy way to deliver safer and satisfying results to their patients. Inter specialty respect and sharing of knowledge ultimately benefits both patients and physicians. The American Academy of Cosmetic Surgery exemplifies this value.
The question remains, how do you as a prospective patient make a decision on who to choose for your facelift? Ask questions and judge each doctor on their own merit. Here is a simple list of questions:
1. Do you do facelifts?
2. How frequently do you do facelifts?
3. Can you show me your before and after photos?
4. Where do you perform your surgery?
5. Is your facility accredited?
6. May I speak to or meet someone who you have performed facelift on?
Although this list is not all inclusive and patients usually ask me at least 20 more questions during consultation, you should get the “vibe” from the doctor and the office staff about the quality of work being done there. Speak to the administrative and medical staff at the office. If you have any concerns or reservations, ask questions until you are satisfied.

Leaving politics and turf wars aside, the true answer to your question is:  it depends.

Oculoplastics surgeons are trained under the control of the American Society of Ophthalmic Plastics and reconstructive surgery. THe curriculum is tightly controlled and monitored. Face and Neck lift surgery is part of the curriculum in this rigorous 2 year fellowship. However, not all programs get the same amount of experience. Some have more than others.

Pick your surgeon based on their experience and results, not on their title.

Although you would find exceptions to the rule, why would you want to go to a surgeon with the least amount of training in this particular procedure for your facelift. Would you want a plastic surgeon to eye surgery like cataract surgery after he has taken some courses??

Here is what I would recommend personally to find the most qualified surgeon to perform your facelift:

Picking the Best Plastic Surgeon for your face lift procedure: Finding Dr. Right

The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon.

My Background

Dr. Larry Nichter
I have been a practicing plastic surgeon for more than 25 years, having trained scores of plastic surgeons as a tenured professor of plastic surgery at USC, and I have had a private practice in Orange County since 1993. Speaking from all this experience, here is my advice and the criteria I would use to find the best plastic surgeon in Orange County, Los Angeles, California, or anywhere in the United States. These are the criteria I would use to select a plastic surgeon for my friends, my family, or myself.

First, I want to stress some general observations I have found to be true over the years.

Caveat Emptor: Buyer Beware
The longer a surgeon trains at his craft, the finer his skills and the better his judgment become. Board certification in Plastic Surgery (see below) is a bare minimum. Board certification in an additional surgical field recognized by the American Board of Medical Specialties, or for that matter “triple-board certified,” attests to a doctor’s advanced training and skill and judgment. It also means that they have attained Chief Resident Status in more than one field during their training which means they essentially ran a large departmental service and had senior decision-making and independent operating responsibilities. It is this step that is most maturing for a surgeon.

The institution where the surgeon trained is also important. More renowned schools usually attract the best faculty.

You can use the internet to research the background of a prospective plastic surgeon quickly. Please do this prior to making an appointment. “Just because you wear a baseball cap it doesn’t mean you are a good ball player.” The same applies to anyone wearing a white coat—it doesn’t make you a plastic surgeon, much less a great one.

Caveat Emptor in Latin means “Buyer Beware.” In most states, including California, any physician with a medical school diploma and state license is viewed as a doctor and a surgeon—even without any formal surgical training. In some cases even doctors who have completed only the minimal requirements (medical school, licensing examination, and a one-year internship that need not include surgical training) are touting themselves as “cosmetic surgical experts.” They make these claims of expertise despite the fact that they are only formally trained as family practitioners, OB/Gyns, emergency physicians, dermatologists, or ear-nose-throat specialists. Even physician assistants and nurses have made such claims.

7-Step Process for Finding the Best Plastic Surgeon
The following are my screening guidelines and criteria for picking the best plastic/cosmetic surgeon.

1. Board Certified Plastic Surgeon by the American Board of Plastic Surgery
The American Board of Plastic Surgery is the only certifying board in Plastic Surgery that is a member of the American Board of Medical Specialties. Use these links to look up a prospective surgeon’s status.

To become a plastic surgeon certified by the American Board of Plastic Surgery requires a minimum of five years of surgical training with a minimum of two years of training specifically in plastic surgery. Then the applicant must also pass a comprehensive written board exam. If successful, the candidate must present his/her clinical cases for critical review by board examiners (I was one such board examiner) and if accepted will take a series of oral examinations.

Since the 1990s, the American Board of Plastic Surgery Certification is only valid for ten years. To retain your board certified status, a plastic surgeon must complete a Maintenance of Certification including written testing and case review. This means that all who pass are trained and experienced in all plastic surgery procedures including facial procedures, breast, and body; essentially all cosmetic and reconstructive procedures.

If a Plastic Surgeon is additionally board certified by another surgical specialty recognized the American Board of Medical Specialties, then this also marks additional expertise and training at the highest level. The American Board of Facial Plastic Surgery (ABFRS) is not a licensing body nor an educational institution and the certificates it issues are not legal licenses to practice facial plastic and reconstructive surgery. The ABFRS is not recognized by the American Board of Medical Specialties (although it does note additional specialty training/interest in facial aesthetic surgery).

Likewise, beware of physicians armed only with certification from other non-ABMS recognized boards or special society memberships other than those I have recommended (eg. “Cosmetic Surgery Board,” “Lipoplasty Society of North America,” etc.).

2. Fellow of the American College of Surgeons: FACS
The American College of Surgeons is dedicated to improving the care of the patient and to safeguarding standards of care in an optimal and ethical practice environment. Members of the American College of Surgeons are referred to as “Fellows.” The letters FACS (Fellow, American College of Surgeons) after a surgeon’s name mean that the surgeon’s education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College.

To be a member you have to:

be board certified in a surgical specialty recognized by the American Board of Medical Specialties
be in practice in one location for a number of years, with a background check, nomination, and interviews which verify that you are an ethical and safe surgeon among other criteria.
Hint: Look for the “FACS” (or “FRCS,” see below) after the “MD” in a doctor’s title or in his/her Curriculum Vitae to see if he/she is a “real surgeon.”

Note for patients in Canada: The equivalent of FACS in Canada is the Royal College of Physicians and Surgeons of Canada, FRCS.

3. Member of the American Society of Plastic Surgeons (ASPS)
The American Society of Plastic Surgeons is the largest organization of plastic surgeons in the United States and one of the largest in the world. ASPS members are uniquely qualified because of the society’s membership requirements:

Members of the American Society of Plastic Surgeons must be Board Certified by The American Board of Plastic Surgery complete at least 5 years of surgical training with a minimum of 2 years of training specifically in plastic surgery. The more years of Plastic Surgical Training the better – this includes fellowships in a plastic surgical field.
American Society of Plastic Surgeons members are required to adhere to a strict code of ethics and must fulfill rigorous Continuing Medical Education (CME) requirements including patient safety issues.
Lastly, ASPS members are required to operate at accredited surgical facilities certified by one of the following USA organizations: American Association for Accreditation of Ambulatory Surgical Facilities, Inc., Accreditation Association for Ambulatory Health Care, Inc., or the Joint Commission on Accreditation of Health Care Organizations.
Beware of physicians without this membership but belonging only to similar-sounding societies as their claim to excellence eg. “American Society of Cosmetic Surgery,” “Lipoplasty Society of North America,” etc.

4. Member of the American Society for Aesthetic Plastic Surgery (ASAPS)
This is the most elite society in the United States and perhaps the world for Aesthetic Plastic Surgery. To be a member means that your career is focused in cosmetic surgery at the highest level. Among the requirements for invitation and election to ASAPS membership, a plastic surgeon must:

Be certified by the American Board of Plastic Surgery (or in plastic surgery by the Royal College of Physicians and Surgeons of Canada);
Be in at least the third year of active practice following board certification;
Participate in accredited Continuing Medical Education (CME) to stay current with developments in the field of cosmetic plastic surgery and patient safety;
Document the performance of a significant number and variety of cosmetic surgical cases to demonstrate wide experience;
Be sponsored by two ASAPS-member plastic surgeons to help ensure that the applicant’s professional reputation meets the high standards required by ASAPS;
Adhere to current ethical standards for professional conduct as outlined in the Code of Ethics observed by all ASAPS-member surgeons;
Operate in accredited surgical facilities; and
Be elected by at least 80% of the Active Membership.
Find an ASPS member online.

5. Hospital privileges to perform the same type of surgery
Hospitals often examine qualifications of doctors applying for hospital staff privileges and restrict privileges to only surgeons best trained and qualified to do certain procedures. For example, in order for surgeons to be granted plastic surgery privileges in most hospitals in Orange County, California, that surgeon must have completed plastic surgery residency training and must be board-eligible or -certified in plastic surgery to be allowed to perform plastic surgical operations in that hospital.

Non-surgeons and other physicians that are not plastic surgeons circumvent this process by performing surgery in their offices or in outpatient surgery centers where the credentialing process is less rigorous or nonexistent. In these settings non-plastic surgeons perform procedures in which they have no formal residency training.

I am not warning against use of outpatient surgery centers or in-office procedures. I am only recommending that you check that your physician has hospital privileges for these same procedures.

6. Surgical Experience in the procedure you are having
Few patients ask how long doctors have been doing a certain procedure or how many they have performed. When you consult with a plastic surgeon:

Ask to see typical “before and after” photos;
discuss the details of the procedure in a manner that is clear to you;
review benefits and potential complications;
get full answers to your questions.
7. Evidence of Excellence, Experience and Commitment to the field of Plastic Surgery
Here are some additional criteria to look for in your plastic surgeon.

Surgical Board Certification in more than one field
Plastic Surgical Fellowships in addition to Plastic Surgical Residency.
Number of years practicing.
Peer Review Honors in their own board certification from groups such as Best Doctors, Top Doctors, Super Doctors.
Current or Prior position denoting excellence in the field or high regard by their peers such as:
Prior or present Professor or Faculty affiliation with a University Plastic surgical program (the higher the rank the better)
Chairman of a Department of plastic surgery at a regional hospital
Honors from surgical societies of which they are members such as Board Examiner, etc.
Published Plastic Surgical papers in peer review journals are also a good sign that they are committed to being on top of their field.
Feel Comfortable with your choice
It is very important that after you have done this screening and met with your potential surgeon that you feel confident in your choice.

Complications are not common in cosmetic surgery, but if one did occur are you confident that this surgeon would take charge and handle just about any problem?

Do you feel that he listens to you and communicates well by answering your questions completely, doesn’t rush you in to a decision but rather makes you part of the decision-making process? You should truly feel that it is a combined effort.

Does the surgeon’s office run smoothly? Do the staff take good care of you? If you answered in the affirmative and have gotten this far in your screening guidelines then I think you have found your “Dr. Right.”

—Larry S. Nichter, MD, FACS