What does it mean when a PA says a surgeon is mostly cosmetic?

Question

I was referred to an ENT/Facial Resconstructive surgeon by my local ENT doctor for revision rhinoplasty which would include aesthetic as well as functional corrections. This would be a revision from a cosmetic revision rhinoplasty that did not go well over 20 years ago. Unfortunately, my insurance changed so I was no longer able to see that particular reconstructive surgeon but I asked if she was familiar with two other surgeons that I had researched on my own. One is in private practice and a facial plastic surgeon. The other is the head of a plastic surgery department at a major hospital and is board certified for full body from ABPS. Both are ENT's also. The PA responded and said that both are great but the one is private practice is 'mostly cosmetic'. Was this PA subtly trying to tell me that this other surgeon would not be able to fix my functional problems with my nose? What is the ettiiquete around doctors recommended other doctors? Are they only allowed to promote doctors within their own hospital groups or networks?

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Revision rhinoplasty is extremely complex. You should really only go to an expert. Here is some general advice when selecting a surgeon.

I highly recommend that my patients focus much more on real longterm before and after photographs rather than 3D imaging.   I encounter so many patients in my practice who see me for revision rhinoplasty who previously had surgery elsewhere who feel like they were mislead into surgery by surgeons who relied heavily on 3D imaging without adequate real before and after pictures to back it up.  Photoshop is easy but real surgery is very different.

I always recommend that you carefully evaluate your surgeon’s online before and after gallery on their website for both quality and quantity of results. Make sure that there are hundreds of real before and after pictures which demonstrate long-term follow up results with standardized lighting and standardized background. If your surgeon is posting mostly on-table results without real long-term follow up results, that is usually a major red flag.  If a surgeon is posting mostly just splint removal day videos without longterm follow-up pictures, or all patient selfie’s without real longterm in-office formal pictures that can also be a red flag.   Long-term results are much more meaningful than on table results or 1 week post-op results. Selfie’s can also be fun to look at, but these can often have a filter and do not represent true longterm results because of this and are not as valuable as real longterm in-office before and after photographs on your surgeon’s website with standardized lighting and standardized backgrounds.

Make sure you are going to a surgeon with hundreds of long-term before and after pictures on their website with standardized lighting and standardized backgrounds. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D. FACS
Harvard-trained board certified plastic surgeon

Randal Haworth, MD, FACS · Answer

I can't speak for what the PA meant, but "mostly cosmetic" usually describes the mix of a surgeon's practice rather than ability. A facial plastic surgeon trained in otolaryngology has been trained in the nasal airway; the more useful question is how often that surgeon repairs breathing problems in a nose that has already been operated on, sometimes more than once. After prior revisions and more than 20 years, the septum may have little usable cartilage left, so ear or rib grafts, internal valve support, and turbinate work may all be part of the discussion. Ask each surgeon directly how many functional revisions they do, how they assess your airway, and to see revision results that address both breathing and appearance. Referrals often follow hospital networks and insurance relationships rather than a ranking of skill, so I would not read too much into one comment. Consulting both surgeons in person is the most reliable way to decide.

What does it mean when a PA says a surgeon is mostly cosmetic?

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