Do This Don’t Do That, Can’t You Read the Signs

The “right” treatment isn’t surgical or nonsurgical: It’s the one that is best for your patients, meets their expectations and provides longevity.

Those were the words of an oldie but goodie song originally done by the Five Man Electrical Band in the 70’s. In a way, it applies to cosmetic treatments among various specialties. You look at their marketing and the sign says, “Get rid of your double chin.”

If everyone is honest and fair, puts their ego and profit aside, they would agree that there are numerous specialties that do numerous surgical and nonsurgical treatments in aesthetics. Unfortunately, a lot of professional bickering and jealousy still goes on, especially for those doctors with antiquated thoughts and their heads in the sand. The truth is that a plethora of cosmetic treatments are available for the average patient from their primary care doctor, their dermatologist, their maxillofacial surgeon, facial plastic surgeon and otolaryngologist, ophthalmologist/oculoplastic doc and plastic surgeon to name a few. This also extends to RNs, general dentists, medspas and even health clubs. The bottom line is there is no shortage of providers for cosmetic procedures, especially the nonsurgical variety.

This can be very confusing for patients and even confusing to a certain extent to professionals. Contemporary cosmetic procedures involve many surgical and nonsurgical treatments from a variety of specialties. So, if a patient has some fullness, do they get Kybella from their derm, Coolsculpting from their local medspa, lipo or submentoplasty or facelift from their surgical specialist? That is the question. The answer is somewhat harder.

We all have something to offer. I personally feel that the biggest advances I have seen in my three-decade surgical experience have been mostly nonsurgical. In the mid 1990s a whole lot of stuff happened at once. This period ushered in neurotoxins, fillers, liposuction, laser technology, tumescent liposuction, endoscopic surgery and other advances. It was a beautiful time for progress, but a somewhat slippery slope for treatment as much of what we regard as “standard” today was hashed out by trial and error in the 1990s. When I purchased my first CO2 laser then, there was no “instruction manual” and the evidence-based literature was in its infancy. The settings that many providers take for granted today were hashed out by pioneers and often fraught with overtreatment and lawsuits.

Although some of this will always occur with new technology, I feel that today’s providers are on much more solid ground with treatment protocols.

Back to my initial question, what is the correct treatment for the patient that walks in with submental fullness? Well, it is provider driven. Let’s start with the least invasive. In my hometown, there are many places where one can receive treatment with various devices for skin tightening, fat freezing or fat melting. If they have a relationship with an office that does these procedures, they may think that this is the precipice of treatment. These treatments, for the most part, do something, but are usually limited to conservative cases with minimal skin excess. The next step up may be Kybella or similar mesotherapy injections, which are pretty noninvasive. Again, they have their place but usually don’t produce earth-shaking results and do nothing for skin excess. Thread lifts are a little more invasive but don’t have a great track record for longevity. I mean no ill press to those providers who offer this, but it seems to come in and out of vogue every decade. Perhaps the technology will continually improve. Finally, the patient could find themselves in a surgical office and may opt for liposuction, chin implant, submentoplasty or facelift. Yep, it is surgery, I admit it. But I also think it remains the gold standard for most advanced aging problems. Yes, I am a facial surgeon — full disclosure!

I recently saw a news clip form a major Derm meeting in Hawaii and the author of the article is a friend. However, she said something like “surgery is out, no one does that anymore.” Well, I beg to differ as I performed 109 facelifts last year.

So what procedure should a patient undergo and whom should they see? The honest answer is, “Every one [with relevant training] is right and you should do the procedure that best fits your budget, recovery, lifestyle and desires.” Sometimes this is difficult due to misinformation from nonsurgical providers overhyping the results and longevity of a given procedure or a surgeon prematurely operating on a patient that may benefit from less invasive treatment.

Ethically, all providers are charged with three main things: Patient safety, predictable outcomes and honesty. I have seen numerous patients that had significant neck skin excess waste thousands of dollars on skin tightening devices, thread lifting and other undertreatments. Over the years, I have seen many patients for a facelift consult that did not desire surgery and opted out, only to see them two years later after they spent more than the facelift would have cost on devices and therapies that were ineffective. I have also seen patients from other offices that had minimal aging and were way overtreated with surgeries, so it happens on both sides of the non-invasive/surgery coin.

Our job, our charge, our goal is to do what is right for the patient. It takes an ethical doctor to tell patient that they could undergo a given procedure, but it just won’t meet the patient’s expectations or provide longevity. It is hard (especially for younger doctors) to turn away a patient, an aging problem and a check book, but it is ethically imperative. For every surgical patient I evaluate, I ask myself “would I do this procedure on a family member?” That credo has severed me well for decades. There have been hundreds of patients over my career that I told that they were not ready for a facelift and that they should see a colleague for a less invasive procedure. It all comes back to you in the end as our reputation is our only brand. Do what is right, do what is best for the patient regardless of economics and you will be respected and appreciated.

When I look around at the most successful practitioners I know from all specialties, they have some common denominators: They are joyous, they love their profession, they care deeply about their patients and they are always honest with their patients.

Joe Niamtu, III, D.M.D., is an internationally recognized cosmetic facial surgeon practicing in Richmond Virginia.
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