Doing Due Diligence (Certification)

Just how does one perform due diligence when selecting a cosmetic surgeon? Being an informed consumer seems more difficult than ever, given the bewildering display of high-profile disasters.

Michael Jackson, at the peak of his earning power and fame, repeatedly received very poor value for his surgical dollar. (And no, boys and girls, that's not a prosthesis; it's surgical tape on the tip of his nose.) If having more than enough money and unlimited access doesn't ensure a good outcome, what does?

The common online sentiment casts the ethical cosmetic surgeon as paternalistic gatekeeper. Most of the public expects these and all physicians to at a minimum abide by primum non nocere (not actually part of the Hippocratic Oath). It's safest to stick with caveat emptor: "let the buyer beware."

The most often hyped consumer advice is to choose a board certified surgeon. This is what Kanye West's dead mother did not do, having apparently evaluated her surgeon's credentials based an Oprah appearance.

For the prospective patient, board certification is the most readily accessible confirmation of a surgeon's training and experience. This is different than state licensure, ie, is the doctor behaving, which is confirmed here.

The vast majority of safe elective cosmetic surgery is performed by board certified plastic surgeons and otolaryngologist–head and neck surgeons. There is plenty of bad territorial ju-ju between the two specialties arising from intense competition for cash. It colors and distorts most of what is published about how-to-pick-a-surgeon. What makes these two kinds of cosmetic surgeons different from one another? There are two divergent training and certification pathways.

Here, along with the alphabet soup, is a set of cliff notes and links so you can be an informed consumer.

All physicians with M.D. after their name complete the basic 8 years post-high school education of undergraduate and medical school.

Cosmetic plastic surgeons go on to an additional 7+ years of training and certification in:

• General Surgery Residency - 5 years
• Plastic Surgery Residency - 2 years (some combined programs are 3 years of each)
• ABPS board written and oral examination in Plastic Surgery

If passed, the surgeon (and about 6,600 others) now has a ABPS-recognized specialty certificate in plastic surgery and joins the member society ASPS.

• optional Fellowship - 1 year
  
• ABPS board subspecialty examination (Plastic Surgery Within the Head and Neck)

This surgeon will continue to identify him/herself as a plastic surgeon or cosmetic plastic surgeon. More societies will be joined: ASAPS. These specialty societies are the sources of the yearly continuing education of the surgeon.

Cosmetic otolaryngologist–head and neck surgeons go this direction for 5+ years:

• General Surgery residency - 1 year
• Otolaryngology - Head & Neck residency - 4 years
• ABOto board written and oral examination in Otolaryngology - Head & Neck Surgery
  

If passed, the surgeon (and about 12,000 others) now has a ABOto-recognized specialty certificate in Otolaryngology and joins the member society AAO-HNS for continuing education in the field.

• optional Fellowship - 1 year
  
• ABOto board subspecialty examination (Plastic Surgery Within the Head and Neck) or the ABFPRS subspecialty exam

This fellowship-trained surgeon will now refer to him/herself as a facial plastic surgeon. More societies will be joined: AAFPRS. More continuing education.

The American Board of Medical Specialties (ABMS) is the major examining organization whose Member Boards (of which the ABPS and ABOto are two) certify physicians in more than 130 specialties and subspecialties. For a chart listing the current certificates offered by ABMS Member Boards, go here. (There are other, overlapping certification organizations as well.)

These board certification exams are probably the most difficult, stressful part of the not-so-young physicians training experience. The written boards are all-day specialty-specific computer-based examinations (completing the more general knowledge exams taken at the end of the first residency year). If passed, an excruciating oral examination takes place where senior physician examiners interrogate the candidate and pass judgment on the ethical and technical aspects of his/her practice.

Subspecialty certification is not required in order to practice cosmetic surgery. It's important to physicians preparing to practice because it is a recognition of exceptional expertise and experience specifically in that field.

What's important for the consumer is that board certification under the ABMS umbrella brings with it an requirement for continuing education and re-testing every 10 years. That makes these surgeons a safer bet for you and me.



Like the Music We Played On-Air?

Fatal Attraction (Death)

When and why does cosmetic surgery prove fatal? Rapper Kanye West's mother arrived in the emergency room DOA Saturday night, subsequent to undergoing an outpatient abdominoplasty (tummy tuck) and breast reduction on Friday. Of course the American Society of Plastic Surgeons (ASPS) has immediately issued press releases to say how rare this is– they don't actually keep statistics on all who die during or as a result of undergoing elective aesthetic surgery– but who wants to die?

Is it always the doctor's fault? Yes and no. Many variables are outside the control of the surgeon– from anesthesia to the vagaries of healing to patient non-compliance. In general, though, there is one personal variable that has tripped up the established, credentialed plastic surgeon more than any other. That liability is his own ego. Operating on a patient who shouldn't be operated on, deluding oneself about one's surgical omnipotence, can lead to disaster. Sometimes this is compounded by poor judgment and/or skill set.

That may indeed be the case with this death.

The surgeon, Dr. Jan Adams (53), has two previous malpractice suits under his surgical scrubs and three more in gestation (one of which also involves a co-morbidity: diabetes). Shown here in his booking photo, his most recent convictions for DUI in March and April of 2006 led the California Medical Board to consider suspending his license (it's pending with the State). Of the 60 ASPS board certified plastic surgeons listing Beverly Hills as their venue, Adams isn't one of them. When it comes to checking out a physician, Google is your friend.

Dr. Jan Adams considers himself a top plastic surgeon in Beverly Hills, despite his lack of board credentials. He authored Everything Women of Color Should Know About Cosmetic Surgery. He hosted Discovery Health's Plastic Surgery: Before and After show and has been featured pretty much everywhere on the talk circuit. Check out the OprahAftertheShow chat. He's a showman. Is he the most articulate spokesman for plastic surgery? Nope. Was his handiwork on display lovely? Nope. But he is a rare commodity: a black surgeon marketing to women of color.

Donda West (58) also consulted with another Beverly Hills surgeon, Dr. Andre Aboolian. This board certified plastic surgeon insisted on a preoperative clearance from an internist because of an underlying condition. "I always insist on a medical clearance for women over 40, and in this instance, it was particularly important because of a condition she had I felt could have led to a heart attack."

The operating surgeon's response? Adams claims that he did nothing wrong and shared his opinion of his colleague Dr. Aboolian: “[h]e is sleazy and manipulating the truth to elevate his own importance.” That's not generally anything a reputable plastic surgeon would publicly say.

Using a board-certified surgeon at an accredited facility and operating on a healthy person with medical clearance is the prudent route. It isn't possible eliminate all risks in elective aesthetic surgery, but it can really reduce them by not doing too many procedures at one time and by screening for medical conditions beforehand.

Dr. Aboolian didn't specify the underlying morbidity due to patient confidentiality, but the autopsy results will be out in 6-8 weeks. It could very well be that Donda West had an abnormal heartbeat. Arrhythmias (irregular heart rhythms) can result from coronary artery disease, but also occur in normal, healthy hearts particularly as we age. Many don't require any treatment at all, but do pose an additional risk when having surgery. Electrolyte imbalances in the blood (such as low sodium or potassium) brought on by excessive postoperative vomiting can precipitate a heart attack.

Is it safe? The real question to ask is how to make it safer, relative to the risks of any surgery. Once you, the prospective patient, have done your due diligence and selected a physician, here is what you can and should do to protect yourself:

• Don't lie to your surgeon. Devulge everything, everything, truthfully: the smoking, the drugs, the OTC, the supplements, that "baby heart attack" you had 10 years ago....it really does make a difference.

• Involve the primary care physician who knows you top to bottom by getting him/her to medically clear you for surgery. Elective aesthetic surgery should carry the same standard of clinical medicine as any other surgery: it's not fluffy spa medicine.

• Stick with 6 hours or less of anesthesia; you can always come back for more.

• And last, but not least, know how to reach your surgeon that first night. You want– and s/he will give you– all the secret numbers, so you can phone about anything untoward. Before you crash, call your surgeon. Really. Wake them up! Your surgeon wants you to live.