Volume 136, Number 2 • Letters for surgery; however, for those committed to multiple stages, it certainly may make more sense. An interesting aspect of the article by Jandali et al. is that they select patients with a body mass index less than 30 to reduce complications. Despite this, they still have a 33 percent T-point delayed healing rate, which they state is in all active smokers. Patient selection is obviously important in all plastic surgery populations. To optimize results, the authors should have stated in their Discussion that they will no longer operate on active smokers. We will continue to work on modified techniques to optimize results for all patients that present for thighplasty. DOI: 10.1097/PRS.0000000000001420
Jeffrey Gusenoff, M.D.
Department of Plastic Surgery University of Pittsburgh 3380 Boulevard of the Allies, Suite 180 Pittsburgh, Pa. 15213
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCE 1. Jandali Z, Loh CY, Athanassopoulos T, Müller K. An improved dual approach to post bariatric contouring: Staged liposuction and modified medial thigh lift. A case series. Indian J Plast Surg. 2014;47:232–235.
Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Sir:
W
e read with great interest the Special Topic article entitled “Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification.”1 We agree with the authors’ assertion about nonphysicians and the impact they are having in the marketplace in terms of patient safety. The American Society for Dermatologic Surgery Consumer Survey on Cosmetic Dermatologic Procedures revealed that the specialty in which the physician is board certified ranks as number one (of 11 factors) in a consumer’s selection of a practitioner. A 2013 American Society for Dermatologic Surgery Association Truth in Medical Advertising Survey revealed that 99 percent of respondents want to know what type of practitioner is performing their cosmetic medical procedure, and 95 percent want to know the board certification of their physicians. Clearly, the public is as concerned about this issue as we are. Instead of taking to task American Board of Medical Specialties board-certified physicians, who the authors acknowledge have received Accreditation Council for Graduate Medical Education–recognized
training encompassing cosmetic procedures, this study should have focused on nonmedical and non–Core Four practitioners offering cosmetic treatments and the significant patient safety issues involved. Instead, this study purported to analyze the extent of practitioners performing “cosmetic surgery” who are not board certified by the American Board of Plastic Surgery. Using the top 50 Google results for search terms for the analysis skews the results to Web pages with strong search engine optimization and is not representative of each state’s practitioners. The search terms sometimes return millions of results for one state. It also did not make sense to search for the non–Accreditation Council for Graduate Medical Education–recognized terms of “cosmetic surgery” and “aesthetic surgery,” as they are used in an inconsistent manner in the medical and nonmedical communities. We disagree with the statement that dermatologists were considered to be practicing out of scope if they were performing “elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures.” Boardcertified dermatologists, along with facial plastic surgeons and oculoplastic surgeons, are recognized as part of the Core Four specialties that are—like plastic surgery—involved in the science, practice, and teaching of aesthetic surgery. In 2013, American Society for Dermatologic Surgery members performed 6.5 million cosmetic surgical procedures, including injectables, tumescent liposuction, vein treatments, hair transplants, and more. According to Accreditation Council for Graduate Medical Education guidelines, dermatology residents must receive instruction in and demonstrate knowledge of liposuction, scar revision, laser resurfacing, hair transplants, and invasive vein therapies in addition to botulinum toxin injections and soft-tissue augmentation. Also, under Accreditation Council for Graduate Medical Education guidelines, procedural dermatology fellows receive added instruction and experience in fillers, tumescent liposuction, fat transplantation, hair replacement surgery, skin resurfacing and tightening, and cosmetic laser procedures. On consumer-facing Web sites, board-certified dermatologists appropriately call their work “cosmetic surgery” or “aesthetic surgery.” We have not seen dermatologists “marketing themselves as plastic surgeons” and neither has your study. We encourage the American Society of Plastic Surgeons to join with American Society for Dermatologic Surgery to promote truthin-advertising legislation about American Board of Medical Specialties board certification to inform and protect the public. DOI: 10.1097/PRS.0000000000001451
George J. Hruza, M.D., M.B.A.
President, American Society for Dermatologic Surgery Laser & Dermatologic Surgery Center 1001 Chesterfield Parkway East, Suite 101 Chesterfield, Mo. 63017 [email protected]
275e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • August 2015 disclosure The author has no financial interest to declare in relation to the content of this communication. reference 1. Barr JS, Sinno S, Cimino M, Saadeh PB. Clinicians performing cosmetic surgery in the community: A nationwide analysis of physician certification. Plast Reconstr Surg. 2015;135:92e–98e.
Reply: Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Sir:
We appreciate your response to our article1 and believe that ultimately we are very much on the same page, particularly with our colleagues in dermatology who made up only 0.02 percent of the clinicians who met search criteria. By definition, this is because the vast majority of online dermatologists who offer cosmetic treatments do not include the keyword “surgery” on their Web sites, precluding them from inclusion in our search results. Overwhelmingly, dermatologists have chosen not to ascribe a surgical aura to their aesthetic practices. Moreover, your observation, that we “acknow ledge[d] [physicians who] have received Accreditation Council for Graduate Medical Education–recognized training encompassing cosmetic procedures,” is somewhat off point and incomplete. We simply compared online offerings to the practitioner’s residency training requirements outlined by the Accreditation Council for Graduate Medical Education “for a respective residency” and, generously, “or additional fellowship training in a specific area [emphasis added].” We also did not purport “to analyze the extent of practitioners performing ‘cosmetic surgery’ who are not board certified by the American Board of Plastic Surgery” (see prior sentence). We agree with your point regarding the potential inaccuracies of Internet searches, which is why we stated, “First and foremost, the search results of Internet queries may not accurately represent the true proportions or practices of surgeons treating patients in the community.” With respect to dermatology, we stated, “Dermatologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures.” Perhaps it is an error of surgical chauvinism on our part, but many would consider “scar revision,” “liposuction, fat transplantation, [and] hair replacement surgery” on the spectrum of minimally invasive procedures; the other procedures you cite defined the remainder of the scope of practice for dermatology. We literally are on the same page as you when it comes to dermatology.
And perhaps more lax overall, “The purpose of labeling these surgeons as practicing out of scope is not to ostracize or question technical skills or training. Instead, the point is to demonstrate the unregulated manner in which cosmetic surgery is being performed across the country.” Interestingly you state, “It also did not make sense to search for the non–Accreditation Council for Graduate Medical Education recognized terms of ‘cosmetic surgery’ and ‘aesthetic surgery’ as they are used in an inconsistent manner in the medical and nonmedical communities [our highlights].” You then end with the somewhat contradictory, “On consumer-facing Web sites, board-certified dermatologists appropriately call their work ‘cosmetic surgery’ or ‘aesthetic surgery’ [our highlights].” We suppose this is the crux of the issue. Although we wholeheartedly embrace the American Society for Dermatologic Surgery Association Truth in Medical Advertising effort and admire Dr. Ashley A. Smith’s work,2 the problem is that whereas “99 percent of [survey] respondents want to know what type of practitioner is performing their cosmetic medical procedure, and 95 percent want to know the board certification of their physicians,” we suspect that a great many do not know what that information means, which we believe is an inescapable conclusion of our study. DOI: 10.1097/PRS.0000000000001423
Jason S. Barr, M.D. Sammy Sinno, M.D. Pierre B. Saadeh, M.D. Institute of Reconstructive Plastic Surgery Department of Plastic and Reconstructive Surgery New York University Medical Center New York, N.Y. Correspondence to Dr. Barr Institute of Reconstructive Plastic Surgery New York University 305 East 33rd Street New York, N.Y. 10016 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Barr JS, Sinno S, Cimino M, Saadeh PB. Clinicians performing cosmetic surgery in the community: A nationwide analysis of physician certification. Plast Reconstr Surg. 2015;135:92e–98e. 2. Bryn Mawr Communications. Practical Dermatology (Web site). ASDSA names 2014 patient safety hero award winners. Available at: http://practicaldermatology.com/2015/01/27/ asdsa-names-2014-patient-safety-hero-award- winners. Accessed February 6, 2015.
276e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Jeffrey Gusenoff, M.D.
Department of Plastic Surgery University of Pittsburgh 3380 Boulevard of the Allies, Suite 180 Pittsburgh, Pa. 15213
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCE 1. Jandali Z, Loh CY, Athanassopoulos T, Müller K. An improved dual approach to post bariatric contouring: Staged liposuction and modified medial thigh lift. A case series. Indian J Plast Surg. 2014;47:232–235.
Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Sir:
W
e read with great interest the Special Topic article entitled “Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification.”1 We agree with the authors’ assertion about nonphysicians and the impact they are having in the marketplace in terms of patient safety. The American Society for Dermatologic Surgery Consumer Survey on Cosmetic Dermatologic Procedures revealed that the specialty in which the physician is board certified ranks as number one (of 11 factors) in a consumer’s selection of a practitioner. A 2013 American Society for Dermatologic Surgery Association Truth in Medical Advertising Survey revealed that 99 percent of respondents want to know what type of practitioner is performing their cosmetic medical procedure, and 95 percent want to know the board certification of their physicians. Clearly, the public is as concerned about this issue as we are. Instead of taking to task American Board of Medical Specialties board-certified physicians, who the authors acknowledge have received Accreditation Council for Graduate Medical Education–recognized
training encompassing cosmetic procedures, this study should have focused on nonmedical and non–Core Four practitioners offering cosmetic treatments and the significant patient safety issues involved. Instead, this study purported to analyze the extent of practitioners performing “cosmetic surgery” who are not board certified by the American Board of Plastic Surgery. Using the top 50 Google results for search terms for the analysis skews the results to Web pages with strong search engine optimization and is not representative of each state’s practitioners. The search terms sometimes return millions of results for one state. It also did not make sense to search for the non–Accreditation Council for Graduate Medical Education–recognized terms of “cosmetic surgery” and “aesthetic surgery,” as they are used in an inconsistent manner in the medical and nonmedical communities. We disagree with the statement that dermatologists were considered to be practicing out of scope if they were performing “elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures.” Boardcertified dermatologists, along with facial plastic surgeons and oculoplastic surgeons, are recognized as part of the Core Four specialties that are—like plastic surgery—involved in the science, practice, and teaching of aesthetic surgery. In 2013, American Society for Dermatologic Surgery members performed 6.5 million cosmetic surgical procedures, including injectables, tumescent liposuction, vein treatments, hair transplants, and more. According to Accreditation Council for Graduate Medical Education guidelines, dermatology residents must receive instruction in and demonstrate knowledge of liposuction, scar revision, laser resurfacing, hair transplants, and invasive vein therapies in addition to botulinum toxin injections and soft-tissue augmentation. Also, under Accreditation Council for Graduate Medical Education guidelines, procedural dermatology fellows receive added instruction and experience in fillers, tumescent liposuction, fat transplantation, hair replacement surgery, skin resurfacing and tightening, and cosmetic laser procedures. On consumer-facing Web sites, board-certified dermatologists appropriately call their work “cosmetic surgery” or “aesthetic surgery.” We have not seen dermatologists “marketing themselves as plastic surgeons” and neither has your study. We encourage the American Society of Plastic Surgeons to join with American Society for Dermatologic Surgery to promote truthin-advertising legislation about American Board of Medical Specialties board certification to inform and protect the public. DOI: 10.1097/PRS.0000000000001451
George J. Hruza, M.D., M.B.A.
President, American Society for Dermatologic Surgery Laser & Dermatologic Surgery Center 1001 Chesterfield Parkway East, Suite 101 Chesterfield, Mo. 63017 [email protected]
275e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • August 2015 disclosure The author has no financial interest to declare in relation to the content of this communication. reference 1. Barr JS, Sinno S, Cimino M, Saadeh PB. Clinicians performing cosmetic surgery in the community: A nationwide analysis of physician certification. Plast Reconstr Surg. 2015;135:92e–98e.
Reply: Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Sir:
We appreciate your response to our article1 and believe that ultimately we are very much on the same page, particularly with our colleagues in dermatology who made up only 0.02 percent of the clinicians who met search criteria. By definition, this is because the vast majority of online dermatologists who offer cosmetic treatments do not include the keyword “surgery” on their Web sites, precluding them from inclusion in our search results. Overwhelmingly, dermatologists have chosen not to ascribe a surgical aura to their aesthetic practices. Moreover, your observation, that we “acknow ledge[d] [physicians who] have received Accreditation Council for Graduate Medical Education–recognized training encompassing cosmetic procedures,” is somewhat off point and incomplete. We simply compared online offerings to the practitioner’s residency training requirements outlined by the Accreditation Council for Graduate Medical Education “for a respective residency” and, generously, “or additional fellowship training in a specific area [emphasis added].” We also did not purport “to analyze the extent of practitioners performing ‘cosmetic surgery’ who are not board certified by the American Board of Plastic Surgery” (see prior sentence). We agree with your point regarding the potential inaccuracies of Internet searches, which is why we stated, “First and foremost, the search results of Internet queries may not accurately represent the true proportions or practices of surgeons treating patients in the community.” With respect to dermatology, we stated, “Dermatologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures.” Perhaps it is an error of surgical chauvinism on our part, but many would consider “scar revision,” “liposuction, fat transplantation, [and] hair replacement surgery” on the spectrum of minimally invasive procedures; the other procedures you cite defined the remainder of the scope of practice for dermatology. We literally are on the same page as you when it comes to dermatology.
And perhaps more lax overall, “The purpose of labeling these surgeons as practicing out of scope is not to ostracize or question technical skills or training. Instead, the point is to demonstrate the unregulated manner in which cosmetic surgery is being performed across the country.” Interestingly you state, “It also did not make sense to search for the non–Accreditation Council for Graduate Medical Education recognized terms of ‘cosmetic surgery’ and ‘aesthetic surgery’ as they are used in an inconsistent manner in the medical and nonmedical communities [our highlights].” You then end with the somewhat contradictory, “On consumer-facing Web sites, board-certified dermatologists appropriately call their work ‘cosmetic surgery’ or ‘aesthetic surgery’ [our highlights].” We suppose this is the crux of the issue. Although we wholeheartedly embrace the American Society for Dermatologic Surgery Association Truth in Medical Advertising effort and admire Dr. Ashley A. Smith’s work,2 the problem is that whereas “99 percent of [survey] respondents want to know what type of practitioner is performing their cosmetic medical procedure, and 95 percent want to know the board certification of their physicians,” we suspect that a great many do not know what that information means, which we believe is an inescapable conclusion of our study. DOI: 10.1097/PRS.0000000000001423
Jason S. Barr, M.D. Sammy Sinno, M.D. Pierre B. Saadeh, M.D. Institute of Reconstructive Plastic Surgery Department of Plastic and Reconstructive Surgery New York University Medical Center New York, N.Y. Correspondence to Dr. Barr Institute of Reconstructive Plastic Surgery New York University 305 East 33rd Street New York, N.Y. 10016 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Barr JS, Sinno S, Cimino M, Saadeh PB. Clinicians performing cosmetic surgery in the community: A nationwide analysis of physician certification. Plast Reconstr Surg. 2015;135:92e–98e. 2. Bryn Mawr Communications. Practical Dermatology (Web site). ASDSA names 2014 patient safety hero award winners. Available at: http://practicaldermatology.com/2015/01/27/ asdsa-names-2014-patient-safety-hero-award- winners. Accessed February 6, 2015.
276e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
