Discussion Discussion: Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Christopher R. Davis, M.R.C.S. Lorne K. Rosenfield, M.D. Stanford, Calif.

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old standard aesthetic surgery practice in the United States includes board certification by the American Board of Plastic Surgery, completion of a dedicated aesthetic surgery fellowship, continuing medical education of aesthetic advances, self-audit, and research publication. Plastic surgical training is stringent, extensive, and thorough to create expert clinicians performing evidence-based surgery to optimize outcomes and maximize safety. Unfortunately, not all aesthetic surgery providers meet gold standard requirements. Government legislation and regulation lag behind the rapidly expanding aesthetic surgery industry, where complex procedures may be commercially trivialized and inappropriately performed by inadequately trained non–plastic surgeons practicing below the proposed gold standard level of excellence. In their article, Drs. Barr, Sinno, Cimino, and Saadeh from New York University Medical Center have produced a formidable national review of aesthetic surgery practice by exploring surgeon certification with the American Board of Plastic Surgery.1 After screening 7500 Web sites, 3077 practitioners performing aesthetic surgery were identified, of which 2396 (77.9 percent) were American Board of Plastic Surgery–certified plastic surgeons. Alarmingly, 681 individuals (22.1 percent) performing aesthetic surgery were not board-certified plastic surgeons, with most surgeons from other specialities operating outside their anatomical area of training. By highlighting the “wandering scalpel” of non–plastic surgeons, a buyer-beware market exists with heterogeneous surgical quality. Aesthetic procedures performed by non–plastic surgeons, such as primary care From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University. Received for publication August 22, 2014; accepted August 27, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000819

physicians or dentists, contribute to the misunderstanding within popular culture of surgical risk and exemplify the ostensible “benignity” of a procedure. Patients may feel that an aesthetic procedure conducted at a primary care practice, for example, is a less significant health event than consulting a surgeon. Dangerous reassurance in a pseudo-safe environment is inappropriate if patients are unaware of the full extent of risks, complications, and surgeon training. The accompanying article represents a “bestcase scenario” of aesthetic surgery practice, given the authors’ generous inclusion criteria of operating capacity for non–plastic surgeons.1 Defining specialty scope is controversial, but applying Accreditation Council for Graduate Medical Education guidelines and American Board of Medical Specialties recognized training is an admirable attempt to establish evidence-based standards for defining “out-of-scope” practice. Furthermore, their perceptive search strategy cleverly generated data from a patient perspective looking for a local aesthetic surgeon. Encouragingly, the majority of surgeons identified were American Board of Plastic Surgery–certified plastic surgeons. However, 22.1 percent were not plastic surgeons, despite use of terms explicitly searching for a surgeon. The true percentage may be greater because of non–board-certified practitioners with low search engine optimization outside the Google search results, or patients succumbing to the seemingly luxurious and falsely cost-effective combination of travel and surgery embarking on a “one-way ticket to surgical complications.”2 Who is best positioned to perform safe and high-quality aesthetic surgery? Barr et al. quantify an alarming proportion of aesthetic surgery performed by non–plastic surgeons [n = 681 (22.1 Disclosure: The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article.

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Plastic and Reconstructive Surgery • January 2015 percent)], nonsurgeons [n = 174 (5.7 percent)], or nonclinicians [n = 1 (

Discussion: clinicians performing cosmetic surgery in the community: a nationwide analysis of physician certification.

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