A call for plastic surgeons to protect clinical judgment, patient-centered care, and surgical craft as trends, technology, and volume increasingly shape the specialty.
By Scott R. Miller, MD, FACS
By any measure, a rhinoplasty patient I operated on when she was 16 had a beautiful result: a refined bulbous tip, a smoothed out dorsal hump—a nose no one would ever guess had been touched. That was not just my assessment but also that of all those close to her, including her mother, sister, and best friend. Nearly a decade later, in the middle of the COVID lockdowns, she was in New York with nothing to do but scroll Instagram. An overly operated-on influencer pointed her toward a doctor who was, rather tellingly, still operating in March 2020, when most cosmetic surgery practices in the city had shut down by law. She brought in a photo of a nose she liked. And he gave it to her.
What she unfortunately did not understand was that a dramatic, over-styled, over-filtered photo and a living, breathing, animated face are not the same thing. The result was a nose so upturned you could see into her nostrils as you stood in front of her, and she is not tall! The columella was flattened, with no natural curve left. But there was too much curve on the dorsum.
She came back to me distraught. We waited for the tissue to settle, bridged the worst of it with filler, and eventually took her through a long, complicated revision to get her back to something proportional. Unfortunately, she learned the hard way that cosmetic plastic surgery is not “cut & paste.” And body parts, unlike evening makeup, need to work for all seasons and all aspects of life.
This case has stayed with me over the years. Not because the surgery was hard, but because it was so avoidable. It’s what happens when a trend or AI-enhanced photo drives the decision instead of reflection, perspective, balance, and judgment. It’s sadly becoming the norm rather than the exception in our field.
What’s Driving Commodification
What we’re seeing now is productivity pursued at the expense of judgment. Some of it starts with the companies developing our tools. A device gets built for one indication, underperforms, and gets repositioned around whatever secondary benefit shows up in use. Often the easiest customer is the med spa, where patient expectations run lower than those in a surgical practice and fewer questions get asked. Marketing creates demand, patients arrive asking for a treatment by name, and providers feel compelled to adopt it to stay competitive rather than because it solves a real problem.
But here’s what so many are forgetting to ask nowadays: what problem does this actually solve, and does it solve it better than what I’m already doing?
A few years ago, “tissue glues” resurfaced as a plastic surgery product. This was chemistry we’d studied decades earlier as residents, now repackaged to help flaps adhere in tummy tucks. Some patients had allergic reactions to it. The problem it was solving — tissue adherence, avoiding the need for drains — already had a better answer: progressive tension sutures, a technique developed by a group of surgeons in Dallas. It was the same outcome, achieved by technique and skill instead of a product purchase. That’s not meant to be an argument against innovation. Tranexamic acid, used topically and as a tissue infiltrate, has meaningfully reduced blood loss in our procedures (as well as subsequent cauterization and the resultant inflammation), and that is a genuine advance. But we need to question whether an innovation solves a real problem or just manufactures a market.
Why Plastic Surgery Is Uniquely Exposed
Cardiologists own the heart. Neurosurgeons own the brain. But plastic surgery owns nothing. We creatively operate everywhere on the body, but we claim no territory as exclusively ours.
That’s the most enticing thing about this field, and at the same time, the trickiest.
Often when our specialty innovates a new technique, the specialties anchored to that anatomy eventually absorb it. That’s the nature of a specialty defined by a way of thinking rather than a body part, and it’s why we have less room for error than specialties with anatomical ownership.
If our judgment as plastic surgeons is commoditized, there’s nothing left.
Judgment isn’t a value-add to this specialty; it is the hallmark of our specialty.
It’s worth noting that Joseph Murray, who performed the first successful kidney transplant and later received the Nobel Prize for his work in transplantation, was a craniofacial plastic surgeon. Murray’s work demonstrated how the principles and problem-solving approach of plastic surgery could be applied far outside the specialty’s usual territory—an idea David Furnas, MD, explored in his book, The Principalization of Plastic Surgery.
What Low-Volume, High-Quality Looks Like
I’m not advocating for “going analog” for the sake of pure nostalgia, but for my practice, low-volume, high-quality is a deliberate operating model. It is one that I believe more surgeons in our field should consider. In my book, Authentic Beauty: Defining a New Standard for Care and Results in Plastic Surgery, I contrast the commercial HVLP (High Volume, Low Price) retail mindset with a patient-centered LVHQ (Low Volume, High Quality) paradigm. Where the former operates like a factory conveyor belt prioritizing speed, the latter protects the surgeon’s ‘flow state’ and meticulous clinical judgment. Here are a few examples of what this looks like in practice:
- Simplicity over the newest tool. For example, various sutures have worked for as long as we’ve closed wounds. An experienced surgeon doesn’t need a skin-closure device that saves half a second and adds a risk of tissue reaction. The same applies outside of the OR. I recently watched a physician spend an entire encounter typing into a screen rather than looking the patient in the eye. If keeping my full attention on the patient means jotting down my notes later, or dictating in front of them for repetition and confirmation, that’s a trade worth making.
- Pertinent information and curated judgment over exhaustive generic documentation. I recently needed records for a patient seen by two specialists. One sent five handwritten pages, which included a list of pertinent positives and negatives and a clear opinion. The other sent three inches of templated, checkbox-driven printouts that were technically complete but practically useless. The handwritten notes reflected someone who prioritized judgment and discernment. The other ones reflected a system built to avoid liability, not to help care for the patient and to get answers.
- Consults built around “what result do you want,” not “what procedure.” A man once asked if I could help with his nose. It didn’t look objectionable to me, so instead of starting the conversation with “Let’s take off the bump,” I asked, “What’s actually bothering you?” It turned out his friends’ comments were driving this, not his own view of himself. We talked through what he wanted and what would actually get him there before talking about surgery at all. At least if he decided to pursue surgery, the decision would be well thought out and his own.
- Staff who are treated like residents, not clerks. I run continuing education inside my own practice. I circulate articles that are highlighted and discussed. I hire those who are looking for a calling, not just a job. The return has been staff who know more about our procedures than many first-year plastic surgery residents and stick around to put that knowledge to good use.
- Honesty about fit. Not every surgeon is right for every patient. If a patient’s and a surgeon’s aesthetic don’t align, the right step is to say so and help the patient find a surgeon who’s a better match. This is better than talking oneself into a case that violates your aesthetic sensibilities and judgment.
What This Means in Practice
Three things I’d offer any peer who wants to move in this direction:
- Ask WHAT IS bothering the patient before you ask what procedure they want. Separate the patient-side question (“Why does this bother you?”) from the surgeon-side question (“Why does this exist, and what should be done about it?”).
- Use your own enthusiasm as a diagnostic. If you’re looking at tomorrow’s schedule or scrubbing in and aren’t genuinely excited about the case, something broke down earlier, usually in patient selection or planning. Go back and find where things broke down. This is important.
- Evaluate every new technique or technology with these questions: Does it help the patient achieve their desired, naturally beautiful result? Does it make the result better or more predictable, or the experience better for the patient? Don’t rely on it being new, faster, or heavily promoted. Trust, but verify, and then adopt incrementally.
Here’s the bottom line: As plastic surgeons, we have no organ or body part. All we have is aesthetic vision, proportion, and precision. But that’s our “value-add” to medicine. We are only limited by the dura, the pleura, and the peritoneum, and our own imagination and commitment. Let’s not leave excellence behind in search of trends, volume, and profit. PSP
Photo: ID 129012044 © Andrei Rahalski | Dreamstime.com
Scott R. Miller, MD, FACS, is a board-certified plastic surgeon, author of the Amazon bestseller Authentic Beauty: Defining a New Standard for Care and Results in Plastic Surgery, and founder of Miller Cosmetic SurgeryCenter in La Jolla, California.
