Jeffrey Frentzen

A very well-respected plastic surgeon cornered me at the recent AAFPRS meeting in Chicago, and the discussion drifted over to how well (or poorly) plastic surgeons are trained in cosmetic procedures. He is board certified in both plastic surgery and cosmetic surgery.

Eighty percent of all cosmetic surgery is performed by non-board-certified surgeons, he said. Later, I ran a cursory check on the existing literature and conceded that he was likely correct. However, he continued, 80% of all deaths and 91% of all medical malpractice claims in cosmetic surgery are at the hands of board-certified plastic surgeons.

Several of the major advances in aesthetic surgery over the past 15 to 20 years have come from adventurous dermatologists and cosmetic surgeons. It is something to be aware of, with all of the talk about Botox here, hair transplantation there, laser lipolysis, microcannular liposuction, tumescent anesthesia, and fillers, to name a few. The face of plastic surgery is changing radically, from the latest capabilities of laser-assisted procedures to stem cells.


Where is it headed? First, let’s look at where we have been. One of the fathers of cosmetic surgery in the United States is Richard Webster. When he was making discoveries and innovations, he was not even allowed to present his work at plastic surgeons’ meetings. As a plastic surgeon, he was passionate about teaching cosmetic surgery to any specialty that wanted to learn.

Jeffrey Klein, the dermatologist who developed tumescent liposuction in 1985 and whose advances allowed liposuction to be performed under local anesthesia, received similar brush-offs when he first began presenting. His advances in the safety of the procedure moved it from hospital operating rooms to outpatient or office facilities. Klein also pioneered the use of microcannulas, which allow for more precise fat removal, but in the 1980s he was considered on the fringe by medical societies.

Cosmetic surgery was and is something that physicians learn after their residency training—for example, people do not go, in general, to UCLA or Johns Hopkins University to have a resident do a facelift on them. Over the years, divisions were created between plastic surgeons and cosmetic surgeons and specialists.

The younger plastic surgeons want no part of this battle. They just want to learn cosmetic surgery. They want market share—everyone wants market share. They realize that they are not getting trained in cosmetic surgery, and they know where the business is headed and, naturally, they want to go after it. The same goes for even the obstetricians and gynecologists (OB-GYNs); general practitioners (GPs); ear, nose, and throat specialists (ENTs); and others at the far end of the spectrum who are now able to go into the cosmetic surgery market and do so successfully mostly due to the new generation of technology.

Today’s physicians cannot succeed by using tools, approaches, and attitudes from the 1970s or even the early 2000s. Therefore, why do the “old school” of plastic surgeons or some of the organizations that support them continue to circle the wagons around some antiquated notion of plastic surgery?

I’ll use a publishing analogy. In the 1980s, magazine publishers knew only from the printed page. There was no popular Internet, no digital revolution. Even in the 1990s, publishers who did not adapt to nascent business models on the Internet were doomed to perish. The old business models of publishing were tough to let go of, and the “old guard” was shocked to see people at the fringe, entrepreneurs and new blood coming in the high-tech sectors and television markets. Now, those who did not grow and change with the change in technology and attitudes were either crushed by those paving the information superhighway or absorbed into the landscape.

What are the divisive measures being taken to keep those plastic wagons circling? Take board certification, for example. In the 1970s, an early version of a well-known advertising campaign—such as “don’t let anyone work on you who is not a board-certified plastic surgeon”—was devised by the organizations that supported well-ensconced, high-level, leading plastic surgeons. The result supported a philosophy of protectionism among plastic surgeons, and created separate classes of aesthetic practitioners—the plastic surgeon and everyone else.

On one level, this board-certification promotion—which hasn’t changed much over the years—is an example of how some people in positions of power are pushing an agenda that is inconsistent with reality. Non-board-certified physicians are still taking huge bites out of the plastic surgeon’s market.

For example, my physician friend pointed to the 1994 study by Hanke et al, in which a national survey yielded data on the safety of local tumescent liposuction in 15,336 patients from 66 responders. The result: no patient deaths, no hospitalizations or deep vein thrombosis, etc. Compare that to a 1-in-5,000 death rate among plastic surgeons. The plastic surgeons’ rationale was, “Hey, this procedure is so dangerous that only we should do it.”

Perhaps there should be a movement among well-ensconced, high-level, and leading plastic surgeons to make additional positive moves to accommodate the evolving marketplace.

For example, where is the determination among these folks to require a third year in medical school so plastic surgeons can learn cosmetic surgery? Not just 2 or 3 months, which you might find at only the top schools.


The idea is to remove barriers to understanding and redraw the old-time class system—a system that is not relevant in an age in which a GP can pair up with a dermatologist and effectively perform procedures that were once the exclusive province of plastic surgeons.

I’m not suggesting the elimination of safety-first ad campaigns. I’m just looking for some consistency.

Currently, many plastic surgeons have to dabble in cosmetic procedures in order to stay alive financially. That is a “top down” phenomenon, in which physicians must embrace cosmetic markets as a competitive response to the myriad specialists who are working from the “bottom up.” These bottom-up specialists will soon be able to perform procedures that plastic surgeons hold dear in their domains. Why? The technology is becoming available to accommodate such a change.

Over the years, many big discoveries have been driven by plastic surgeons. However, they are not the only ones who have made significant contributions to technologies and techniques.

We have also seen a lot of solid advancements from cosmetic dermatologists who get together with ENTs, who get together with forward-thinking plastic surgeons—the combination of skills and technology does and will evolve the field. In response to this phenomenon, many plastic surgeons will look down their noses and complain, “Derms! They aren’t even surgeons. They treat acne!”

You can’t blame plastic surgeons for being upset—the whole world has eaten their lunch. The real bottom line is what used to be a singular specialty situation is now the domain of many specialties.

The answer? Uncircle the wagons, give up the internecine battles, and promote physician education. The sea changes happening now in the different plastic and cosmetic domains will not reverse.

The best course to take is to try to work together and facilitate these technological and marketplace-related changes so that your patients receive only the best care from all physicians.

Jeffrey Frentzen
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