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-plastic surgeons, he said. Later, I ran a cursory check on the existing literature and conceded that he was more or less correct. However, even though only 20% of all plastic surgery is performed by board-certified plastic surgeons, 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.

Sixteen of the 21 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. The organizations and people behind the meetings in the early days wanted to talk about “big time” procedures and techniques that were important to them, such as free flaps and the very precise science of aesthetic medicine.

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 the University of California, Los Angeles, 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 from 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 Carter Administration, in the late 1970s, and the Federal Trade Commission were involved in trying to put a halt to that campaign. Why? The issue of board certification was creating separate classes of aesthetic practitioners — the plastic surgeon and everyone else.

Currently, this board-certification promotion — which hasn’t changed much over the years — is simply an example of how some people in positions of power are pushing an agenda that is inconsistent with reality. Other qualified surgeons that are not board-certified in plastic surgery 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.”

Where is the movement among well-ensconced, high-level, and leading plastic surgeons to make additional positive moves to accommodate the marketplace, rather than to pooh-pooh the nonplastic surgeon practitioners who are making the procedures safer and more successful for patients? For example, where is the determination among these folks to require a third year in plastic surgery residency 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 knock down 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. The plastic surgeon of 2008 has to dabble in cosmetic procedures in order to stay alive financially. That is a “top down” phenomenon, in which physicians must embrace markets that were traditionally beneath them 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 all of the procedures that plastic surgeons hold dear in their domains. Why? The technology is becoming available to accommodate such a change.

The big discoveries are, by and large, happening among the dermatologists who get together with the ENTs, who get together with a forward-thinking plastic surgeon — the combination of skills and technology does and will evolve the field. For example, new laser-based products will soon let an OB-GYN perform a tummy tuck with the same finesse as most artistic plastic surgeons. It won’t be because the OB-GYN has a steadier hand or the attitude of a DaVinci. It will be because the machine he or she uses will have that artistry programmed into it.

The answer is to uncircle the wagons and promote patient safety and physician education above everything else—including internecine warfare and territorial disputes. The changes happening now in the different plastic and cosmetic domains will not reverse. And the best course to take is to work together and facilitate these technological and marketplace-related changes so that your patients receive only the best care from all physicians.