What makes a surgeon a rhinoplasty expert? Which surgeons have the necessary rhinoplasty skill to create the nose you desire? The following are my thoughts and observations collected over the years. It should be of interest to the thoughtful patient trying to do the research to find their best surgeon. I sympathize with anyone confused or frustrated by this search. There is no manual or guide easily available. It’s near impossible to access the needed information. What’s out there is often tainted by lack of independency or conflict of interest. There’s competition between local surgeons, regional societies or national organizations.
Unfortunately there’s no independent rating agency. Doctors of course have obtained their board certification. As far as rhinoplasty is concerned, that bar is set much too low. It means the doctor has been assessed by his teachers in residency as having the minimal skills needed to be considered safe for the procedures falling within the domain of that specialty. Unfortunately rhinoplasty may have not have been a strong area in that particular university program. It also means he has passed his board examinations. This consists of a written and oral test. Rhinoplasty will have been subject of at least a part of this process. But to then consider the successful candidate proficient in the art of rhinoplasty is patently absurd.
It’s the same with most, possibly every service industry. Who is the best lawyer? Who is the best dentist? Or the best car mechanic? Or best educator. There isn’t an available measurement system. One could be created I expect if there was the political will and resources. Public companies are rated. However there isn’t presently Moody’s or a Standard and Poor’s rating for surgeons.
It’s an accepted truth by everyone that people vary in their skills and abilities. Beethoven could compose, Einstein could think, and Fisher could play chess. They all were acknowledged to do so better than most everyone else. They were considered the best of their time. Hours of conversation have been spent on who is currently the best hockey player, the most beautiful supermodel/actress, and the most skilled poker player.
It’s the same with surgeons. We vary in our skills. Medical educators see it while teaching and monitoring their student interns and residents. The lucky few start with a natural, innate gift of knowing how to operate. Some surgical trainees quickly learn and advance from stumbling and hesitant towards smooth and slick. Others unfortunately don’t improve much at all.
I have come to classify the trainees who pass through my service into six categories. There are those few, those very few who are gifted and realize this. These students have the opportunity to go on and become excellent surgeons, some developing international careers. There are some who are equally skilled, but aren’t aware how good they really are. They too have a promising future. Their career is filled with grateful and happy patients. The great majority of students possess satisfactory surgical abilities. Most have make an accurate self-assessment and are aware of their level of competency, while a small group haven’t. They all go on to have what I believe are fulfilling careers and provide society with competent medical care. They are the smart ones. In fact they are often more intelligent than the gifted surgeon. And they are almost always a more balanced human being. Finally there are a few who don’t possess the qualities a surgeon needs, but are aware of this. Having recognized this, then choose a type of practice with minimal need for surgery. Fortunately in my specialty there is that opportunity. Some who initially resist this insight, early on in their career generally find their experience convinces them to move into a limited or non-surgical field of medicine. They are safe surgeons; as they know what is possible and what is better referred to their colleagues. Finally they are unfortunately those who are poor surgeons and are unaware of it. These are the dangerous few. They are unable to learn from experience. Nor will they listen to advice from those in a position to give it. These are the 0.1% who ended up on the front pages of newspapers or find their medical regulatory bodies admonishing them for incompetency.
Like the prima ballerina of an internationally recognized troupe, it’s the mark of having attained complete mastery of the art, when it looks effortless and easy. Simple enough that the audience feels it doesn’t appear that difficult, and some feel they too, with a little time and effort, could probably achieve the same. These foolish people don’t recognize what’s hidden behind the performance. They miss the long hours of repeated practice, the continuous corrections, the repetitive exercises, the perpetual honing of their skills and the unwavering hope of reaching the pinnacle of their chosen profession.
The leaders in educational theory believe it takes 10,000 hours to master a skill. It doesn’t seem to much matter what; table tennis, golf, piano, or public speaking. The best way to consider 10,000 hours is to realize it represents about five years of a 40 hour work week. Unfortunately it’s a much longer process with rhinoplasty surgery. First consider this, most surgeons practicing rhinoplasty do less than 25 cases a year. This group of surgeons will never master rhinoplasty. Even those doing a large number, and this would be a hundred by most people’s calculation, are completing perhaps 300 hours of rhinoplasty a year. If you add another 300 hours for study, attending conferences, visiting recognized experts and reviewing articles and books on the subject, then it becomes over 15 years to reach the mark.
There’s another reason it takes many years to become a master rhinoplasty surgeon. The results of surgery take months to appear. Unless a surgeon takes detailed and meticulous notes, complimented by illustrations, photos and videos, he won’t remember what took place. This extends well beyond the sequence of the surgery. It’s not enough to recall the surgical steps and the various techniques utilized. Important facts need to be remembered; the decision process, the reasons for the many choices a surgeon makes during every operation, the shape and texture of the cartilages, the response of the tissues to surgical manipulations, the visual and tactile information. These are all important if a surgeon wants to learn and thereby improve. However in my experience this is rarely done. When I read an operative note in preparation for a revision rhinoplasty, it seldom provides me with useful information. Often only the briefest outline of the surgical steps is provided. Mostly I now don’t request the note from the previous surgeon as it’s usually not worth the bother.
So what makes a great surgeon?
What are the qualities needed in a surgeon to produce a consistently high degree of surgical success? There are many I believe. Firstly the surgeon has had to have the training. He has to have been shown the operation by those who know how to do it. Not one or twice but many, many times. There has to have been exposure to the operation. This means graduating from a surgical training program large enough to have a few high volume rhinoplasty surgeons. It usually also means additional training under the mentorship of a senior surgeon skilled in rhinoplasty. I recall a surgical observer telling me he had never seen a particular technique throughout his residency training. Although this junior surgeon wished to practice rhinoplasty, he was already at a disadvantage.
A good surgeon has what’s called “respect for the tissues”. This is fundamental to all areas of surgery, but is particularly critical to rhinoplasty. Respect means reducing the surgical trauma to a minimum. Rhinoplasty is no different than a baseball to the nose or a fall face first and fracturing the nasal bones, except that it’s controlled trauma. Reducing the damage to the structures of the nose occurs throughout the operation. Making one instead of several attempts to place a suture makes for less injury. Tying down a knot snugly and not so tight so as to strangle the tissue is another example. Maintain a near bloodless operative site. Accurately and carefully applying the tape over the nasal skin at the end of surgery when everyone is tired has a small but still important contribution to the final outcome. Each action in itself may have little discernible impact, but the accumulation of all these maneuvers adds up. I’m fond of telling my residents that if a surgeon needs to use suction to clear away blood prior to reaching the internal septal work deep inside the nose, then he’s doing the wrong operation. The body most easily and atraumatically separates apart between recognized layers. It’s analogous to peeling an orange. Get into the correct layer and it’s easy, otherwise it’s a messy affair and ruins the orange. With rhinoplasty as with all surgery, this is called “maintaining the surgical plane”. It is in this plane the least amount of blood vessels is cut and the minimum amount of blood created. Hence a gifted surgeon has a delicate touch. Compare the concert pianist to the honky tonk piano player or a master cabinetmaker to a weekend handyman.
A surgeon rushing to complete his list of cases that day isn`t going to create the conditions for success. He will be able to point to his amazing results; just he won`t have many. If you give a million monkeys type writers and wait a million years, you will probably produce one play worthy of Shakespeare! Surgery done well takes time. Time to reflex and come to a decision as to what is the best solution to the problem at hand. Time also to carry out the maneuvers needed to produce the best result. Surgeons are by nature busy, productive people. If the surgical day is booked with too many cases the surgeon will feel the pressure to finish and respond by accelerating. Doing less than desirable, rushing, becoming tired, feeling both mentally and physically exhausted, becoming irritated because of an approaching appointment after work he can`t miss, or being angry because of an unexpected surgical problem has occurred are all not what creates the greatest likelihood for success.
Patients often wonder if having an artistic sensibility is an asset. I`m convinced it is in the field of rhinoplasty. The goal is to create a pleasing three dimensional sculpture out of human flesh. The materials and therefore the techniques are different, but the ability to visualize is the same as a cabinet maker working in walnut or a craftsman turning burled maple. There are differences, as the visual artist choses a material to express himself, while a surgeon is confronted sometimes with less than ideal quality tissues. The surgeon`s office will give a clue to his artistic taste. Most cosmetic surgeons have fancy offices. They are designed to impress. Patients expect to enter an upscale well-appointed office. It reassures a patient this doctor has an established practice capable of supporting a luxurious establishment. An expensive place creates confidence. However a tony address and an ostentatious waiting room provides little indication of the surgeon`s own taste. I`ve seen consultation rooms where I felt it would have been best to have given a competent interior designer complete control over the outcome. Although patients realize a surgeon`s photo gallery represent his best work, it`s still a chance to consider his ability. If the same “cookie cutter” nose reappears again and again, it means either he has a limited sense of harmony and proportions or essentially possesses only one surgical technique. Neither is a quality an intelligent patient is looking for.
Assuming the surgeon has the necessary physical capabilities- steady hands, clear sight, excellent hand-eye coordination; then I think the most important quality is attitude. Does he bring the right attitude to his work? In the field of space exploration; does he have the right stuff? The right attitude is the aggregate of many, many things. An example is discovering more damage than predicted preoperatively and then spending the additional hour and a half to complete what needed to be done to achieve the best result possible. A good example is an ability to maintain an intensity of concentration from the start to the end of the rhinoplasty, remaining consistently at your best performance, case after case, week in and week out. A final example is the ability to separate all the noise and distractions of life once a surgeon walks through the operative room door and focuses exclusively on the task at hand, a patient’s rhinoplasty.