Richard E. Davis, MD FACS - The Center for Facial Restoration in Miramar, Florida

Selecting the Best Surgeon for Your Rhinoplasty

One of the most important steps in assuring a satisfactory rhinoplasty outcome is selecting the right surgeon. Since rhinoplasty ranks among the most challenging of all cosmetic procedures, at a bare minimum you should find a surgeon with genuine rhinoplasty expertise, considerable rhinoplasty experience, and a resume of consistently favorable results. A good surgeon will also be an effective communicator, a patient listener, and a compassionate caregiver. Although there are many surgeons who meet these criteria, there are many more that fall short, so careful and conscientious research is mandatory. And because rhinoplasty is an elective, non-emergent procedure, there is no excuse for failing to investigate the qualifications and credentials of your care provider — failing to do so means gambling with your face.

While the quality of your rhinoplasty outcome depends in large measure upon the quality of your rhinoplasty surgeon, finding a surgeon skilled in cosmetic nasal surgery is sometimes difficult. Unfortunately, there is no single reliable method for finding the right surgeon. Moreover, information sources may be inaccurate, contradictory, or difficult to access. Consequently, information is best gathered from all available sources and then carefully evaluated and cross-referenced to derive the best possible assessment. The process can be time-consuming and challenging, but for most individuals, a satisfactory choice eventually becomes clear.

Although the choice of surgeon is critically important, no surgeon can guarantee a perfect outcome. To the contrary, because nasal surgery is performed on swollen and distorted tissues that can change shape without warning, slight cosmetic imperfections are inevitable in virtually any nose, regardless of who performs the surgery. Even a well-meaning and highly talented surgeon cannot foresee or prevent every conceivable problem, so realistic expectations are essential. However, the time spent finding an established rhinoplasty specialist with a track record of happy patients is well worth the effort. Finding the right surgeon can make the difference between a dramatic cosmetic enhancement, and a scarred, unattractive nose.

What to Look for in a Rhinoplasty Surgeon

Valid Medical License

In order to legally perform rhinoplasty, a valid medical license is required in all 50 states. An active and unrestricted state medical license insures that the state medical board has confirmed the minimum academic training (medical school) and at least one year of post-graduate training (internship) for the license holder. The state board of medicine can also be a source of information regarding disciplinary action(s) taken against a doctor for non-compliance, medical malpractice, or other reportable infractions. A clean medical license is typical of most reputable surgeons.

Board Certification

Certification by an American Board of Medical Specialties (ABMS) board (or a recognized equivalent) denotes successful completion of both an ACGME-accredited residency program and a comprehensive oral and written competency examination specific to a given medical specialty. As a surgeon certified by both the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology (two of the three medical board certifications that encompass cosmetic nasal surgery), and as a frequent oral board examiner for both organizations, I am a strong advocate of the board certification process. However, board certification does not guarantee surgical proficiency in rhinoplasty. To the contrary, it merely insures a minimum level of book knowledge and clinical competency at the time of the examination. Moreover, board certification does not certify dexterity, artistic skill, compassion, integrity, continuing study, or extensive surgical experience. In fact, a large number of board-certified surgeons have little or no practical experience in rhinoplasty surgery. To use an analogy, passing a driving test and obtaining your driver's license does not necessarily mean you will drive a vehicle safely, responsibly or skillfully. By the same token, board certification is not a guarantee of talent, experience or quality.

Malpractice History

Another commonly used screening tool is malpractice history. Certainly no one wants to entrust their face to a surgeon with a history of willful negligence and disastrous surgical outcomes. Therefore, contacting the state medical board for malpractice activity are wise initial steps in the selection process. Although malpractice claims are often frivolous and without merit, numerous malpractice judgments or settlements against a particular surgeon are a cause for suspicion and should be factored into the decision-making process.

Specialty Niche

In general, surgeons who specialize in a particular surgical niche tend to have greater interest and skill in that subspecialty. Typically, this translates into better and more consistent surgical outcomes, whether it is vascular tumors of the brain, total hip replacements, or cosmetic nasal surgery. Although finding a surgeon board certified in plastic surgery or facial plastic surgery is a good start, it by no means assures a satisfactory rhinoplasty will ensue. There are several different paths that can lead to credentialing in rhinoplasty surgery, including plastic surgery, otolaryngology (ear, nose, and throat surgery), facial plastic surgery, and oral surgery. Each has advantages and disadvantages and no educational pathway has an exclusive lock on quality outcomes. Leaders in rhinoplasty have emerged from each of these educational pathways and in virtually every instance, their practices have been focused largely on nasal surgery.

Word-of-Mouth Endorsements

Another reassuring indicator of a quality rhinoplasty surgeon is a word-of-mouth endorsement from a trusted friend or family member. First-hand accounts of a positive surgical outcome, favorable bedside manner, responsiveness to patient concerns and appropriate follow-up care are always reassuring. Moreover, when multiple endorsements are accumulated from independent sources, the level of reassurance rises. However, be careful not to compare apples to oranges, since a good breast augmentation or facelift does not automatically equate to a good rhinoplasty result — be sure that you are getting the name of a good rhinoplasty surgeon.

Internet Endorsements

Recently, internet message baords and other online forums have become another source of word-of-mouth referral information. On balance, the dialogue generated by these websites has been positive by promoting greater patient awareness, exposing incompetent practitioners, and generating a "virtual" support network among rhinoplasty patients. However, there is also a growing downside to internet discourse, as misinformation, character assassination, and fraudulent postings are occurring with increasing frequency. A single disgruntled patient, with or without valid justification, can nullify thousands of satisfactory rhinoplasty results because of one unfavorable outcome, real or perceived. Sadly, the anonymous nature of the internet and the corresponding absence of accountability make these abuses difficult to prevent. Therefore, when assessing the merits of any surgeon from internet sources, consider the motives of the poster and take harsh disparaging comments with a grain of salt — there are two sides to every story.

Surgical Portfolio

Perhaps one of the most effective ways of assessing a rhinoplasty surgeon’s skill and ability is to review his or her surgical portfolio of before and after photographs. Most serious rhinoplasty surgeons will take pride in their photography and standardize the photographic background, lighting, and positioning for more accurate comparison. Multiple views of the face, not just profile views, will also give a much more accurate assessment of the cosmetic outcome. Viewing patients with nasal deformities similar to your own is an even more effective way of judging a surgeon’s ability to correct your specific problems. This is particularly reassuring when multiple patients with similar deformities have been treated successfully. Viewing before and after photographs of patients with dissimilar problems also helps to establish both the depth and breadth of a surgeon’s rhinoplasty skills – another indication of genuine talent. Successful correction of badly damaged noses is perhaps the most telling indication of a rhinoplasty surgeon’s skill, since complex revision cases are considerably more challenging and complicated than most virgin noses. A dramatic restoration of a badly misshapen nose speaks volumes. Although even a mediocre rhinoplasty surgeon can offer a few good shots, only an accomplished rhinoplasty surgeon can provide a large portfolio of satisfactory cosmetic outcomes. Because the camera detects even the smallest contour imperfection, a good before and after photo virtually always translates to a beautiful nose when seen in person.

Academic Standing

Another important indicator of a rhinoplasty surgeon’s reputation is his or her standing in organized medicine. For facial plastic surgeons like myself, participation in distinguished organizations such as the American College of Surgeons, the American Academy of Facial Plastic and Reconstructive Surgery, the American Board of Facial Plastic and Reconstructive Surgery, the American Academy of Otolaryngology – Head and Neck Surgery, and the American Board of Otolaryngology, as well as state and local medical societies, indicates a willingness to serve the public interest. Teaching appointments, publications in refereed or peer-reviewed specialty journals, and participation in national or international specialty symposia as an invited speaker on rhinoplasty all denote a surgeon of high scholarly standing whose achievements are recognized by their peers. Participating as an examiner for the oral board certification exam is also an honor bestowed by fellow practitioners.

A Quality Consultation

Regardless of the medical complaint, the consultation visit is designed to accurately diagnose the problem, derive an effective treatment plan, and convey relevant information such as alternatives, risks, and anticipated outcomes. While originally intended to convey accurate information and facilitate an informed medical decision, rhinoplasty consultations have all too often degenerated into brief, pre-packed infomercials in which little if any meaningful knowledge is acquired. Many surgeons spend little time examining or listening to the patient, much less explaining the problem or the treatment rationale. In my opinion, a proper patient history, nasal examination, and thorough explanation of the recommended treatment and the associated risks can seldom be accomplished in under one hour. In my practice, computer imaging is used to simulate changes in the nasal contour so that patients can more easily envision the cosmetic goals. A review of the surgeon’s own before and after photos from patients with similar nasal irregularities should also be part of any quality consultation. It is during the consultation that the relationship between patient and surgeon is formed and it is during this time that you will ultimately decide whether or not to entrust your face to his or her hand.