Finding the right plastic surgeon

With doctors themselves crossing scalpels over cosmetic turf at times, the onus is on patients to seek out bona fide specialists, writes CHEAH UI-HOON

WHEN do you see a plastic surgeon, a cosmetic surgeon or an aesthetic surgeon for cosmetic procedures? If you're a tad confused over these terms, or have a hazy concept about who can administer cosmetic procedures, then join the club.

Despite the growing popularity of cosmetic procedures in Singapore, plastic surgery is still pretty much an unregulated field - with the members of the medical fraternity themselves crossing scalpels over cosmetic territory at times.

Just a month ago, a number of gynaecologists had written in response to a BT article about plastic surgeon Martin Huang's administration of new procedures such as Laser Vagina Rejuvenation (LVR) and Designer Laser Vaginaplasty (DLV), protesting the fact that a plastic surgeon can 'claim to be certified to perform gynaecological vaginal and stress urinary incontinence surgery after only three days of training'.

Dr Huang's reply was that plastic surgeons 'are the most versatile of all surgical specialists, and are trained to operate on virtually every part of the body, including the vagina', citing the example of gender re-assignment surgery and vaginal reconstruction for congenital and acquired deformities as two areas of plastic surgery that involve the vagina. Besides, the intent of LVR has been misunderstood - as it's not intended to be primarily a treatment for stress urinary incontinence but to enhance sexual function.

A case of turf wars? It sure looks like it, especially as plastic surgeons themselves have grouses against doctors like GPs who aren't trained in plastic surgery but administer Botox or gynaecologists who administer liposuction.

The Ministry of Health has said that the issue of aesthetic medicine is currently being studied by a Specialist Accreditation Board-appointed committee, which is expected to deliver a report by February. However, the fact of the matter is that aesthetic medicine hasn't been regulated thus far, as it's not illegal for doctors of any discipline to administer cosmetic procedures.

So why the need to visit a plastic surgeon for cosmetic procedures, and how does one tell a bona fide plastic surgeon from any other doctor who's jumping onto the cosmetic surgery bandwagon?

The nature of the beast

The nature of cosmetic surgery is that it's very much a 'consumer-oriented' branch of medicine. 'It's different from other kinds of medicine in that it's purely elective; like a luxury item which you spend your disposable income on, not because you need it, but want it for psycho-social reasons,' says Dr Huang, who's the executive director and consultant plastic surgeon of The Cosmetic Surgery Clinic, Pacific Healthcare Holdings Ltd.

'Because of the nature of the practice, it's become very much an activity that's governed by free market forces, by supply and demand. So it's not like other branches of medicine. The patients also behave very differently - being more like consumers or shoppers and not sick persons looking for a cure,' he adds.

All of which lead to plastic surgery being very much a business, and also a high income generating branch of medicine.

But even if one might regard plastic surgery for aesthetics' sake with disdain, there's no denying that plastic surgery is a specialised field in medicine, says Andrew Khoo, immediate past-president of the Singapore Society of Cosmetic (Aesthetic) Surgeons, and consultant plastic and aesthetic surgeon of the Aesthetic & Reconstructive Centre.

'A plastic surgeon in Singapore has to go through six years of basic medical training, three years of basic surgical training and four years of advanced surgical training. They then go through an examination to earn an exit certification called a FAMS (Plastic Surgery) which allows them to be registered on the Specialist Register of the Singapore Medical Council as plastic surgeons,' Dr Khoo explains.

If you want to find out who are the qualified plastic surgeons in Singapore, the list is available on the Internet at www.smc.gov.sg, under the 'list of specialties' in the 'medical registration' section. The same goes for dermatologists, who are trained to administer non-surgical cosmetic procedures.

Dr Khoo points out that confusion occurs when terms like aesthetic surgeon, aesthetic physician or cosmetic surgeon are used.

For the record, 'plastic surgery' is a recognised specialty, which encompasses two main areas - reconstructive and cosmetic. 'Other than this, there is no training programme, examination or exit certification for 'cosmetic' or 'aesthetic' surgery,' points out Dr Khoo.

Dr Ivor Lim, plastic surgeon and medical consultant for the MedSpa at Camden Medical Centre, points out that the training course for plastic surgery is long and comprehensive and most importantly, involves apprenticeship under experienced senior plastic surgeons. 'We watch and learn, and that's how you progress, and we study and have to understand the whole body's anatomy,' he points out.

For a procedure like liposuction, for example, there should be an understanding of what the anatomy of fat is like, the proper amount of fat to be removed and so on. 'It's wise to go to a plastic surgeon even for something like Botox - which sounds simple - because we are aware of where the facial muscles are. Botox does alter facial muscle control after all,' he says.

Emerging face of aesthetics

Today, with aesthetics being at the forefront of plastic surgery, we tend to forget that plastic surgeons are firstly trained in reconstructive surgery. 'Unfortunately, the layman's view is that plastic surgery is aesthetic and cosmetic only. The reconstructive aspects of plastic surgery include treating congenital abnormalities such as cleft lips, treating burns patients and reconstructing patients after removal of tumours to restore function and form,' says Dr Khoo. 'This serves as the basis for good aesthetic surgery.'

Dr Huang agrees, pointing out that reconstructive surgery is the foundation for plastic surgery. 'Because it's crucial and essential to make something abnormal, normal, before you go on to improve upon the normal and make it better than normal.'

'There is no short cut to getting experience from treating reconstructive patients,' adds Dr Khoo, who has an interest in breast reconstruction, and therefore his work is 40 per cent reconstructive and 60 per cent aesthetic in nature.

Plastic surgeons say that non-surgical cosmetic work can be done by trained dermatologists, while a specialist with a plastic surgery background is the most appropriate one to do cosmetic surgery.

And while there seems to be the occasional spat over who should do what, cross-specialty cooperation in the management of patients is more the norm, says Dr Khoo. 'For example, reconstruction of the female genital tract is done by plastic surgeons in close cooperation with their gynaecology colleagues.'

Another issue is that with aesthetics being the lucrative frontier, this has resulted in an increasing number of 'proprietary' trademarked or patented procedures being invented for aesthetic treatment the world over, which could mean 'non-disclosure' contracts.

Critics have pointed out that when copyright laws prohibit the sharing of techniques, results and complications, it goes against doctors' Hippocratic Oath.

Dr Huang, who offers trademarked plastic surgery procedures, points out that such non-disclosure agreements pertain only to the sharing of techniques among the medical fraternity - 'Like how Coca-Cola wouldn't share its recipe with Pepsi-Cola,' - and not the sharing of results and complications with patients.

The Singapore Medical Association (which is the national medical organisation representing the majority of medical practitioners in both the public and private sectors) has also stressed the importance of doctor-patient communication.

'It is a doctor's responsibility to ensure that a patient under his care is adequately informed about his medical condition and options for treatment so that he is able to participate in decisions about his treatment. If a procedure needs to be performed, the patient shall be made aware of the benefits, risks, and possible complications of the procedure and any alternatives available to him,' says Dr Raymond Chua, SMA's honorary secretary.

Given that cosmetic surgery is truly an elective procedure, and with it becoming the norm in society, here's some advice from a plastic surgeon that's worth noting.

In a new book called Your Body, Your Beauty, Your Safety, US-based plastic surgeon Dr Joe Gryskiewicz estimates that as many as 10 per cent of cosmetic surgery patients are not too happy with the outcome of their surgery because of unrealistic expectations.

'Often, the patient's psychological reasons for having a procedure aren't considered or discussed prior to the surgery,' he says in a press release. The book provides a checklist to help a patient determine whether they're ready to undergo plastic surgery.

Some of his reasons not to go under the knife are: to please your spouse or partner, as a reaction to mid-life crisis, as a reaction to a life-changing event such as death or divorce, if you suffer from ongoing depression, if you have major health problems, to land Mr or Mrs Wonderful or to just be happy.

'Plastic surgery isn't a band-aid to life's problems, but a long-term lifestyle change,' he notes.

Source: Business Times, 6 January 2007