Twenty Five Years: Now What?

The American Journal of Cosmetic Surgery

Vol. 25, No.4, 2008

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EDITORIAL

Jane A. Petro, MD, FACS

Patrick McMenamin, MD President Elect AACS

Twenty Five Years: Now What?

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quarter of a century provides a platform in breadth, depth and duration to accurately reflect on who we are, what we do, and what we stand for. As the American Academy of Cosmetic Surgery celebrates its Silver Anniversary it is worth reviewing the last 25 years for the lessons learned and issues resolved and provides an important focal point from which to anticipate future challenges and needs. The AACS has been a central player in the establishment of cosmetic surgery as a respected profession. Emphasizing the importance of education, scientific evaluation, and presentation with open and fair critique has enhanced a continuous cross fertilization among the surgical disciplines involved. Promotion of patient safety and physician education has permitted this organization to experience steady growth, maintain its original mission, and become a fully professional, well staffed membership organization. Coalesced combined groups share certain characteristics, including conflict, inclusion, and exclusion. The AACS was born out of the frustration cosmetic surgeons felt when their work was dismissed by their peers as unimportant. Richard Webster MD, a plastic surgeon and one of the AACS founders, wrote about his dismay that submissions on rhinoplasty, otoplasty and other cosmetic subjects were routinely rejected while his presentations on cancer reconstruction and repair of congenital anomalies were routinely accepted in peer reviewed journals and national meetings.'

The historical review of cosmetic surgery eloquently summarized by Richard Dolsky MD at the Dubai Meeting last year, and printed in this issue, provides an admirable survey of the emerging organizations devoted to plastic and cosmetic surgery in the 20th century. He recounts how even such widely known pioneers as Jacques Maliniac MD and Gustave Aufricht MD were denied membership in one organization, only to go on and found another. Intense rivalries also played out behind the scenes and were part of an ongoing conflict between these two European surgical giants. Although they both trained with Jacques Joseph MD, and then emigrated to New York they remained rivals, not colleagues, something that has continued among many of our professional peers. This is one of the reasons there are often competing organizations espousing similar philosophies and goals. Webster rightly lamented the state of cosmetic surgery in its early evolution because "good solutions to certain cosmetic problems took years to spread by word of mouth: men scattered here and there, again and again, had to make the same mistakes made elsewhere, because they were in isolation." 1 Webster credits Dr Mario Gonzalez-Ulloa with the establishment of his Dalinde Seminar on Cosmetic Surgery in Mexico City as the first forum dedicated exclusively to cosmetic surgery. He goes on to note that part of its success may have been because it was held outside the United States.

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Table 1.

Original Contributions to the Field of Cosmetic Surgery

Hair Transplantation Liposuction Scalp Reduction Face Lift Mid face lift Tumescent Liposuction Dermabrasion TCA Peels Botox

Norman Orentreich Dennatology Georgio Fischer ENT Dominic Brandy Emergency Medicine Suzanne Noel Dermatology Norman Shorr Ophthalmology Jeffery Klein Dermatology Farber and Alt Dermatology Gary Monheit Dermatology Jean Carruthers Ophthalmology Alastair Carruthers Dermatology (One can also include Skoog, Mitz and Peyronie, Goldman .... the list goes on and on.)

Divergent organizations, the American Association of Cosmetic Surgeons and the American Society of Cosmetic Surgeons, united in 1985 to form what we now are celebrating, the American Academy of Cosmetic Surgery. This was not the first organization that Webster helped found. Others include the American Association of Aesthetic Plastic Surgeons (founded 1967), and the American Cleft Palate Association. In describing the goals of the ACPA (founded in 1979), Webster attributed several key elements that would apply subsequently to the Cosmetic Surgery field: 1. Insistence on accuracy and honesty in reporting 2. Use of long term results and longitudinal (growth) studies 3. Importance of revealing deficiencies and complications 4. Efforts to include younger members in the running of the association 5. Continuing search for members of other disciplines to add insights and expand horizons of those who are already members In the formation of the American Association of Cosmetic Surgeons Webster emphasized that the organization would include "men from all of the disciplines and plastic surgeons deeply interested in cosmetic surgery." As we end the first quarter century, Webster's original vision remains intact. Sadly, it is also obvious that cosmetic surgery as a discipline is still under assault from those who would claim "ownership" of the field, its credentialing and reputation, and deny the quality or competence of practitioners from other surgical and medical disciplines. Dr Gonzalez-Ulloa, in writing the developmental history of cosmetic surgery formulated a "manifesto" on the subject? In his analysis of the situation he states:

" ... the gradually increasing demand for the surgical improvement of appearance ... was often met by charlatans, medical practitioners unqualified in this field, and, in a somewhat hypocritical manner, by those who had the background to practice it adequately but chose not to let it be known for fear of tainting their reputation. "

This comment is prescient, describing the state of cosmetic "medicine" today. The continuing work by the American Board of Cosmetic Surgery in its legal battle for recognition has moved in fits and starts since establishment of the Board in 1979. Although not recognized by the American Board of Medical Specialties the Board has achieved acknowledgement through other educational organizations. Because the ABMS has not accepted a new specialty designation in over 3 decades, despite the addition of 145 recognized subspecialties, it is likely that a competing board certifying agency will emerge in the near future, something that Richard Webster likely would have spearheaded. The function of the ABCS as a credentialing entity is separate from but firmly supported by the AACS representing the multi specialty educational arm of cosmetic surgery. The unsubstantiated but repeated claim by plastic surgery (American Society of Plastic SurgeonsASPS) to be the central organization credentialing cosmetic surgery can be readily refuted by examining the primary sources of original contributions to the field. It would be fair to point out that one of the fathers of rhinoplasty, Jacques Joseph, was an orthopedic surgeon, working before plastic surgery became a specialty. Modem advances, however, seem to belong to a diverse, not singular field. In no particular order, the following examples are offered in Table 1. No individual can claim to have truly invented any of these procedures or treatments. The table acknowledges the contributions these individuals have made in the


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Table 2. Timeline of Cosmetic Surgery Organizations in the Last 87 years (US)

1921 1921 1931 1937 1938 1941 1942 1942 1946 1953 1954 1963 1964 1966 1968 1969 1969 1969 1969 1970 1970 1974 1979 1980 1981 1982 1982 1984 1985 1985 1985 1999 2003 2005(?)

2007

American Association of Oral Surgeons American Association of Plastic and Reconstructive Surgeons American Society of Plastic and Reconstructive Surgeons American Board of Plastic Surgery ABPS became subsidiary of General Surgery ABPS approved by ABMS of the AMA American Academy of Facial Plastic Surgery American Otorhinologic Society for the Advancement of Plastic and Reconstructive Surgery (American Otorhinological Society for Plastic Surgery) American Board of Oral and Maxillofacial Surgery American Society of Facial Plastic Surgery The American Rhinologic Society Dalinde Seminar on Aesthetic Surgery (in Mexico) American Academy of Facial Plastic and Reconstructive Surgery formed by merger between American Otolaryngologic Society of Plastic Surgery and the Society of Facial Plastic Surgery Baker Gordon Seminars on Aesthetic Surgery American Society of Aesthetic Plastic Surgery American Academy of Facial Plastic Surgery at Cook County Hospital initiated first cosmetic teaching course in the US (not just rhinoplasty) American Association of Cosmetic Surgeons incorporated American Society of Ophthalmic Plastic and Reconstructive Surgery American Association of Cosmetic Surgeons first educational meeting International Society of Aesthetic Plastic Surgery American Society of Dermatologic Surgery Am Assoc Cosmetic Surgeons incorporated American Board of Cosmetic Surgery incorporated First ABCS meeting First ABCS Exams Am Society of Cosmetic Surgeons Incorporated American Society of Liposuction Surgery American Journal of Cosmetic Surgery Published American Society of Cosmetic Breast Surgery American Academy of Cosmetic Surgery formed by merger between American Society of Cosmetic Surgeons and the American Association of Cosmetic Surgery First Scientific Meeting of the American Academy of Cosmetic Surgery ASPRS renamed American Society of Plastic Surgeons (ASPS) Multi-Specialty Foundation for Aesthetic Surgical Excellence Foundation for the Advancement of Medical Education FAME) American Academy of Cosmetic Physicians American Academy of Cosmetic Gynecologists American Academy of Cosmetic Family Medicine American Academy of Cosmetic Plastic Surgeons College of Cosmetic Medicine

early stages of that evolution. Many, if not most, reflect the individual's realization of the significance of the process and they became the refiner and promoter of the newly developed technique. Proudly, many are members of the American Academy of Cosmetic Surgery. Silicone implants for breast augmentation were developed and first used by the plastic surgeons Thomas Cronin and Frank Gerow. Subsequent contributions to the procedure have been made by Claude Crockett MD (total submuscular augmentation), and J. Dan Metcalf

MD (subfascial placement), and Gerald Johnson MD (TUBA technique), all members of the AACS. The articles in this issue relate the histories of the development of lasers in cosmetic surgery, hair transplantation, the organization of the AACS, and personal memoires of the origins of the Academy. There were, and are, amazing people involved with this organization and it is easy to see why it has lasted these first 25 years, with steady growth, and constant improvement. But the organization has not existed in a vacuum, and

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will not do so in the future. Who are our allies, and how do we continually evolve, despite the pressures of the economy and organizational competition? A listing of cosmetic surgery organizations formed over the past 80 years provides a useful guide (Table 2). Many of the organizations listed merged into others, or have simply disappeared. From this table it can be seen that there has been a leveling off of new cosmetic surgery organizations in the US since the founding of the AACS. New, more recent organizations are emerging as cosmetic medicine not surgery. This is in line with trends toward less invasive rejuvenation procedures, in keeping with a growing public demand, and consistent with keen medical interest in developing financially rewarding practices. CME accreditation and sponsorship was described recently on a brochure promoting "3 rd Annual Cosmetic Conference" from the Foundation for the Advancement of Medical Education. The brochure came from Elsevier's Office of Continuing Medical Education (EOCME) which appears to be the primary sponsoring organization. None of the organizations involved in the conference appear to be independent membership groups, and may in fact all be subsets of a for-profit company. The topics and the CME are legitimate. But included in the program are surgical subjects, including vaginoplasty, breast augmentation and abdominoplasty. The target audience is not defined by surgical training, but physicians "seeking to implement various cosmetic procedures into their existing office practice ... " Here is a key challenge for the Academy. What separates cosmetic surgery and cosmetic medicine? Who should be doing what? As cosmetic procedures increasingly are seen as revenue streams throughout medicine, the emergence of organizations, meetings, and commercial ventures to promote cosmetic practice is inevitable. How can we, as professionals in the field, much less the general public, distinguish legitimate organizations and well trained practitioners from those with less competence or professional accomplishments? Katz and McBean, writing in a medical journal, discuss trends in laser hair removal, hyaluronic acid injections and Botox, and do not flinch from the mixture of medicine and commerce. "A practitioner who did not stay current with the market trends might have missed an opportunity to serve patients appropriately, and this oversight might have resulted in decreased profit margins." (Italics addedr' In keeping with our historical precedence for inclusion, it would not be

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appropriate to deride these organizations but it would be wise to remain somewhat skeptical and even vigilant. Patient safety is a mantra, rightly, for all cosmetic surgery. Can anyone learn and become competent to use injectables? What about liposuction? Are 45 CME's sufficient? This is not a new dilemma in the history of cosmetic surgery. In writing about the history of rhinoplasty, Frank McDowell, refers to a "sordid chapter.':" He is referring to the period between the late 1940's and early 1950's when "there was a spate of "quickie" courses on rhinoplasty given by teachers whose abilities were questioned by many ...usually given by ... persons who for the most part had never even considered doing any esthetic operation before, but whose practices based on sinus and mastoid surgery had fallen apart with the advent of antibiotics." These short courses did not require any prerequisite training and were often given with sponsorship by surgical instrument makers, requiring both tuition and a mandatory purchase of a set of instruments . . . sound familiar? We stand on the precipice of a new beginning. A changing economy, increasing competition, explosive technology, education and information at our fingertips, patients and the marketplace determining the direction and flow of our practices-this is your father's Oldsmobile with jet engines and accelerating afterburners. Let us know if we're moving too fast for you ... The striking feature of cosmetic medicine programs is the movement of cosmetic technology into nonsurgical fields. The promotion of both anti-aging strategies, along with less invasive surgical procedures in this setting poses a real dilemma. How can nonsurgically trained physicians become surgeons in the name of cosmetic surgery? Recognition of cosmetic surgery as a legitimate field has faced controversy at each step along the path to specialty acceptance. The AACS, including multiple specialties, has continued to acknowledge the value of surgical education for our members, including the specialty of cosmetic dermatologic surgery. However, technology can be the great equalizer. Scientific advances and implementation have the capability of decreasing (or outdating) our surgical training and its importance. Our challenge for the coming years is to proactively balance between inclusion and the recognition that credentials require more than just membership. How we define ourselves and how we respond to the next set of challenges to this definition will determine the nature of our Golden Anniversary in another 25 years.


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References 1. Webster, Richard. Cosmetic Surgery: Its Past, Present and Future. American Journal of Cosmetic Surgery 1:3-14, 1984. 2. Jage, J. Joris. Gonzales-Ulloa's Manifesto on Aesthetic Surgery. PRS 110: 1167-1171, 2002.

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3. Katz, Bruce, McBean, Jason. Incorporating a Medical Spa into a Physician Run Medical Practice. Derm Clin 26:307-319, 2008. 4. McDowell, Frank, History of Rhinoplasty. In The Creation of Aesthetic Plastic Surgery ed. Gonzalez-Ulloa, Mario. Springer-Verlag, New York, 1976.