“All or nothing at all”: How to distinguish a professional from an amateur in a complex world

The recent film “Midway” (2019) by Roland Emmerich deals with the turning-point battle of the Pacific in 1942, where the desperate American carrier naval fleet faces imminent destruction at the hands of a superiorly equipped enemy navy. The theme of this film focuses not on the equipment, but on the determination and professionalism of the squadron of “dive bombers” that are the core to attacking the enemy’s ships. The audience learns very quickly that the effectiveness of the dive bombers in hitting an enemy carrier is completely related to pilot ability, and that this ability is very difficult to assess in advance. The filmmakers, for contrast show inexperienced Midway-based “glide-bombers” that are completely ineffective (except at drawing fire), and are considered amateurs by the enemy fleet leaders although on the surface they seem indistinguishable from the professionals. The use of the Frank Sinatra song “All or nothing at all” in the film highlights the theme in this disparity.

In fields like rhinoplasty/nasal surgery, it can be equally challenging to distinguish amateur from professional surgeons. Less sophisticated readers will assume I am talking about age of the surgeon – I am not. A very youthful surgeon with the right training and experience can have much more effective technique than an aging surgeon. Professionalism is more of a mindset about setting and achieving very specific goals to reach success, while amateurism is about showing up and following a series of predetermined steps that may or may not actually achieve anything. Sadly, today, I notice our education system seems to train and reward more the list-maker and step-follower mindset than the objective oriented, but not in all cases fortunately.

As a surrogate to find the right surgeon, many use the name of the institution where the individual trained, or is affiliated to attempt to find the higher rate of professionalism. Unfortunately, this is in many cases so misleading as to be a very unreliable indicator, although the institutional names do look good on t-shirts and rear-window stickers. Similarly, flashy websites and videos, celebrity/socialite endorsements, rankings, publicized pro-bono work and elaborate office settings are frequently only camouflage to mask actual surgical amateurism (explaining why celebrity surgery is frequently lower quality than predicted).

So, then, how does one identify the amateur rhinoplasty/nasal surgeon from the professional? It is not easy at all, and will take some work, just like my wife and I learned it took months of work to find a great house to live in by intensely studying the real estate market via visits and comparisons. But how does one even find the right indicators, if I just discredited all of the typical indicators?

Perhaps type of board certification helps? Maybe, but only as a sign of commitment to a field, as a surgeon can be professional or amateur from any background if they take the time to master the anatomy and aesthetics. The key differentiation of amateur to professional is evaluating the surgeon’s ability toward “goal oriented” thinking. In other words, can the surgeon communicate specifically the end results and goals of treatments, and then logically explain how specifically these goals can be achieved in a way that actually makes sense, and then actually be able to execute all or most of the goals? I know that this does not sound impressive or useful, but let me illustrate this with an example:

A patient has had a lifetime of a slightly bent or crooked nose, with some breathing issues through the nose, occasionally pressure feelings near the nose in the morning and night, and frequently a dry mouth in the morning. They do not like looking at profile pictures of themselves, although they don’t mind the frontal appearance. They have been told by their primary doctor and dentist that they have nasal allergies, a deviated septum, and need to have their wisdom teeth removed as well. Now in their twenties, the patient is ready to improve their symptoms, and interviews several physicians in consultation:

The first physician diagnoses the patient with nasal obstruction and sinusitis based on symptoms, office-based CT (cat) scan, and sends the patient to their scheduling assistant to plan endoscopic sinus surgery, reduction of the turbinates (swellings in the nose), and removal of an offending piece of the septum. The procedure has minimal downtime, is covered by insurance and sounds not too invasive, and very scientific, plus, the physician is highly regarded in the community. This all sounds…good right? Well, it is certainly within the “standard of care” in the US. The surgeon has crafted a plan that is not goal based, but follows a series of conventional established steps that ensures insurance reimbursement, but makes no actual logical sense beyond sounding sophisticated, and never explains how or why the plan would result in any benefit to the patient, so is unlikely to achieve any improvement. What about the use of high-definition scopes and complex laser/thermal frequency or robotic equipment? These tactics are only promote a form of tunnel-vision and failure to see the big-picture, focusing on teeny blood vessels instead of root-cause anatomic problems.

The next surgeon makes the diagnosis of nostril collapse and multiple aesthetic deformities for this same patient. They plan a rhinoplasty surgery with grafts and sutures planned to address all of the deficiencies, and plan to “shave” the hump at the same time. Again, this plan is within the “standard of care” but again, the surgeon simply will follow a series of recommended steps each addressing a “micro”-problem, like a dent or depression here or there, or using the “if its weak, add strength” concept. Again, no strategy is offered, and one could even consider this complex plan to be pretty limited despite its extremely broad acceptance.

Finally, the patient sees the last surgeon. In just a short time, after analysis of the entire facial skeletal anatomy, the surgeon points out what the patient always knew, but was unable to communicate: The nose is grossly out of proportion with the size of the facial structure, particularly the bony nasal opening. This caused the septum to buckle internally (deviation), and caused the nose or septum to extrude (protrude outward) during growth, and to appear long and droopy because it grew downward towards the lip. In proportion to the petit mid-face, the jawbone is small as well, creating a propensity to mouth-breathing during sleep due to mechanical properties. This mouth-breathing causes tongue collapse during deepest sleep (REM), especially when the patient is on the back, and this causes snoring and morning headaches as a variation of sleep apnea. The inside of the nose, particularly the “turbinates” appear large on exam due to disuse/underuse of the nose due to the mouth-breathing, and the lining of the nose swells to fill unused airspace. The surgeon explains that the solution is a strategy to discourage mouth-breathing and encourage nasal breathing via nonsurgical or surgical means to increase lower jaw closure tone, or to improve nasal airflow at the nostrils and septum via stream-lining. The aesthetics and breathing can be surgically improved at the nose via septal resizing and repositioning to appropriate size for the facial skeleton as part of this strategy. This makes logical sense to the patient, and the patient begins to test this hypothesis on their own with non-surgical means and simulations, and are under no pressure to proceed with surgery. But, once the decision to proceed with surgery is made, “all or nothing” restructuring of the nasal framework is undertaken, as half-way measures are only more destructive or at least not helpful. Just as the dive-bomber pilots at Midway described in the first paragraph, either one gets the job done properly, or the mission should be avoided completely.

If you are a surgeon, and want to learn more about this strategy, contact me, or check out my new book (Rethinking Rhinoplasty and Facial Surgery/Springer 2020):



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