., is an internationally recognized cosmetic facial surgeon practicing in Richmond Virginia.

Joe Niamtu III, D.M.D.

Most practitioners are indebted to their community for the success of their practices. I truly believe that most fulfilled and successful doctors are eager to give back to their communities. I, like many readers of this article, have provided pro bono services, participated in volunteer efforts, become involved with numerous charitable organizations, and simply tried to make my community a better place. I performed many charitable reconstructive surgeries on children in the earlier part of my career. I have 2 special needs children with severe disabilities but was active in helping children years before my sons were born. Having said that, much of my current charitable work centers around children and adults with disabilities.

Like many, my practice is called on frequently for charitable fundraising support for innumerable causes. This began as a trickle 20 years ago and has developed into a streaming pipeline. Despite this, I've tried to support any request. The most common request is the donation of a cosmetic item for a charitable auction. Providing a neuromodulator or filler treatment or a skin care basket has been an easy way to support these groups.

Many of the groups are well-known national charities. Additionally, I have supported public and private school fundraising auctions, gymnastic team auctions, golf tournaments, and pretty much every describable request within a community.

For the most part, this has been extremely bilaterally beneficial. My practice gets to assist organizations with raising funds for their good work and at the same time I get recognition as a provider of cosmetic services in my community. Some fundraising “winners” have become regular patients. Generally, this is a win-win situation.

Whether it be seen as good or bad, the more charities you support with donations of products or services, the more requests you get for further donations. As I mentioned earlier, what began as a trickle became a significant investment.

This did not bother me because in the end, I am helping people in need.

Even when they are soliciting with the best of intentions, some people find a way to take advantage of the person or practice donating. In the beginning, we simply accepted all requests and printed a certificate redeemable for a given service. We had no rules and assumed it would be an easy situation.

In years past, some people would come to the practice holding crumpled and tattered auction certificates issued 3 years prior. Others would show up with a certificate they personally did not bid on and once, someone showed up with a photocopy of a certificate demanding redemption.

We quickly learned there had to be some rules, so we refined our certificates. We began putting a chronological number on the certificate as well as issuing an expiration date and declaring that the certificates are nontransferable.

This immediately solved some of our problems, but unfortunately our diligence was not enough. After implementing the updated rules, I would ask certificate recipients what price they had paid in the auction. Frequently, and especially for nationally known charities, the bidder had paid far more than what the actual auction item was worth in the fun of a charitable bidding war.

This made me feel great because the charity really benefited. Other times, people would show up with a certificate for neuromodulator treatments or injectable filler that had a retail worth of $1000 and they had only spent $20 for the winning bid. After this, we started informing charities that if the item did not sell for a reasonable portion of its value, it should not be auctioned, and we would re-donate the next year.

Just when we thought we had everything under control, a member of my staff noticed that a person who had requested auction items for various “charity golf tournaments” had not only picked up the certificate from our office but also personally redeemed it. At first this did not set off red flags. I have seen auction chairs purchase an item they personally requested from a practice because they either wanted the service or product themselves or wanted to drive up the value for the organization.

However, the reality was that the person collecting these golf tournament certificates would pick them up and redeem them when different staff was in my office. Well, that is until someone noticed. At this point we investigated the charitable golf tournaments: we could find no record of 1, another responded that they had never asked for or received any auction item from the practice, 1 didn’t respond at all, and the last said they did not keep records of charitable donations.

It was at this moment we realized we had been scammed. Adding to the hurt was the fact that some of this malfeasance was done in the name of children’s charities.

This situation made us review our entire process and add additional safeguards. First and foremost, we issued a compliance list for receiving, auctioning, and redeeming a charitable certificate, with the following requirements:

The certificate cannot be redeemed by the person requesting it or collecting it from the office.

The person picking up the certificate in office must provide a photo ID which we then copy and keep in our records.

The receiving organization must provide us with detailed information about the certificate winner. This is documented in a form that we give to the organization and must also include the amount of the winning bid. The certificate cannot be honored without this information. This puts some of the responsibility on the organizations, which can be lazy with record keeping.

Needless to say—and shame on us for not doing more research—we now investigate any organization that requests a charitable gift. Due to the amount of requests we receive, we have also started rotating the smaller venues (sports teams, PTAs) instead of honoring every single request.

It has been my pleasure to support national and local charities and organizations within our community. Like anything else in life, there are situations where people may take advantage of one’s generosity. We learned much of this the hard way and I would like to pass along some caveats, which include the following:

Investigate all requesting organizations for legitimacy and obtain detailed information about the requesting individual.

Invest some time and thought into a professional redemption certificate that includes:

Expiration date of service or product redemption

An accompanying form that must be filled out and followed exactly for redemption. Clearly state the necessity of this form on the actual certificate: If the form is not completed and returned by the organization, the certificate is void.

When the charitable affiliate comes to collect the certificate, obtain a copy of their photo ID. We request personal pick-up and don’t mail out certificates.

Inform all people involved that any fraud will be reported to authorities.

I still believe that the more you give, the more you get. Just give wisely.

Articles

Donating to charitable organizations is a great way to give back to the community. However, physicians and practices need to create concrete safeguards to protect against being scammed, says Joe Niamtu III, DMD, who knows the hurt of this very real situation.

No Good Deed Goes Unpunished

So if I ask you how was 2014, you'd probably have to scratch your head and really try and think of what happened that year. But there's no doubt in the future when you ask somebody about 2020 they will tell you exactly what happened!

The coronavirus has brought so many changes to every single faction of our life, but not all of these are necessarily negative. Many situations have evolved that have actually made some parts of practice better and easier.

I have to say that I do not miss having a waiting room full of patients. Unfortunately, to get from one side of my office to the other, I have to walk by part of the waiting room, and many times I tiptoed and hunched down because I was running behind and felt bad about it. If you would have told me a decade ago that patients would wait in their car in the parking lot and be happy about it, I would have called you crazy. However, this has become the new norm. They're comfortable. They don't need to sit next to a stranger. They have their own music, can adjust their own temperature, recline their seat, and simply don't seem to mind waiting in their car. I am not saying that I would never go back to a traditional waiting room, but I certainly would do it on a smaller scale.

Another thing that this pandemic has underlined is unnecessary appointments. Being a busy surgeon, I've always thought that I needed to see my postoperative patients frequently to make sure that they were not having problems. Reducing foot traffic and patient visits due to the coronavirus has been a positive situation, as I have more time to see new patients and am spending less time with postoperative patients. Contingent with this is the grand acceptance of the Zoom platform. Even the most resistant practices to telemedicine have now found online consultation and follow up a normal part of practice. This is one part of my practice that won't change even when the pandemic is over.

In terms of professional meetings, I heard a key opinion leader say the other day that meetings are dead. I think this is a gross understatement, and I think that people are getting a bit Zoomed out. At first it was pretty cool to sit there and either watch or present lectures on these interactive platforms, but after a while, everybody was asking you to lecture at every meeting without compensation, and for many of us it became problematic. Even for those who just attended online meetings and did not present, we have all been saturated with these meetings. So, I strongly disagree that annual meetings are dead. In fact, I can't wait to get back to Las Vegas with the smells and sounds of the casinos and have libations and share stories with my friends from around the globe. My prediction is just the opposite: Meetings will become very popular once again because people have been stuck at home and will be ready to get out when it's safe.

I also have to admit, like many of my colleagues in the past, I was at times somewhat complacent about personal protective equipment, and the severity of this pandemic has been a constant reminder to me and my staff of how important it is to protect ourselves to, in turn, protect our patients and families.

From the necessities and conveniences of telemedicine to the reality of virtual meetings, this is Dr. Joe Niamtu’s take on changes that have affected specialty in 2020.

Reflections on 2020 and the Aesthetic Practice

Video conferencing applications have made the virtual cosmetic surgery consultation via telemedicine possible, but avoiding issues — from audio to lighting — requires planning and at-hand solutions for success. Joe Niamtu, D.M.D., offers a realistic look at what can go wrong, and how to avoid and/or correct your course. 

Videos

Dr. Joe Niamtu offers pearls and pitfalls of the virtual cosmetic surgery consultation in telemedicine.

Virtual Cosmetic Surgery Consultation Tips for Telemedicine

Like many of the people reading this article I have given hundreds if not thousands of academic presentations over three decades, spanning six continents. I always end my lectures with a slide of me with my collection of speaker badges.

Yes, I guess I am a hoarder, but each meeting reminds me of a special experience.

. I am not sure where I first heard these words and I certainly did not make them up — probably the Egyptians or Romans did, as the idea is timeless. For some of us our job is simply employment, and I have friends who unfortunately yearn for two things in their life: Friday and retirement!

Hating your job is not a great way to go through life. On the other hand, I have so many other fulfilled friends like myself who truly love what they do and are passionate about their job. When I say job, it is really a misnomer, as I should say “career.”

When I speak to students or residents, I always stress the point that most people in the workforce are “TGIF” because they can't wait to get away from their jobs. Whereas I am really TGIM, and I can't wait till Monday. After three decades of practice, I started taking Fridays off of work and, I can tell you, by Sunday night, I'm excited to go to work on Monday and perform a facelift. I feel very lucky to have such a passion where my vocation is my avocation.

I do have friends and partners that don't mind their jobs, but it is really more of a nine-to-five situation for them. They don't do much continuing education and they really don't participate in any formal teaching, publishing or have an online presence. They are very good at what they do but I think they're missing out on a lot.

Anyone in life — and it does not only apply to doctors — can be a lifelong teacher and a lifelong student. I feel that we are all always learning and, for many of us, we are always teaching. Teaching may formally relate to giving lectures or demonstrations to colleagues and students. It may also refer to helping staff be better at what they do. And it may also refer to interaction with our families. Most people that I know who are truly fulfilled in their personal and professional lives are teachers and students, always.

Again, like many people reading this article, I’m a bit over the top when it comes to being involved in my profession. I maintain an extremely busy surgical schedule (I did 110 facelifts last year). I personally do all of my clinical photography and before and after pictures. I do all of my own social media and manage my own website. I teach a yearly cosmetic surgery course at my office, lecture about 15 weekends a year and am continually writing some journal or textbook article. For some people that would be a horror show but, again, I love what I do and this all plays into the satisfaction of watching my practice grow to an international entity.

Although some doctors don’t consider themselves teachers, we actually all teach, if nothing else by example. Teaching allows more experienced people to interact with less experienced people, which is invigorating and a necessity for mentorship. Everyone reading this article can think of a given person or persons in their life that pointed them in the right direction and inspired them to become what they are today. For a person reading this that says, “Who in the heck am I going to teach?” that is a simple answer: Begin at work. Although most of our staff understand what we do, taking time to teach them the finer points of anatomy, physiology and surgical technique can improve them personally and professionally. This will pay off for you in the long run by better assisting, better consults and more informed employees.

In this day and age of digital technology, all you need is your phone (as a camera) and PowerPoint on your laptop and — BANG — you have something to offer. Teaching a particular clinical skill, for example, “How to Set Up the CO2 laser,” simply involves creating a short PowerPoint or phone video. Now, not only does your current staff have a resource for understanding how to correctly set up your laser, but new hires can view the file at any time, which saves the office time, the doctor frustration and increases patient safety.

If you have a residency program in your city, having young doctors shadow you or observe you during surgery is rewarding for both sides. I work with residents from Virginia Commonwealth University on a weekly basis and, I have to say, I have learned as much from them as I have taught to them. The same thing is possible with medical and dental students or even college students. There are many levels of students that would love to hear a lecture that includes information about a given specialty, anatomy, practice management and more.

Having residents or students observe or shadow in the office can be a very rewarding experience for all involved.

I publish frequently mostly in the cosmetic and aesthetic print literature or online. I frequently get asked by younger doctors, “How did you get chosen to be in that magazine?” and my answer is, “I picked up the phone and called them or sent them an email and asked them if they would be interested in having me write an article on a given topic.” You would be surprised how many media outlets are interested. Some ignored my requests, often multiple times, but slowly, one article at a time, my efforts blossomed. Media outlets are continually searching for content and if you can provide topics of interest and deliver them ahead of deadline, you are way ahead of the pack and can become a regular contributor.

Most of this article has addressed teaching, but the other important part of this equation is to always be a student. When I look around at really successful colleagues, I see numerous common denominators. One of them is energy. These people are never lazy. They are continually juggling projects and have a quest for knowledge. Another attribute is a sense of wonderment. Movers and shakers are never satisfied with the basics but always interested in looking deeper into the way things work and questioning all of their surgical techniques to see what they can do better and what can deliver the most predictable outcomes for their patients. They read. They study. They watch videos. They attend meetings. These people are not clinical nerds, they all have nonclinical passions and hobbies to balance out their lives.

One of the things that I do as student is when I can’t remember a specific anatomic entity or the name of a drug or a new drug on the market, I add it to a list on my phone. When I have time, I go down the list and educate myself. Usually it is reeducation, as I knew it once but forgot. If you don’t write down these things (“Hey Siri, remind me to look up….”) you will forget.

Every night when I go to bed I ask myself, “What did I do today to enrich myself or those around me? What did I do to make a positive contribution to society?” It is not a good day if I don’t have an answer.

I believe, to be the best that we can be: 

Not only are these words that Dr. Joe Niamtu lives by, but he believes all the best (and most fulfilled) doctors do too. 

Always Be a Teacher. Always be a Student.

Those were the words of an oldie but goodie song originally done by the Five Man Electrical Band in the 70’s. In a way, it applies to cosmetic treatments among various specialties. You look at their marketing and the sign says, “Get rid of your double chin.”

If everyone is honest and fair, puts their ego and profit aside, they would agree that there are numerous specialties that do numerous surgical and nonsurgical treatments in aesthetics. Unfortunately, a lot of professional bickering and jealousy still goes on, especially for those doctors with antiquated thoughts and their heads in the sand. The truth is that a plethora of cosmetic treatments are available for the average patient from their primary care doctor, their dermatologist, their maxillofacial surgeon, facial plastic surgeon and otolaryngologist, ophthalmologist/oculoplastic doc and plastic surgeon to name a few. This also extends to RNs, general dentists, medspas and even health clubs. The bottom line is there is no shortage of providers for cosmetic procedures, especially the nonsurgical variety.

This can be very confusing for patients and even confusing to a certain extent to professionals. Contemporary cosmetic procedures involve many surgical and nonsurgical treatments from a variety of specialties. So, if a patient has some fullness, do they get Kybella from their derm, Coolsculpting from their local medspa, lipo or submentoplasty or facelift from their surgical specialist? That is the question. The answer is somewhat harder.

We all have something to offer. I personally feel that the biggest advances I have seen in my three-decade surgical experience have been mostly nonsurgical. In the mid 1990s a whole lot of stuff happened at once. This period ushered in neurotoxins, fillers, liposuction, laser technology, tumescent liposuction, endoscopic surgery and other advances. It was a beautiful time for progress, but a somewhat slippery slope for treatment as much of what we regard as “standard” today was hashed out by trial and error in the 1990s. When I purchased my first CO2 laser then, there was no “instruction manual” and the evidence-based literature was in its infancy. The settings that many providers take for granted today were hashed out by pioneers and often fraught with overtreatment and lawsuits.

Although some of this will always occur with new technology, I feel that today’s providers are on much more solid ground with treatment protocols.

Back to my initial question, what is the correct treatment for the patient that walks in with submental fullness? Well, it is provider driven. Let’s start with the least invasive. In my hometown, there are many places where one can receive treatment with various devices for skin tightening, fat freezing or fat melting. If they have a relationship with an office that does these procedures, they may think that this is the precipice of treatment. These treatments, for the most part, do something, but are usually limited to conservative cases with minimal skin excess. The next step up may be Kybella or similar mesotherapy injections, which are pretty noninvasive. Again, they have their place but usually don’t produce earth-shaking results and do nothing for skin excess. Thread lifts are a little more invasive but don’t have a great track record for longevity. I mean no ill press to those providers who offer this, but it seems to come in and out of vogue every decade. Perhaps the technology will continually improve. Finally, the patient could find themselves in a surgical office and may opt for liposuction, chin implant, submentoplasty or facelift. Yep, it is surgery, I admit it. But I also think it remains the gold standard for most advanced aging problems. Yes, I am a facial surgeon — full disclosure!

I recently saw a news clip form a major Derm meeting in Hawaii and the author of the article is a friend. However, she said something like “surgery is out, no one does that anymore.” Well, I beg to differ as I performed 109 facelifts last year.

So what procedure should a patient undergo and whom should they see? The honest answer is, “Every one [with relevant training] is right and you should do the procedure that best fits your budget, recovery, lifestyle and desires.” Sometimes this is difficult due to misinformation from nonsurgical providers overhyping the results and longevity of a given procedure or a surgeon prematurely operating on a patient that may benefit from less invasive treatment.

Ethically, all providers are charged with three main things: Patient safety, predictable outcomes and honesty. I have seen numerous patients that had significant neck skin excess waste thousands of dollars on skin tightening devices, thread lifting and other undertreatments. Over the years, I have seen many patients for a facelift consult that did not desire surgery and opted out, only to see them two years later after they spent more than the facelift would have cost on devices and therapies that were ineffective. I have also seen patients from other offices that had minimal aging and were way overtreated with surgeries, so it happens on both sides of the non-invasive/surgery coin.

Our job, our charge, our goal is to do what is right for the patient. It takes an ethical doctor to tell patient that they could undergo a given procedure, but it just won’t meet the patient’s expectations or provide longevity. It is hard (especially for younger doctors) to turn away a patient, an aging problem and a check book, but it is ethically imperative. For every surgical patient I evaluate, I ask myself “would I do this procedure on a family member?” That credo has severed me well for decades. There have been hundreds of patients over my career that I told that they were not ready for a facelift and that they should see a colleague for a less invasive procedure. It all comes back to you in the end as our reputation is our only brand. Do what is right, do what is best for the patient regardless of economics and you will be respected and appreciated.

When I look around at the most successful practitioners I know from all specialties, they have some common denominators: They are joyous, they love their profession, they care deeply about their patients and they are always honest with their patients.

The “right” treatment isn’t surgical or nonsurgical: It’s the one that is best for your patients, meets their expectations and provides longevity.

Do This Don’t Do That, Can’t You Read the Signs

When I first started injecting fillers in the mid 1990s there were two choices: Zyplast and Zyderm, both bovine collagen products. At least one allergy test (usually in the forearm) was required and then the patient would have to wait at least a month to see if there was a reaction. All that aside, the fillers did not do much, were not reversible and sometimes the effect only lasted for weeks. We have come a long way since then. In the first part of the 21st century, hyaluronic fillers were introduced and they were FDA approved, which was a true paradigm shift.

These fillers changed the minimally invasive cosmetic landscape and offered safe, reversible, natural and and long-lasting results. At first, the basic indication for these new fillers were plumping lips and filling nasolabial folds. No one, ever, came into my office in the late 1990s and requested “tear trough” or “mandibular angle” or “temple” fillers. These, along with many other innovative and useful treatments were developed by numerous providers from a plethora of specialties. While on the subject, the original gangsters of fillers included dermatology, ophthalmology (oculoplastic), ENT facial plastic surgery and plastic surgery. These specialties were natural choices as they all had expertise in facial surgery. I have always included my own specialty, oral and maxillofacial surgery in this qualified group. I think if you look back 15 years ago, the sum total of filler injectors were from a handful of specialties. In many instances some of these specialties attempted to monopolize filler treatment and availability to other peers. The excuse was patient safety, but I believe it was mostly economic and aimed to limit competition. In many instances, it was a combination of both. Personally, I have welcomed and taught any injectors over the past 20 years who were legally licensed to perform these treatments. I always thought that limiting education and availability to other specialties would be akin to only allowing certain specialties to use penicillin when it was first discovered. Having said this, I think it is essential to teach the safe way to do these treatments. Not just “where to put the needle” but much more importantly, essential head and neck anatomy and danger zones.

For those injectors who don’t want others perform these procedures, it is too late; that train has left the station! It is the responsibility of the expert injectors to pass on their knowledge to make sure legal injectors have the proper training for injection safety.

Virtually all of the doctors that had large injection practices 15 years ago were doing their own injections (including me). Looking at these same practices today, more injections are performed by physician extenders such as RNs, NPs and PAs. Although I still do a fair number of my own injections, I have taught my nurses how to safely and effectively inject.

This dispersion of available legal injectors has filtered down to virtually every specialty and also includes med spas and general dental practices. This is good news for filler companies, not so good news for profit or doctors fearing competition. I personally feel that as long as these treatments are being done safely, then it merely represents progress. Taxi drivers don’t like the entire Uber ride share phenom, but again, it is progress and delivers a service to a wider base. Whereas fillers may have been very profitable for doctors before they became available on every corner, today they are becoming commoditized. Every day I see offices or spas advertising lower and lower fees for a syringe of filler. This always has an effect on competition and profit and is a fact of life that happens in most every business; it represents progress. Most of my doctor friends that once did hair removal no longer do, as they can’t compete with med spas and patients can be very price conscious. The entire LASIK situation went from being thousands of dollars to hundreds of dollars and many ophthalmologists simply stopped doing it. Similarly, 10 years ago, it was uncommon to have orthodontic treatment by a non-orthodontist. Today many types of dentists perform orthodontic treatments due to advances in technology where removable plastic trays have preplaced “wire bending” skills. I promise you most orthodontists did not welcome this, but again it is progress.

The key to progress must include the same safety margin as performed by traditional practitioners that originally pioneered and delivered these treatments. There is never a substitute for patient safety and predictable outcomes.

Taking all of the above into account, the progress of filler choices and injection site choices has ushered in a new era of complications. Blindness or massive tissue necrosis was truly rare in the early days, but have become more common and downright scary. The inclusion of treatment areas such the periorbital, perioral and glabellar regions has put the needle in close association to important vascular structures, which can lead to vascular occlusion resulting in blindness and tissue loss. Although I hear a lot of doctors blame this on unqualified injectors, it really can happen to anyone. Having said this, it makes sense that the more times a procedure is performed, the greater the risk of complications. A doctor that performs three facelifts a year may have few complications whereas a surgeon that performs 100 lifts a year will likely see more complications by virtue of statistics. Although I have seen severe complications from nontraditional injectors, I have seen many complications, some tragic, that were performed by well known, top-tier injectors. None of us are immune to this. Even the best surgeons and anatomists can experience an intravascular injection by virtue of abnormal anatomy or sometimes simply bad luck.

When I hear doctors rail about the competition, I shake my head as no one can prevent or change this, nor should they. Remember, it is progress. What they can do is to insist that all licensed injectors regardless of specialty or degree, receive the proper training required to do this safely. These safeguards may include petitioning state boards to require anatomy, didactic and proctored training for injectors that did not receive training in their core education. The filler companies can also take an active part in the dissemination of education to those who purchase their products. New injectors should avoid higher risk areas such as the tear trough or glabella. Understanding various options such as cannulas, aspiration, “vascular locating technology” retrograde or antegrade injection techniques, needle choices, syringe thumb pressure and tissue plane and vascular anatomy is requisite. 

All injectors must be able to immediately recognize filler emergencies and begin the initiation of emergent treatment. It is the obligation of any injector to know the steps of treatment and have on hand the required medications or equipment necessary for immediate treatment. This is the “ACLS” of filler emergencies. Knowing when to treat, when not to treat, and when to refer are all virtues of prudent injectors, regardless of specialty, seniority or type of practice. Finally, it is the obligation of every single injector to have proper written and oral informed consent that includes catastrophic complications such as stroke, blindness and tissue necrosis.

According to Dr. Joe Niamtu III, knowing when to treat, when not to treat, and when to refer are all virtues of prudent injectors, regardless of specialty, seniority or type of practice.