From Anatomy Lab to Rhinoplasty: A Surgeon’s Journey

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You're listening to the Confident Choice Podcast with me, Dr.
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Roberto Garcia, a double board certified facial plastic and reconstructive surgeon.
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Honest conversations and expert advice about the decisions that make you feel your best.
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Yeah. Well, thank you for having me. I, you know, my initial just first steps,
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my initial first steps were in medical school.
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I think much like you, you know, when you do gross anatomy and you kind of,
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you, you enjoy certain parts of gross anatomy.
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I, I certainly enjoyed anatomy of the head and neck. And that was my favorite
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section of gross anatomy.
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To me, everything seemed so small and precise and everything seemed almost like
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the inside of a clock or a watch.
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Everything just kind of was worked together in synchrony and it was fascinating.
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That's really where my original interest started.
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Then you move on to your clinical clerkships, you know, where you do pediatrics
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and internship or in internal medicine and surgery and whatnot.
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And I developed an interest in surgery.
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I really enjoyed the problems and the procedures that surgeons did.
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And then you go on and you refine and you start to see what different subspecialties
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there are within surgery.
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Otolaryngology was the one that I chose because, again, it gets back to that head and neck element.
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And that's where my original interest started. And then, of course,
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you apply for residency, and otolaryngology, as you know, is one of the more
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competitive residencies to do.
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Yeah, so sorry to interrupt you.
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In the year that I applied, and probably there were less people when you applied,
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there were 270 spots in the country. Right.
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In the year I applied for fellowship, there was 35 fellowship spots.
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I mean, it's probably close to how.
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Yeah. And out of those 270 spots, you probably have 900 applicants,
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1,000 applicants. The acceptance rate's low. Yeah.
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You got to, you got to understand though. And what learning intricate surgery,
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like otologic ear surgery, right? Where it's all microscope driven.
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You're learning how to be a technician. Yeah.
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Right. The techniques that we use that naturally fell, fell into a more natural
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surgery for us when we were doing say blepharoplasty or things with much finer
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threads for us, it was normal, right?
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Because we had already developed those techniques of working on our microscopes.
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Correct. And that's one distinguishing thing between us as otolaryngologists
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or head and neck surgeons is being able to work in that small environment using
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the small muscles of your hand.
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And everything is very focused. You're working in a small area.
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And so you develop those fine motor skills, like you said.
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And then back to my story, during residency, you begin to develop interests in fellowships.
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And, you know, where I did my residency in the Bronx, we did a lot of facial
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trauma. There was a lot of reconstruction and a lot of facial trauma.
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So that evolves into cosmetic nasal surgery, rhinoplasty.
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And so you want to learn more about rhinoplasty and the way you learn more about
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that is by doing a fellowship. And like you said earlier, the fellowships are competitive.
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You and I both did one of the more sought after fellowships in the country. Yeah.
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And we, we learned, we learned how to do rhinoplasty very well.
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And, and, and then of course you, you learn aging phase surgery and that kind of thing.
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But the point that I'm trying to make
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in all of this is the fact that you gradually hone in on the specialty.
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And you only focus on that specialty. You don't do this or do that every once in a while.
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You are only working in this small little circle of procedures.
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And like you, we do eight different procedures, seven different procedures in the face.
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Yeah, but you know, there's something to be said about, I almost feel that surgeons who.
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Don't specialize in the face, who are doing surgeries everywhere,
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I almost feel like it's a disservice and a disrespect to the specialty of the face.
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Well, you know, it's not really taken that serious.
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And this is something that you and I look at differently, right?
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Yeah. Yeah. I feel like obviously other surgeons, if they are surgeons and they
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are board certified to do the procedures that they do, that's perfectly fine.
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But board certification is a minimum.
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Board certification just means that you have the minimum knowledge base and
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you've met a minimum standard to do those procedures.
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What differentiates one specialty from the other is the scope of your practice.
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And when you talk about the scope of, and I can only speak to my practice, rhinoplasty.
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I do rhinoplasty every week. It's a repetitive thing and over and over and over.
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And like anything else, when you repeat what you're doing, your misses become
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smaller and your details become greater.
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And so because of that, you're able to.
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Translate all that I believe into excellent results
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yeah and that's where where it all happens it's not that
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we're necessarily more intelligent or
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brighter than anybody else it's the repetitive nature of what we do and this
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this is all we do it's just one after another of the same thing or roughly the
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same thing well so so you get into you get into practice in north florida what year,
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In 2001, I started my practice two weeks, three weeks after 9-11.
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Yeah. October 1st, 2008. You know the start of it.
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So, you know, what did you, obviously, there weren't a lot of facial plastics guys doing work.
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No, what there were at that time were the general plastic surgeons who did everything.
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Yeah. And then you had some otolaryngologists who did facial plastic surgery.
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So a lot of these guys did.
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They might do a rhinoplasty. They might do a rhinoplasty every once in a while.
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Yeah, every great once in a while, they would do an aging face operation,
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but mostly they paid their bills by doing overlander gals, sinus surgery,
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tonsillectomies, those kinds of things.
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So that's where I think when I came into the community, I made a commitment
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to myself that I was only going to do facial plastic and reconstructive surgery.
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And it wasn't an easy commitment to make financially because at the time I was
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trying to develop a cosmetic surgery practice in the town where I was from,
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but nobody really knew who I was as Dr.
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Garcia, the facial. Well, nobody knew that a specialty called facial plastic
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surgery existed. Correct.
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I mean, I remember reading an article that back in 1992, 95% of all facial cosmetic
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surgeries were done by general plastic surgeons, board-certified plastic surgeons.
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And in 2003, they did the same study, and 94% were now done by facial plastic surgeons.
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Now, I'm going to speak on that for a second.
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You think about it. That's 180% turnaround and the volume of how things,
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it's a complete paradigm shift.
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But interestingly, the reason it happened was, you know, back when the board was created, right?
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1986, right? After that skim milker.
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82 sorry and now all
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of a sudden facial plastics as a
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specialty became prominent at the academic level
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yeah and now every ent program not
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in the 80s but eventually over the course
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of the next decade 15 years had a guy
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trained in facial plastics yeah right yeah because there
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have been fellowships up until that point but there wasn't
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a board and so now all of a sudden you had facial
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plastics guys in the academic institutions taking on
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those facial cases where before they had gone to
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the general guys and now the general guys are graduating and they don't have
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the volume and now they get into practice and they don't feel comfortable with
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their practice they can't do it well yeah or they feel less comfortable yeah
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i think that a lot of that speaks to what you said about the, the,
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the, the turnaround in the, the percentage of cases that our specialty does
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as compared to 40 years ago.
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And you know, you're, when you, when you try to explain something like that,
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it's really not that there's the majority of people in this country are under
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some sort of mass delusion and we've been able to delude them and to think.
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No, that's the only thing that existed. That's correct.
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So, the only other alternative is results, right?
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The results are really what refers patients to you if you have your best results.
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And that's how I've been able to build my practice.
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That's how, you know, everybody else in facial plastic surgery has been able
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to build their practice. better results with rhinoplasty, happier patients.
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They tell other patients and so on and so forth.
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So it's just the progression of the growth in our specialty.
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Yeah, and I can tell you that, you know, there has been over the course of years different...
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And I don't like to use the word, you talk to some of these gung-ho guys in
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our academy, and they call it encroachment into our specialty.
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Anybody's free to do, I don't have that, I'm not that militant guy.
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You know, if you do good work, I don't care what specialty you are, you do good work.
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Because even within our specialty, there's guys, and you can probably attest
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to this, you go to a meeting, and you're looking at the presentation,
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and you say, which one's the before, which one's the after?
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Many times. You know, and you know, they got the little Ivy league logo at the
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bottom or whatever it is.
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And, and you say to yourself, okay, well, that's not going to float in the real world.
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And so I have met very, very, I mean, Dick Webster was a general plastic surgeon,
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one of the best in the game. Well, he was the first president of the American
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Academy of Facial Plastic Surgery, but Dick Webster was an interesting guy because,
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first of all, he was a very gracious guy.
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Dick Webster was a plastic surgeon from Boston, and he was a very gracious individual.
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He brought in people from all different kinds of specialties.
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He brought in otolaryngologists and, you know, some of the people from our lineage.
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He brought in people from our lineage into his practice to teach them how to
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do facial plastic surgery.
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But that was an exception in the world of plastic surgery.
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There were really no other Dick Websters out there. He was truly a gracious person.
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Well, with regards to sharing knowledge. With regards to sharing knowledge, right.
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The academy, like you said earlier,
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the board was born out of a $1.5 million lawsuit that Jack Anderson,
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one of the pioneers in our academy from New Orleans,
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One in a libel case against two general plastic surgeons in Atlanta who posted
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a series of articles in, I think, some kind of Georgia archives magazine.
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Yeah. And it might've been the, the, the journal for the Georgia medical society
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or something like that. Yeah.
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I, in my office, in one of those rooms, I have it.
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Yeah. And so they, they basically, they took a position that anybody who wasn't them was not real milk.
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It wasn't whole milk. It was skim milk that we were diluted.
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When in fact, you look at the history of facial plastic surgeon all the way back to Jacques Joseph.
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Who was one of the, if not the father of modern plastic surgery,
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he was an otolaryngologist from Germany who pioneered rhinoplasty.
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Even Harold Gillies, who was an English plastic surgeon, he was an otolaryngologist
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who took his practice to plastic surgery, but his original training was otolaryngology.
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And so when you go back to that whole history, it's really all otolaryngology
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based where the division happened is a group of people decided that they weren't
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going to be inclusive. And this was in the, in the interwar period.
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And they said, this is our territory and we're not going to share where we're
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going to create our own board, which was their right to, to create whatever
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group they, they wanted to,
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but we had to do our own thing.
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Our predecessors had to do our own thing because we were just as,
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if not more qualified to do these procedures that we do.
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Yeah. In that case, in the court case, they actually brought up examples of,
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you know, with a brow lift,
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an ENT is more qualified to do a brow lift because he has done osteoplastic
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flaps. He's done frontal sinus surgery.
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With a facelift they've done parotidectomies for years you know with eyelid
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surgery they've done trauma periocular trauma and with nasal surgery of course
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we've done sinus and internal uh internal nasal work so in fact.
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Our base, the otolaryngologic base, the ENT base, was better suited for this. Cosmetic surgery.
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Cosmetic surgery. It was a natural progression. Right.
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It's not a natural progression when you've been doing bowel surgery for a year,
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and then all of a sudden you're thrown into doing a rhinoplasty.
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Right? Because if you remember, and I do want to get to this point,
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if you remember, we didn't just jump into rhinoplasty as second-year residents.
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Right? We started off doing septoplasties, and we'd watch a lot of rhinoplasties,
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but it wasn't until my chief year that I was actually doing osteotomies and moving bones.
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And definitely in my fellowship, you learn more. And so that's one of my biggest
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fears that I have now with this younger crop of physicians that's coming up.
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They're going to have a longer period of fear. I think every young surgeon when
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they graduate from residency or fellowship has a period of fear,
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you know, like that, holy cow, I'm on my own now.
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Yeah. I'm slightly looking over my shoulder. I remember those days.
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Yeah. Losing sleep before you're ready.
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You know, you're sitting there like, what if I, what if this happens?
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What if that happens? Whatever.
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And so, but you got to realize we were doing that on the heels of 4,500,
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maybe 5,000 cases that we had done just in the face during residency.
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Well, now with all the resident restriction work hours, these kids are graduating
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with two-thirds of the cases low data.
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Yeah, I think that that's inherent in what is coming out of residency right now.
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I don't think that the way residencies were designed when you and I were in
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it, I don't know that that was the best way to educate.
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And all of that, I'm digressing here, but all of that was born from the father
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of modern surgery in the United States.
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There's a big statue of him at Hopkins. I can't remember his name now. I don't agree with that.
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Well, he was a cocaine addict. No, no, no. I'm not saying him.
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And he was up at ungodly hours of the day. He wouldn't sleep.
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And so his residents wouldn't sleep either.
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And that whole educational system in surgical education was born out of a cocaine addict.
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So it became very punitive. So it became punitive and it became this,
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it doesn't matter how much you don't sleep or how much you do sleep.
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Yeah, but there's the argument though, and I'm not totally disagreeing with
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you, but there's the argument that a Navy SEAL is the warrior that he is because
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he doubted his entire existence in his training, right?
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That he got taken to the brain. But he got pushed to the left.
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And if you don't take these kids and you don't push them and have the fear in
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there, because right now these residents don't have the fear of being fired.
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That's correct. That's something that we have that fear. And every day you went
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into a case and if you weren't ready for it, you knew you were going to get blasted.
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I mean, I don't know, my fourth year of residency, one of my attendings,
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Rick Kelly, if you're listening to this, it was you and who I ended up loving.
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And he and I are good friends.
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He looked over at me and he goes, you might be Dr. Garcia, the dumbest person
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I've ever met in my life. And it was only because I didn't know one particular
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part of this laryngology procedure we were doing.
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And so you have a choice at that point. Yeah, yeah. And you can say,
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all right, does he really think I'm the stupidest? Like, really, the stupidest?
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There's guys with IQs of 50. That guy, BB?
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Or is he just saying it to challenge me, to make me really rethink something
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and never make this mistake again? And it's obviously the law.
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Yeah, yeah. We all know that you have to push the motor to the limit to know
00:18:00.882 --> 00:18:04.582
what the motor is capable of. I don't disagree with that part of it.
00:18:04.902 --> 00:18:11.482
The part that to me was the most distasteful part of residency was the hazing
00:18:11.482 --> 00:18:17.942
and the mental torture side of it. the, I went through this process and I'm
00:18:17.942 --> 00:18:19.342
going to make you go through this process.
00:18:19.642 --> 00:18:23.582
I thought that was totally unnecessary, but maybe it was, it was a little bit more malignant.
00:18:23.802 --> 00:18:29.122
My, my residency was malignant. It was in New York city and it was all in all.
00:18:29.262 --> 00:18:33.342
I do take away good memories from residency, but that, that was the way that
00:18:33.342 --> 00:18:36.522
the educational system was and that's, you just went through it.
00:18:36.582 --> 00:18:39.962
And it's a very important point that you brought up that, especially when I
00:18:39.962 --> 00:18:45.102
was an intern, I will, I, I'm every day that I was, I walked into the hospital,
00:18:45.362 --> 00:18:51.082
you are under fear or threat of being fired and you don't know.
00:18:51.282 --> 00:18:55.602
And if you're fired from internship, remember you're already accepted to residency,
00:18:55.602 --> 00:18:58.002
which is what you're going to do for the rest of your life.
00:18:58.142 --> 00:19:02.522
And if you're fired from that internship, there goes your entire career plan
00:19:02.522 --> 00:19:04.322
because you're no longer a resident.
00:19:04.422 --> 00:19:10.902
So you've now got, you, you've, you have to figure out. And I'll give you a quick anecdote.
00:19:11.142 --> 00:19:20.442
I got called in to the chairman of surgery's office one time because I was late to a conference.
00:19:20.862 --> 00:19:24.142
I was late because I was taking care of the patients on the floor.
00:19:24.262 --> 00:19:26.822
I mean, I had a valid reason. Somebody was crashing here.
00:19:27.342 --> 00:19:30.202
And I was late. He saw me walk in late.
00:19:30.442 --> 00:19:34.942
After the thing, he called me into his office. And I can tell you that I honestly
00:19:34.942 --> 00:19:39.842
thought I was going to get fired. and I was convinced this is it I'm done and.
00:19:41.442 --> 00:19:46.722
How much good that did to my fortitude and the creation of character.
00:19:47.102 --> 00:19:52.542
That's tough to say. I don't know, but you're absolutely correct in your assessment
00:19:52.542 --> 00:19:55.222
about pushing that engine. Yeah.
00:19:55.722 --> 00:19:59.422
Well, and look, I mean, if we were to kind of wrap this up, I,
00:19:59.502 --> 00:20:02.042
and I wanted to, I do something really cool at the end.
00:20:02.182 --> 00:20:04.022
I don't know if I've told you this, but we'll talk about it in a minute,
00:20:04.122 --> 00:20:08.642
but 20 years, 25 years later. Okay.
00:20:10.482 --> 00:20:16.322
Now patients come seeking facial plastic surgeons. Right. They come seeking the specialty. Yeah.
00:20:17.122 --> 00:20:19.982
And, you know, it's something to be proud of.
00:20:20.182 --> 00:20:25.262
Yeah. It's something to be proud of that, you know, you and I have been steadfast
00:20:25.262 --> 00:20:29.242
in our commitment to the specialty in this community and in this part of the country.
00:20:29.562 --> 00:20:36.282
Yeah. And, you know, our reputation precedes us really as individuals that were,
00:20:37.031 --> 00:20:40.331
is characteristically driven towards a particular model.
00:20:40.751 --> 00:20:44.551
And, and I think that a lot of that, and this is going to lead me into our last
00:20:44.551 --> 00:20:46.031
segment, which is perfect.
00:20:46.391 --> 00:20:51.531
Okay. You guys all laugh at it every time I do it, this all leads us to lessons
00:20:51.531 --> 00:20:53.651
that we learned from dad, you know?
00:20:53.951 --> 00:20:58.671
And so, you know, dad died. My dad, I say this every week, but our dad died
00:20:58.671 --> 00:21:01.971
last year in June, June 16th, almost a year.
00:21:02.331 --> 00:21:09.411
And dad, uh, as well, you know, dad loved to teach dad loved to talk to us and
00:21:09.411 --> 00:21:13.051
he loved to talk to everybody and along the lines.
00:21:13.151 --> 00:21:18.931
And I think this is so appropriate for this conversation was the lesson or the,
00:21:18.931 --> 00:21:24.571
the, the kind of that, that ongoing message of in order for you to succeed,
00:21:24.911 --> 00:21:26.791
you have to fail countless times.
00:21:27.711 --> 00:21:32.331
And the, you know, the idea, the Thomas Edison concept of the light bulb,
00:21:32.471 --> 00:21:34.171
right? Failed, I don't know how many times.
00:21:34.651 --> 00:21:39.111
And I tell patients all the time, I said, you know, the surgeon that I was at
00:21:39.111 --> 00:21:42.051
the beginning of my career, it's a completely different surgeon than I am now.
00:21:42.411 --> 00:21:48.431
And really not only in the medical field, but in a personal, right?
00:21:48.811 --> 00:21:52.011
Interactions with my employees, interaction with friends, interaction with family.
00:21:52.971 --> 00:21:56.251
You, you learn, okay, that's not the right way to talk to that person.
00:21:56.411 --> 00:22:00.271
That's not the right thing to say. Let me correct that. And let me get a little bit better.
00:22:00.371 --> 00:22:07.491
But the difference in dad spoke about this, you can't be hubris.
00:22:07.931 --> 00:22:11.111
And when you make a mistake, you have to own it.
00:22:11.251 --> 00:22:15.991
You have to make a correction and you have to adjust and become a better person
00:22:15.991 --> 00:22:19.991
because the goal of this isn't a scoreboard at the end of life where,
00:22:19.991 --> 00:22:21.451
you know, where God says, or St.
00:22:21.611 --> 00:22:23.831
Peter at the gate says, all right, Roberto, good job.
00:22:24.031 --> 00:22:29.191
You won 5,650 times, but the people around you, the world around you hate you.
00:22:29.311 --> 00:22:32.211
You know, that's not how it is. There's no scoreboard.
00:22:32.511 --> 00:22:36.331
What matters is that as you're going along and you make a mistake,
00:22:36.331 --> 00:22:38.671
and to our point about our specialty.
00:22:39.516 --> 00:22:42.396
The details get tighter, right?
00:22:42.516 --> 00:22:46.676
And so now, you know, whenever there's something that you're seeing at three,
00:22:46.896 --> 00:22:51.596
six months after surgery, you can, in your mind say, I know exactly why that
00:22:51.596 --> 00:22:55.836
happened because your, your window of error is this tight.
00:22:56.016 --> 00:22:59.876
Yeah. You pay attention to more details. The big stuff has worked itself out
00:22:59.876 --> 00:23:04.076
throughout your career and you pay attention to those little details a lot more.
00:23:04.076 --> 00:23:08.856
And it makes you better at being, being more effective and
00:23:09.056 --> 00:23:11.856
having better results but if if i may
00:23:11.856 --> 00:23:14.936
say something about dad the the
00:23:14.936 --> 00:23:17.796
thing that in in your segment the thing
00:23:17.796 --> 00:23:26.796
that i i still remember dad telling me is nobody owes you anything and i still
00:23:26.796 --> 00:23:35.176
remember multiple conversations about you know when i finished residency i finished fellowship.
00:23:35.756 --> 00:23:40.296
And, and I said, okay, dad, I'm ready to start my practice.
00:23:40.696 --> 00:23:46.296
And I remember dad saying, and now's when the work starts.
00:23:46.636 --> 00:23:53.476
And that's because he always taught me and I knew as well that you're only as
00:23:53.476 --> 00:23:55.076
good as what you did yesterday.
00:23:55.963 --> 00:23:59.823
Everything can come crashing to an end today.
00:24:00.183 --> 00:24:07.883
You have to have the humility to realize that and to understand that you're
00:24:07.883 --> 00:24:10.023
not owed anything in life,
00:24:10.243 --> 00:24:15.183
certainly in our field, in our specialty, in our practices.
00:24:15.583 --> 00:24:19.543
Nobody owes you anything. You have to work every day and you have to challenge
00:24:19.543 --> 00:24:23.123
yourself every day and, and always be attentive.
00:24:23.363 --> 00:24:27.383
Never take your eye off the ball because there's nothing here for granted.
00:24:27.663 --> 00:24:30.783
So that's my lesson from that. That's beautiful.
00:24:31.183 --> 00:24:36.983
That's exactly right. Yeah. Well, listen, man, it has been absolute honor having you here.
00:24:37.163 --> 00:24:40.663
I really appreciate you coming out here. I know you're busy and we,
00:24:40.783 --> 00:24:43.103
this is honestly, this may be the best one.
00:24:43.563 --> 00:24:48.103
Okay. I know we said that last week. It's because it's me. But it's my bro. Sorry, Patrick.
00:24:48.423 --> 00:24:51.703
But it's my brother. And I do think this one took the cake.
00:24:52.083 --> 00:24:57.323
So any of you thinking about watching the Confident Choice, you want to go to this one first.
00:24:57.743 --> 00:25:02.743
So next week, we're going to be talking about, let me get my card, revision surgery.
00:25:03.303 --> 00:25:08.083
And how is it that we accept not the best results?
00:25:08.323 --> 00:25:13.103
And where do we go as surgeons to that next step? Do we wait a little bit?
00:25:13.263 --> 00:25:15.863
Do we go ahead and get, do we intervene a little bit sooner?
00:25:16.263 --> 00:25:19.623
And how do we plan the proper revision surgery for whatever it is.
00:25:19.963 --> 00:25:22.043
And, folks, I'm going to tell you something. I'll get into this next week.
00:25:22.263 --> 00:25:24.983
Any surgeon who tells you he doesn't have revision surgeries,
00:25:25.363 --> 00:25:28.203
he's either lying to you or hasn't done enough of them. That's a fact.
00:25:29.063 --> 00:25:33.923
And it has nothing to do with the surgeon. It has to do with the way the cookie
00:25:33.923 --> 00:25:36.323
crumbles sometimes. Results happen.
00:25:37.283 --> 00:25:40.223
Biology is different between person A, B, C, and D.
00:25:40.543 --> 00:25:44.523
So we'll dive in a little bit deeper into that next week. And remember,
00:25:44.763 --> 00:25:45.943
Alyssa's going to get me here.
00:25:46.663 --> 00:25:50.383
Better decisions make better information. What is it? Good decisions always
00:25:50.383 --> 00:25:53.263
come from good and free. And good.
00:25:54.307 --> 00:25:58.407
Good decisions always come from good information. We're signing out.
00:25:58.507 --> 00:25:59.447
Have a great week, everybody.