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Oral Surgeons Pushing for Right to Perform Elective Surgery



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SACRAMENTO, Calif. -- The right to perform a nose job is up for grabs in the state Legislature.

In an issue that swirls around Californians' endless efforts to keep up appearances, oral and maxillofacial surgeons are bidding to perform a number of common elective operations now considered the general domain of plastic surgeons. Under proposed legislation, medical professionals more associated with reconstruction of a jaw could tackle everything from eye lifts to wrinkle-erasing Botox injections.

Oral surgeons -- many of whom are not medical doctors -- contend that the state unfairly bars them from undertaking lucrative elective surgery even as they routinely perform identical tasks when medically necessary. The bill would require them to pay a $150 fee and gain board certification before performing the procedures at patients' requests.

"It's an equity issue," Liz Snow, public policy director for the California Dental Association, said Friday. "Many oral surgeons are currently doing work on noses. The common types of injuries in ERs are car accidents or bar fights, which frequently involve broken noses." But some plastic surgeons see the bill, SB 1336 by Sen. John Burton, D-San Francisco, as nothing less than brazen encroachment on their field of expertise.

"This goes through, I'll absolutely guarantee them they'll be doing breast surgery," said Dr. Harvey Zarem, president of the California Society of Plastic Surgeons. Oral surgeons "do great jaw work -- period. They tend to think if you have the right instruments, you can do anything. But to do a face-lift on a 55-year-old lady is a totally different story." Burton's bill -- of which Republican Sen. Jim Brulte is a co-author -- cleared the Senate Business and Professions Committee in April and is scheduled to come before the Senate Appropriations Committee on Monday. Burton, who collected $34,000 in political donations from dentist and oral surgeon groups this election cycle, could not be reached for comment.

Oral surgeons commonly perform some types of facial procedures only when a patient needs them. "Just a few weeks ago, I injected Botox into a jaw muscle, but not for cosmetic issues," said Earl Freymiller, a professor of oral surgery at the UCLA School of Medicine.

In several other states, "if you're allowed to fix a nose that's smunched, you're allowed to fix a nose somebody doesn't like," said Mark Rakich, lobbyist for the California Association of Oral and Maxillofacial Surgeons.

Thomas Hiser, the group's president, said, "Some of the plastic surgery procedures are less traumatic than taking out 25 teeth from somebody." Hiser said oral surgeons would never aspire to move below the chin.

"Breast surgery," he said, "is out of the question." Nips and tucks are on the rise in America. Last year, doctors performed more than 125,000 face-lifts, 172,000 rhinoplasties and 2.27 million Botox treatments -- the latter increasing by 37 percent over 2002, according to the American Society for Aesthetic Plastic Surgery.

The average nose job costs up to $7,000, Zarem said, about half of which is a surgeon's fee.

The profession does not track frequency of procedures by state, but California is understood to be the general leader.

"There's certainly an attitude of California to look your best," said Zarem, who has treated household names from his Santa Monica practice.

"You can tell the difference between standing at the corner in Los Angeles and standing at the corner in Omaha." California has about 1,500 plastic surgeons -- "no shortage," the bill's legislative analysis states. But with an estimated 800 oral surgeons practicing in the state, a change in law could widen a prospective patient's options if oral surgeons move en masse into the field.

"Fights between different types of ... practitioners have always been an important part of medicine," said Dr. David Magnus, director of Stanford University's Center for Biomedical Ethics. "One practice tries to take advantage of a niche. You see it between psychology and psychiatry -- you see it (with) nurse practitioners." "M.D.s are often more expensive than non-M.D.s," he added. Though elective surgery is at issue here, "in an era of managed care, one thing you have to worry about is that health-care plans may push patients into less expensive alternatives." Surgeons quarreling over who can lift a chin may have a distinctly California elan, but "all ... specialties have tried to expand the areas in which they can operate," said Craig McDow, a San Francisco oral surgeon whose practice sits close to Union Square.

"I think of it more as an ability for one to exercise their craft and offer patients perhaps another option, and another technique that may truly address a patients' concern," McDow said. If plastic surgeons "felt it was a money grab, then the other side ... would be: 'We're trying to hold on to all the money we make."' Editor Notes: NONE

c.2004 San Francisco Chronicle

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