A Patient's Story of Cosmetic Surgery and the General Medical Council (GMC)
The following is a summary of the records surrounding Mr Nasser Nasser's clinically pointless incisions, resulting from Dr Veale's flawed recommendation. I reproduce some words in capitals to highlight them as a critical section of the records.
22nd September 2000 - Dr Veale's letter referring me to Mr Nasser, after walking out of Priory Hospital North London -
"I am aware of your desperate desire for cosmetic surgery and you are also aware of my advice that you are likely to be dissatisfied with such an operation. I mentioned that it might be helpful for you to have a consultation with a cosmetic surgeon. I can recommend seeing Mr Nasser (Consultant Oral and Facial Surgeon, 103-105 Harley St, London W1. Telephone 020 7224-1033). He specialises in rhinoplasty. He is also an NHS surgeon and is not attached to any cowboy clinic that will just want to grab your money."
I did not discover until after the ensuing operation that Dr Veale had never referred anyone for a rhinoplasty consultation before and was in ignorance over even the operation's most basic technicalities.
22nd September 2000 - Dr Veale's referral letter for Mr Nasser -
"I would be grateful for your opinion on X who suffers from Body Dysmorphic Disorder. He is desperate for a repeat cosmetic rhinoplasty. I suggested to X that he make an appointment to see you. ... He is convinced that the last rhinoplasty was done incorrectly. My view is that he has a rather distorted image about his nose and that no amount of cosmetic surgery is going to change his internal image."
4th October 2000 - Mr Nasser's letter of reply to Dr Veale, of which I was not made aware -
"The essential problem is that he has had a rhinoplasty which has left him with considerable disenchantment. ... Whilst I agree that X is pre-occupied with the shape of his nose I still believe the appearance of his nose is not helping the situation. ... What he is requesting is volume reduction of the nose which CAN ONLY BE ACHIEVED BY PLACING EXTERNAL INCISIONS ALONG THE SHADOW LINES WHICH DEMARCATE THE ANATOMICAL SUB UNITS OF THE NOSE. I have successfully undertaken these procedures in a number of patients. ... Most particularly I pointed out that the procedure will result in scarring to the nose which may be a source of further trouble to him. However, he is prepared to accept this in return for a reduced volume and a smaller nose. ... I am prepared to undertake this procedure under local analgesia with sedation in my suite here next week but would do so with your blessing. I should be grateful for your comments."
No record exists of a reply from Dr Veale to this letter.
Even though my primary rhinoplasty (as mentioned above) had used the closed approach, I knew almost nothing about rhinoplasty - including the closed or open choice. However, anybody with a basic knowledge of rhinoplasty (which the GMC screeners also appeared not to have) knows that these are the only two accepted approaches to gain internal access to the nose.
Other than a possible base reduction of the alar nostril rims (which creates slight scars that become invisible when done properly), the closed approach involves no external incisions; and the open approach involves only one small incision across the skin between the nostrils at the base of the nose (which also becomes invisible when done properly) whereby the skin is then stretched up over the tip of the nose for clearer access during the operation in more complex cases. At the end of the operation the nasal skin can then either stretch to accomodate the underlying framework, or shrink over it - exactly as mine has now successfully done as a result of the subsequent Chicago operation (aided by Kenalog injections). Occasionally, incompetent surgeons have been known to make more extensive external incisions for even clearer internal access, but due to the placing of the incisions in-question by Mr Nasser they could not have achieved any clearer access than the open incision (which he did use for performing the rhinoplasty, and he also did a base reduction - neither of which have produced problematic or easily visible scars); so it was not 'just' a case of him trying to cover for incompetence.
[To explain it in more detail: On very rare occasions, a vertical external incision to excise a strip of skin, running down the length of the dorsum (otherwise known as the bridge) and stretching into the nose tip, thereby reducing skin volume, has been used by some surgeons on older patients due to lack of elasticity in their skin and its inability to contract; but their skin doesn't scar badly as a result of their age. An old and now retired Californian surgeon named Dr Jack Sheen pioneered this technique. I met him for a consultation and he was outraged by what Nasser had done (and he had no idea that I had been diagnosed with BDD). When I sued Nasser he included photocopies of a book by Sheen, which showed examples of this technique, in his letter to the expert-witness surgeon supplied by his insurers. When I met this surgeon he refused to support Nasser and he let me see the letter. The examples in no way explained Nasser's incisions and neither did anything else in that letter. In any case, the placing of Nasser's incisions - along the upper curve of the nostril and curving down into the base of the nose, as well as curving up the nose and almost meeting in the middle of the bridge at either side, creating a three-spoked effect on both sides of the nose - would not have been effective in reducing skin volume. Excising thin strips of skin along the incision lines in that area has no discernible effect on overall skin volume (particularly not in the tip where the real problem is with thick skin), and risks causing extensive internal keloid scarring (as happened in my case) which actually inhibits skin contracture (not to mention the other serious medical risks such as skin necrosis).]
Mr Nasser's claim, highlighted in the above quote, is untrue and was seriously misleading. This supposed technique is unique to Mr Nasser and clinically pointless. I discovered after the operation that I am the only man to have ever had this done, which in itself amounts to an assault as I would never have had it done had I known. Although women do not tend to scar as easily as men and can cover it with make-up, as far as I'm aware the previous women victims have not complained or sued - quite possibly remaining compliant victims to Nasser's bizarre confidence trick. Most of the victims I saw in photographs in Nasser's office didn't even have thick nasal skin (nor were they all repeat rhinoplasties, so internal scarring from a previous rhinoplasty couldn't have been an excuse for excising skin either, and they were not old). In addition, I saw a photograph where he used a large asymmetric external incision for access to a woman's bridge which stretched half way across her cheek and nose. That almost certainly could not have been justified. Without wanting to get bogged down in psychobabble, I'll just say that I suspect it was, at some obscure level, a kind of subconscious fetishizing (non-sexual) by Nasser of the act of creating needless surgical scars on his cosmetic patients.
There was no explanation or warning given to me at any stage - either verbally or in writing. I made a serious mistake in submitting to Mr Nasser's game of pretence, and regret it. But, at the same time, I feel it fair to remark that I was in a vulnerable state - as a diagnosed BDD sufferer 'fresh' out of a psychiatric hospital; having been recommended the surgeon after a drawn-out process which involved this recommendation initially being used by Dr Veale as bait with which to commence me on treatment at the Priory.
10th October 2000 - Mr Nasser's letter to Dr Veale -
"I have now undertaken nasal surgery on this young man. I spent three hours accomplishing what was an essentially difficult procedure."
18th October 2000 - Mr Nasser's letter to Dr Veale -
"I saw X today and place an injection of Adcortyl on either side of his nose to further reduce any post operative swelling and scarring. Whilst he was initially very enthusiatic about the procedure I now get the impression that he is becoming disenchanted although the aesthetic result of the nose is I think very good. I should have listened to your advice. Kind regards, Yours sincerely"
11th April 2001 - Mr Nasser's letter to Dr Veale -
"This is just to inform you that following his surgery X has become very disillusioned with the results. ... I was at pains to point out all the pre-operative preparation and counselling which was then followed by surgical treatment. ... The external scars on the nose should become inconspicuous with time. If these persist I should be happy to undertake a very minimal dermabrasion procedure."
The extensive pattern of scars all over my nose caused by Mr Nasser´s external incisions were very obvious for a few years and, despite various treatments, remain obvious at a conversational distance over five years later. In addition to the edges of the scars being different levels on one side, he also then left a stitch in the other side which resulted in a hole. (The scars were eventually improved slightly through a surgical scar revision, by Mr Peter Butler.) It is also entirely inappropriate to describe dermabrasion (which scours off the upper layers of skin) of the nose as "very minimal". In fact, on consultation with a senior UK dermatologist, I have learnt that dermabrasion would actually be ineffective (after making an unsuccessful attempt at laser treatment with yet another surgeon). Further significant treatment of the scars (which the dermatologist described as "very prominent") would be lengthy, costly and traumatic; yet would yield only minimal improvement.
