Before the GMC screeners rejected my complaint, both doctors sent the GMC letters in response to it. (The GMC sent both doctors copies of my complaint but did not ask either doctor any questions or make any requests for information, at any stage). Mr Nasser's letter makes no meaningful attempt to clinically justify the incisions in-question, and Dr Veale's three letters contain much of the same standpoint as his letter reproduced in the Priory section; however, there is one point of particular significance in relation to them. Dr Veale sent a letter to the GMC, of 30th April 2002, stating: "I have no evidence that Mr Nasser has a ''delusional mentality'' or of incompetence" (sic). He then sent an ammended letter, of 14th May 2002, stating (I highlight the changes in capitals): "AT THAT TIME, I HAD no evidence that Mr Nasser has a ''delusional mentality'' or was incompetent." Aside from being striking in its intellectual dishonesty; this is a clear indication that Dr Veale - in his capacity as a psychiatrist - was having doubts over Mr Nasser's psychological state, based on the evidence.
The following are the GMC medical screener's notes on my complaint -
27/9/02 -
"Not at all serious" box ticked.
"It is clear the doctor provided services of an appropriate standard, explained possible scarring etc. and was even prepared to see him at his NHS clinic despite difficulties that arose when private fees were not paid."
"It is clear the patient was given appropriate care by Dr Veale and Mr Nasser. No evidence of substandard care. Draft agreed but I feel resurrection clauses should be ommitted. Mr X is acting in this manner partly due to his mental state."
In reality Mr Nasser explained nothing in relation to the incisions in-question. That his insurers have since been forced to pay me a substantial negligence settlement thoroughly disproves the screener's "appropriate standard" claim. It is therefore surely understandable that Mr Nasser's fees weren't settled (in addition to which I suspect that a surgeon arranging to see one of their private patients on their NHS ward to fund further cosmetic treatment is a contravention of NHS funding regulations, and indicates a propensity for deception). I also consider it a very unjust and distorted logic to use my BDD solely as a device with which to discredit my complaint, and to then advise omitting my legal rights based on this prejudice.
(My expert witness GMC report can be read here -)
( http://snipurl.com/v54z ) This can now be read below.
There is clearly a very serious discrepancy between the opinion of the GMC screening doctor - who likely knew virtually nothing about the technicalities of rhinoplasty - and that of the senior and widely respected expert-witness surgeon. Another leading UK rhinoplasty surgeon, Mr Julian Rowe-Jones, has since written to me in response to receiving my expert-witness surgeon's GMC report and the accompanying records (after I met him for a consultation); stating that he doesn't have time to make an appropriately substantive report on "such an important issue" (as he no longer prepares reports due to his operative schedule), but that he considers the report to have been "done excellently" by my expert-witness surgeon.
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11/3/06 - Below is the same report as linked above but with cross-references to academic articles added -
I N D E X
Referral from Dr Veale to Mr Nasser Page 2
Consultation with Mr Nasser Page 3
The Surgical Treatment Page 5
The Post-Operative Management Page 7
Conclusion Page 8
Appendix A Curriculum Vitae Page 10
Appendix B Research/References Page 18
REPORT FOR THE GENERAL MEDICAL COUNCIL
ON BEHALF OF MR X
1.1 This report is prepared for the purpose of being submitted to the General Medical Council, in respect of the clinical medical practice of Mr N A Nasser, while carrying out treatment to his patient, Mr X. In this report I propose to raise questions as to Mr Nasser's fitness to practise, in support of my opinion that an investigation into Mr Nasser?s activities are justified.
1.2 In the preparation of this report I have studied the following documents.
1. Letter of instructions from Alexander Harris, Solicitors, acting on behalf of Mr X in clinical negligence proceedings, addressed to myself.
2. Statement prepared by Mr X
3. Chronology of medical records, supplied by Alexander Harris, Solicitors
4. Copies of medical records provided to Mr X from the General Medical Council, including Mr Nasser's notes and correspondence.
2. REFERRAL FROM DR VEALE, CONSULTANT PSYCHIATRIST,
TO MR NASSER
2.1 The patient, Mr X, was under the care of Dr Veale, Consultant Psychiatrist. He was admitted to a psychiatric hospital on 15.9.00 voluntarily. Assessment from Dr Veale revealed that the patient had a distorted body image concerning his nose, and that no amount of cosmetic surgery was likely to change his internal image. A diagnosis of body dysmorphic disorder was made. Dr Veale was convinced that surgical treatment would not be in the patient's best interests. The patient was treated with Fluoxetine 20 mg daily and was discharged from hospital on 19.9.00, against medical advice.
2.2 Dr Veale referred Mr X to Mr Nasser, a Consultant in Oral & Maxillofacial Surgery. It is clear from the terms of Dr Veale's letter of referral to Mr Nasser that the referral was made to enlist Mr Nasser's support in reinforcing the diagnosis of body dysmorphic disorder from a surgeon who he regarded as knowledgeable about male patients requesting secondary rhinoplasty. It was clear that Dr Veale expected Mr Nasser to advise the patient correctly, (ie that secondary surgical treatment would not be in his best interests), and that Dr Veale did not expect Mr Nasser to carry out any further surgical treatment.
2.3 Cross-reference - (Please see Appendix B for full details of references) (1) Body Image Dissatisfaction and Body Dysmorphic Disorder in 100 Cosmetic Surgery Patients, pages 1644-1649. (2) Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder, pages 218-220. On page 218 Veale emphasizes that; "The worse outcome was found in those who had had rhinoplasty and those with repeated operations." He also confirms that; "Cosmetic surgery cannot at present be recommended for patients with BDD." On page 220 of his paper Veale reports that; "Most patients with BDD reported a high degree of dissatisfaction with cosmetic surgery", and emphasizes that; "some operations, such as rhinoplasty appear to be associated with higher degrees of dissatisfaction."
3. CONSULTATION WITH MR NASSER
3.1 This took place on 4.10.00, a matter of only a few days after the patient's discharge from a psychiatric hospital, against medical advice.
3.2 On page 10 of Mr Nasser's records, he notes that the patient "avoids eye contact". On page 11 of the notes, Mr Nasser recognizes that the patient has made an "unrealistic reduction of plastic model".
3.3 Cross-Reference - (3) "Aesthetic Surgery: Trouble How to avoid it and how to treat it", pages 17-24. In this paper Dr Goin emphasizes the point about unrealistic expectations being a warning sign that patients should not undergo cosmetic surgery. Such warnings are given in many papers and textbooks dealing with the unrealistic expectations of some patients requesting cosmetic surgery.
3.4 In my opinion, the letter of the psychiatrist informing Mr Nasser of a clear diagnosis of body dysmorphic disorder, and his own assessment of the patient's psychiatric state, in failing to make eye contact and in revealing an unrealistic expectation of surgical treatment, alone should have alerted Mr Nasser that the patient would not respond positively to any surgical treatment. Alarm bells should have been ringing and, in my opinion, by continuing to proceed towards surgical treatment Mr Nasser showed considerable incompetence in his assessment of this patient's problems.
3.5 Mr Nasser's letter to Dr Veale, dated 4.10.00, states; "volume reduction can only be achieved by placing external incisions along the shadow lines, which demarcate the anatomical sub units of the nose."
3.6 Comment - This statement is untrue and misleading. In the vast majority of rhinoplasties volume reduction is achieved by reducing the skeletal component of the nasal structures, and the normal elasticity of a young person's skin allows the skin to conform to the reduced shape of the nose without the need for any external incisions or excisions.
3.7 Cross-reference - (4) "Changing The Body: Psychological Effects of Plastic Surgery", page 63; "planned or accidental changes in the size or shape of the actual physical body, desired or not, can exert strong influences on psychic stability." Where patients are at risk because of their general condition to dissatisfaction with a surgical procedure, the placement of external incisions on the patient's nose was, in my opinion, courting disaster. The patient was unlikely to respond positively to a conventional nasal reduction carried out without external scarring and placement of external incisions in this type of patient, producing permanent, visible and unnecessary scars was substandard practice.
3.8 Cross-reference - (5) "Preoperative Identification of Psychiatric Illness in Aesthetic Facial Surgery Patients"; page 66 confirms that the trauma of the surgery itself adds to psychological state of an emotionally stressed individual.
3.9 Cross-reference - (6) "Surgical and Nonpsychiatric Medical Treatment of Patients With Body Dysmorphic Disorder", pages 504-510. On page 505 this paper highlights something widely known in plastic surgical practice, that there are increased difficulties particularly concerning cosmetic surgery in men, something which appears not to have been taken into account by Mr Nasser, in spite of the widespread knowledge that men respond less positively to cosmetic surgery than women.
3.10 Cross-reference - (7) "The Unfavorable Result in Plastic Surgery: Avoidance and Treatment". Pages 30 & 31 highlight the risks of such operations in men.
4. THE SURGICAL TREATMENT
4.1 The surgical treatment took place on 9.10.00, under sedation and local anaesthesia, at Mr Nasser's facility at Suite 315, 103-105 Harley Street, London. At this operation Mr Nasser inflicted unnecessary and visible scars on this patient's nose without achieving the desired result, and completely failing to take into account the psychiatric advice that surgical treatment was not the answer for this patient's problems. Skin ellipses were also excised from the para-glabellar regions, a procedure which apparently the patient did not request and was not included in the consent form signed by the patient and Mr Nasser.
4.2 Mr Nasser's decision to carry out the external incisions on this patient was wholly inappropriate and would not be supported by any reasonable body of plastic,reconstructive/cosmetic surgeons.
4.3 It was obvious that these external incisions would give the patient extra unacceptable, distinctive and unnecessary scarring, but more importantly the use of external incisions in this patient had no medical, cosmetic or functional purpose whatever. This, in my view, is a sufficiently serious matter to warrant investigation. There can be few more serious charges levelled against a surgeon than that he has made incisions that have no clinical purpose.
4.4 Cross-reference - (8) "Plastic Surgery: A Concise Guide to Clinical Practice", pages 580-594. In this paper Millard emphasizes that it is not possible to reduce the skin of the nose by external incisions, which would leave unacceptable and noticeable scars. He compares rhinoplasty with breast reduction or abdominoplasty, where external scars are easily concealed.
4.5 His treatment plan to use these external incisions was contrary to any normal, acceptable practice. In one suffering from body dysmorphic disorder it was inevitable that the operation would provide the patient with extra scarring, which this patient in particular would find totally unacceptable and which would indeed be unacceptable to ordinary patients as well.
4.6 Cross-reference - (9) "Essentials of Plastic, Maxillofacial and Reconstructive Surgery", page 1134-1135. External scars on the nose cannot be concealed by clothing, and the presence of scars on the nose will only aggravate the physical appearance and psychological consequences.
4.7 Mr Nasser's plan to use Wolfe grafts in the glabellar region was also doomed to failure because, although the graft would take well, the appearance would be unsatisfactory and very noticeable, thereby aggravating rather than improving the patient's condition.
4.8 Mr Nasser clearly did not recognize the limits of his professional competence. He completely failed to take into account the clearly stated psychiatric opinion of Dr Veale, and he inflicted visible, distinctive external scars on this patient's nose without any acceptable clinical justification.
4.9 My concern at Mr Nasser's conduct is such that I believe that an investigation is warranted not merely in relation to this case, but also to determine in addition whether or not Mr Nasser has had similar or related problems with other patients in the past (I note that in his letter to Dr Veale, dated 4.10.00, he refers to having performed similar procedures in the past) and to ensure that other patients are not in the future subjected to pointless surgical procedures which produce scarring.
5. THE POST-OPERATIVE MANAGEMENT
5.1 There is little in the notes about the clinical aspects of the post-operative care provided by Mr Nasser. Much of Mr Nasser's correspondence focuses on the patient's refusal to pay Mr Nasser's fees and on the psychological problems resulting from the unsatisfactory outcome of Mr Nasser's surgical treatment.
5.2 On one occasion Mr Nasser offered to see the patient at the Barnet and Chase Farm Hospitals NHS Trust and in his letter, dated 26.7.01, Mr Nasser says in the third paragraph that he has agreed to reverse the para-glabella skin excision by placing post-auricular Wolfe grafts into the area. I would have to say that this is an outrageously silly treatment plan as it certainly would not work, would add extra scarring to the patient's face and ears and would make the patient even more unhappy than he was at that time.
5.3 At this point I feel we should question Mr Nasser's training and experience of cosmetic surgical patients, as his practice seems to be so divergent from what is usually taught to plastic surgical trainees and what is currently practiced in the United Kingdom, Europe and America.
6. CONCLUSION
6.1 From the above-mentioned comments you will rightly conclude that I am extremely critical of Mr Nasser's practice. I question his training, experience and motivation in making the external incisions. He gave the patient wholly inappropriate advice pre-operatively and did not act on the contents of the referring letter or his assessment of the patient, as documented in his own notes.
6.2 The operation that he performed, inflicting external scars on this patient's nose, was wholly inappropriate, without clinical justification and should never have been carried out. This calls into question not merely his ability, but also his motivations, since whatever the reason for these incisions, there was no medical or cosmetic basis for them. His suggestion that Wolfe grafts to the glabella region would solve the patient's problems in that area is also wrong. Since the incisions served no legitimate purpose, this causes me to question Mr Nasser's psychological state. As I have indicated above, his treatment plan was outrageously misguided.
6.3 Mr Nasser's practice was so out of line with normal procedures in the UK both at that time and now that I believe an investigation into his motivation and activities is warranted, not only because of the damage done to this particular patient, but also because of the risk to which others may have been subjected in the past, or may be in the future, including the risk that others may be subjected to surgical procedures which have not recognized medical purpose or benefit.
Expert's Declaration
1. This report has been prepared in accordance with the requirements of Part 35 of the Civil Procedure Rules.
2. I have set out in my report what I understand from those instructing me to be the questions in respect of which my opinion as an expert are required.
3. I have done my best, in preparing this report, to be accurate and complete. I have mentioned all matters which I regard as relevant to the opinions I have expressed. All of the matters on which I have expressed an opinion lie within my field of expertise.
4. I have drawn to the attention of the court all matters, of which I am aware, which might adversely affect my opinion.
5. Wherever I have no personal knowledge, I have indicated the source of factual information.
6. I have not included anything in this report which has been suggested to me by anyone, including the lawyers instructing me, without forming my own independent view of the matter.
7. Where, in my view, there is a range of reasonable opinion, I have indicated the extent of that range in the report.
8. At the time of signing the report I consider it to be complete and accurate. I will notify those instructing me if, for any reason, I subsequently consider that the report requires any correction or qualification.
9. I understand that;
a) My report, subject to any corrections before swearing as to its correctness, will form the evidence to be given under oath or affirmation.
b) I may be cross-examined on my report by a cross-examiner assisted by an expert.
c) I am likely to be the subject of public adverse criticism by the judge if the Court concludes that I have not taken reasonable care in trying to meet the standards set out above.
10. I have included in my report statements setting out the substance of all facts and instructions given to me which are material to the opinions expressed in this report or upon which those opinions are based.
11. I confirm that I have not entered into any arrangement where the amount or payment of my fees is in any way dependent on the outcome of the case.
I confirm that insofar as the facts stated in my report are within my own knowledge I have made clear which they are and I believe them to be true, and the opinions I have expressed represent my true and complete professional opinion.
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Consultant Plastic Surgeon
MEWI (Member of the Expert Witness Institute)
MAE (Member of the Academy of Experts)
CUEW (Expert Witness Accreditation - Cardiff University)
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APPENDIX B
REFERENCES
(1) Body Image Dissatisfaction and Body Dysmorphic Disorder in 100 Cosmetic Surgery Patients by D B Sarwer. Plastic and Reconstructive Surgery, May 1998, Vol 101, No 6, pages 1644-1649.
(2) Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder by D Veale. Psychiatric Bulletin (2000) 24:218-220.
(3) Aesthetic Surgery: Trouble How to avoid it and how to treat it, Edited by Eugene H Courtiss. Published by The C V Mosby Company, 1978. Chapter 3 by Marcia K Goin, pages 17-24.
(4) Changing The Body: Psychological Effects of Plastic Surgery by J M Goin and M K Goin. Published by Williams & Wilkins, 1981. Chapter 7, pages 61-68.
(5) Preoperative Identification of Psychiatric Illness in Aesthetic Facial Surgery Patients by J Regan Thomas, A P Sclafani, M Hamilton and E McDonough. Aesthetic Plastic Surgery (2001) 25:64-67.
(6) Surgical and Nonpsychiatric Medical Treatment of Patients With Body Dysmorphic Disorder by K A Phillips, J Grant, J Siniscalchi and R S Albertini. Psychosomatics (2001) 42:6, pages 504-510.
(7) The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, Edited by R M Goldwyn. Published by Little, Brown and Company, 1972, pages 30-31.
(8) Plastic Surgery: A Concise Guide to Clinical Practice, Edited by W C Grabb & J W Smith. Published by Little, Brown and Company, 1973. Chapter 22 by D R Millard, pages 580-594.
(9) Essentials of Plastic, Maxillofacial, and Reconstructive Surgery, Edited by N G Georgiade, G S Georgiade, R Riefkohl and W J Barwick. Published by Williams & Wilkins, 1987, pages 1134-1135
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